This Virtual Doula's cascade of intervention. Meconium to postnatal depression

What is the cascade of interventions?

In most simple terms the cascade of intervention is that one thing. increases the likelihood of needing another, and on and on it goes.

It can start in pregnancy and finish in postpartum, or be limited to one part of your parenthood journey, unfortunately, it's hard to know when the cascade will lose momentum and stop.

What does the research say about the cascade of intervention?

Research done in Australia in 2011 set out to find the reasons behind a rising cesarean rate.

They looked at a large dataset of women who had vaginal births, and those that had cesareans and tried to identify the factors that were more common in the c-section group.

They found:

'“Labour and delivery complicated by fetal heart rate anomaly” (23%) and “primary inadequate contractions” (22.8%) were the top two reasons for a primary cesarean birth.

But looking one step back they found that:

The most common characteristics among mothers who had fetal heart rate anomalies were as follows: artificial rupture of membranes (39%), oxytocin (32%), no obstruction of labor (42%), and epidural (52%).

For women who had primary inadequate contractions, the most common characteristics were as follows: epidural (33%), oxytocin (49%), artificial rupture of membranes (45%), and fetal stress (56%).

So the cascade here could look like:

ARM - Oxytocin - Epidural - Fetal heart rate anomalies - cesarean

OR

ARM - Oxytocin - Epidural - fetal stress - inadequate contractions - ceserean

Or any combination of the above.

This Virtual Doula's cascade.

To me, this all happened in the blink of an eye, but in reality, this unfolded over several hours, i'm going to highlight the interventions in blue and the outcome in orange, so you can easily see how it unfolded.

Let's start when I decided it was time to go to the hospital, I had a vaginal exam which indicated I was not yet in active labor, so I decided to stay in the assessment unit.

Because I had informed them, that my waters had broken sometime before once it reached 24hrs from that time they arrived with a CTG and declared I needed to put it on and move to the labour ward as I would now need to be 'induced'.

Thankfully my mum stepped in and I asked for another vaginal exam, this showed I was in active labour and I could go to the birth center - phew cascade avoided....so I thought!

I had some time laboring in the birth center, coping well with gas and air, and keeping upright and active.

THEN - My waters go fully and there is thin meconium in them, no other signs of fetal distress at this point.

I am told I now need to be on a CTG monitor, and need to be moved to the labor ward.

Once in the labor ward on the bed they put the CTG monitor on. Quite quickly they decided my BP had climbed (no doubt I was now very stressed!), and they hooked me up to IV fluids.

It is suggested that they could put a 'clip on the babies head' (note: this is the Fetal Scalp Electrode, a spiral wire that screws into the top layer of your baby's skin). This will help them differentiate between my now very high BP and the baby's heart rate and is sold as more convenient for me as the straps won't keep moving. I am still on the bed.

They do a vaginal exam to place the FSE and find out I am now 10cm dilated.

They instruct me to start pushing, on my back, in the bed, and I continue to do so, without the urge to push for nearly two hours.

I am exhausted and scared, and reaching their two-hour time limit, doctors start coming in suggesting the drip or to do an episiotomy and an instrumental birth.

Through stubbornness, I physically force my baby out, suffering a second-degree tear.

I have active management of the placenta but it does not come away and I start bleeding, I am diagnosed with a retained placenta. They try an in-out catheter as they realize I haven't been to the toilet in a while and that could be preventing my placenta from coming away. It doesn't work.

I go to the theatre for a manual removal of my placenta, I have a spinal, and get given antibiotics, and more fluids.

I am separated from my baby.

After this, my baby lost nearly 10% of its body weight in 3 days, I started topping up with formula and stopped breastfeeding.

I am traumatized, physically exhausted, and have postnatal depression.

The cascades

Meconium - CTG - FSE - 10 cm dilated - coached pushing - uterus exhausted - retained placenta and PPH.

Meconium - transfer - stress - high BP - fluids - full bladder - retained placenta

Meconium - CTG - staying on the bed - pushing on the bed - second-degree tear - pph

Meconium - transfer - stress - high BP - fluids- inflated birth weight for baby - big weight loss post birth - stop breastfeeding.

Meconium - CTG - FSE - 10 cm dilated - coached pushing - uterus exhausted - retained placenta and PPH - delay in milk establishing - stop breastfeeding.

Of course, I will never know the could haves and should haves, what is frustrating for me is that the first step in all of these cascades is the meconium, and if I had known what I know today about thin meconium and post-term babies, I would refuse the transfer and CTG.

(note some of these are backed up in evidence, others are my thoughts and feelings on the situations!)

This Virtual Doula's tips on avoiding the cascade, or stepping out of it!

1. Get informed before your birth, if you know the risks and benefits of things you may be able to make informed decisions that enable to you never enter the cascade (like me and the meconium) or enable you to stop it (had I got out of the bed after the CTG and remained active!).

2. Create a birth plan that makes your wishes known, and have a birth partner who knows what your choices and preferences are, and can advocate for you if you are unable to do so yourself.

3. Consider your place of birth, the likelihood of interventions is decreased at home or in a birth center, as is, therefore, the likelihood of one thing leading to another!

4. Hire a Doula or Virtual Doula! Working with a doula has been proven to reduce the likelihood of you having a cesarean, probably because you are more able to avoid the cascade!

Check out my Doula services!

References

Fox H, Topp SM, Lindsay D, Callander E. A cascade of interventions: A classification tree analysis of the determinants of primary cesareans in Australian public hospitals. Birth. 2021; 48: 209–220. https://doi.org/10.1111/birt.12530