Are interventions ever a good thing or simply necessary evils?  Christie, a Birth Sense reader, made the following comment in response to my last post on home birth:

Thanks so much for this post! I’m training to be an L&D nurse and while there is a lot of information out there about trying to avoid any interventions and the good reasons to avoid them when possible, I haven’t found nearly enough on what to do to avoid an intervention cascade when the first intervention truly is necessary. If you know of any other books, posts, articles, etc. related to this, I’d very much appreciate any recommendations.

Excellent question, Christie:  what can we do to avoid the “cascade of interventions”  when the first one is truly necessary?

To answer this question, let’s first consider cases in which some type of intervention is truly essential, and few if any people would debate the need for intervention:

• Complete placenta previa: placenta is totally covering the cervix in late pregnancy
• Baby presenting in a position that is impossible to deliver, such as transverse lie
• Placental abruption (placenta starts to separate prematurely causing lack of oxygen to baby)
• Cord prolapse (umbilical cord washes into the vagina when the water breaks, and is compressed by baby’s head
• Eclampsia in the mother (causes seizures which can lead to brain damage or death of fetus) or severe pre-eclampsia
• Vasa Previa (condition where the baby’s unprotected blood vessels are covering the cervix and will rupture when dilation occurs, causing the baby to hemorrhage
• Rupture of the uterus before or during labor
• Placenta accreta/increta/percreta:  placenta is attached or has grown into the tissue of the uterus, sometimes necessitating hysterectomy

These are some of the conditions for which I believe few people would debate the need for intervention.  There are others, but these are the the more common ones.

Other conditions, which are considered outside the realm of normal but have a number of ways they can be dealt with since they usually are not true emergencies, might include:

• Abnormal fetal heart rate patterns (there is a wide variation of normal here)
• Prolonged labor (again, wide variation of normal)
• Prolonged rupture of membranes (generally defined as greater than 24 hours within conventional medical circles)
• Postdates (traditionally has been considered to require induction when pregnancy reaches 42 weeks, but many are calling for induction at 41 weeks)
• Growth restriction
• Increasing blood pressure in the mother: mild pre-eclampsia or high blood pressure without signs of pre-eclampsia
• Irregular/inadequate labor pattern
• Breech presentation (footling–coming feet first–is generally considered especially unsafe for vaginal delivery)

Again, there are numerous other situations that could be added to this list, but these are some of the more common ones.

What about situations that in which a mother might request intervention, but it is not medically essential to the wellbeing of mother or baby?  These might include:

• Unmanageable pain
• Maternal fatigue
• Pre-labor conditions that are intolerable to the mother (examples might be: severe pain due to a condition that cannot be treated during pregnancy, such as kidney stones; severe pain from separation of the pubic bone; inability to sleep for a prolonged period of time; extreme emotional or mental stress; fear of loss of baby when the mother has experienced a previous pregnancy loss).
• Social situations which cause the mother to request interventions.  Many times these can be simply “I’m tired of being pregnant”, but there are other situations that are more compelling:  the mother who has a history of 1 – 2 hour labors, is having her fourth baby, and lives an hour from the nearest hospital; the woman whose husband is in Iraq and is only given 2 weeks leave to come home and hope he is there when the baby is born; the single mother who has short labors, lives with her three pre-school age children, and has no one nearby to stay with them if she goes into labor at night. 

So, there you have my examples of times that interventions might be absolutely necessary, recommended, or considered helpful.  Over the next few posts, I will be discussing various situations that demand intervention, along with times that a woman might desire intervention.  In these cases, are there ways to minimize the “cascade of interventions”?  Are there ways to intervene in a way that supports, rather than interferes with, the process of birth?  Stay tuned as we explore these very important questions.