The unsung value of interventions

I want start by being very clear that I understand that many interventions are far more common than they need to be, sometimes to the detriment of the health of women giving birth. I don’t buy the ‘if the baby is ok that’s all that matters’ story. When women are traumatized by practitioners carrying out interventions without consent (including failing to be honest about the options available and the risks of the interventions) new mamas may struggle to take care of themselves, let alone their new babies.

However, I really want to take some time to focus on another side of the issue. Over the past five months it feels like I have seen more stories, read more comments, and heard more remarks about the evils of interventions in the birth process. I know it is, at least in part, due to selection bias – I see it because of the experience I had with my own birth. Sometimes there will be a minimal disclaimer at some point starting ‘except of course, when they’re needed,’ but rarely is ‘when they’re needed’ discussed. It can come across as blaming women for making poor choices for their babies. At the very least women are framed as naively ignorant of the risks and alternatives to interventions. I’m going to talk a little bit about my experience and the (many) interventions I had, what brought me to choose them, and how I feel about each one today. My hope is that my story will be a reminder of the reasons interventions are so very important to have as tool.

To start with a little context, I planned a home birth well before I ever considered getting pregnant myself (the plan had always been for MamaLee to carry first), in part due to the fact that home births have far fewer interventions than hospital births of the same risk category. This is without a significant increase in risk to mama or baby in terms of health. (For my personal favorite, see Cheyney et al. 2014 for more details on that here). When it comes down to it I’m a numbers person. I chose to attempt a home birth because it made sense by the numbers for the kind of birth I wanted.

When my midwives asked about what kind of birth I wanted it was simple: I wanted the baby to come out, with preferences for a vaginal birth without interventions. Birthing at home meant a much lower chance of a cesarean, pitocin, an episiotomy, an epidural, antibiotics, my water being broken and so on.

When I went into labor the Bug was firmly wedged onto my right side (as she had been since 32 weeks) and was unable to turn. I had intense back labor starting almost immediately, that was so painful I did what I always do when I’m in pain: I vomited. A lot. I was having contractions 3 minutes apart start-to-start and 60 to 70 seconds long within about an hour of my first crampy contraction and they didn’t let up until the very end of my 27.5 hours of labor. At around 13 hours into labor I had my first intervention: a vaginal exam to see how I was progressing. I was 7 cm dialated. I felt encouraged but tired, and I was getting dehydrated (remember no saline IVs at home). However, four hours later, after trying everything from belly lifts to high stepping down the driveway, I was not progressing in anything but my dehydration and exhaustion. My midwives conferred with each other, then let me and MamaLee know that there were a few more things we could try to turn the baby, but they were aware how tired I was. They asked me how I felt. Transferring was up to me. There was no emergency. The baby was doing great. I asked for another check of my cervix and the moment they told me I had not progressed at all in those four hours I consented, with full knowledge of what my condition was and what transferring meant, to my next interventions: an epidural and saline so I could sleep and rehydrate. I knew then, as I know now, that those interventions were very good things for my situation. If I ran out of steam before it was time to push I could end up with the c-section I wanted to avoid. An epidural would let me rest and IV fluids would help me and the baby stay healthy.

There are downsides to every intervention, of course. The epidural meant I couldn’t walk (although at that point I was basically only able to crawl anyway), and of course some amount of the drug would cross the placenta. As a person trained in economics though, everything is about not simply cost, but opportunity cost. What was the cost of not getting the epidural? In my case, continuing without sleep or rest (back labor contractions 1 minute long with 3 minutes from start to start are not conducive to rest). I knew that without rest at that point, I would have nothing left in me to push, so essentially the opportunity cost of not getting an epidural was a guaranteed c-section.

I continued to labor when the doctor suggested the next intervention I was pretty sure I didn’t want: breaking my water. RIGHT HERE is why it is so very important to have a caregiver you trust implicitly. Making the decision to have an intervention that you were quite sure you wouldn’t need after laboring for over 20 hours can be confusing and scary. For me it was neither. I was able to state why I was concerned about it and when the OB pushed it without giving me any good reason for it, I said I wanted to get my midwife’s opinion. She very clearly explained why it made sense at that point to break my water, and addressed all of my concerns. It took her probably less than three minutes to put my mind at ease that it was the right decision. I still don’t understand why that was so hard for the OB to take the time to do. I accept that I may not have been open to hearing her because of my general understanding that this intervention was bad.

My final major intervention was the one I really never expected. After being in active labor for over 24 hours and pushing for a significant portion of time as well, my contractions began to slow. My uterus was getting tired (seriously, what muscle wouldn’t give it after that!? My uterus is hard core). Contractions began to space out. The baby had late decels  (heart rate decelerating after a contraction had passed) once or twice – I don’t remember, I was at over 30 hours awake on about three hours of sleep per night over the last few days. A very small amount of pitocin was suggested. I don’t remember at that point saying yes, but I remember my midwife saying it was the right call. I trusted her for a reason. She knew I wanted to push this baby out and she knew what it was going to take to get there. It was just a whiff of pitocin, but it did the trick to help me push that baby out.

I avoided two unnecessary interventions that were mentioned by the OB: a vacuum extraction and an episiotomy. However, I can say there are times and places for each of those, and I’ve been told stories where they were used as tools to support a woman in her quest to birth her child the way she chose to, given the circumstances in which she found herself.

It took a few months for me to be really comfortable with my intervention-heavy birth, and to be honest, there are still moments where I become tearful at the thought of the things that I didn’t have due to the transfer. But what I did have was the best birth possible given the cards I was handed. The interventions I had made it possible to have a vaginal birth, one of the most rewarding and powerful experiences of my life.

After processing all of this, the basic gist is this: interventions are tools, and like any tool they can be used appropriately, or abused and used in ways that do not have a laboring woman’s best interest at heart. My question to anyone who was interested enough in this topic to read this far is this: How do we, as a community, support appropriate use of interventions without creating an atmosphere of fear and shame around them?

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18 thoughts on “The unsung value of interventions

  1. I think it’s unfortunate that there’s any shame associated with various interventions. Just like every mother & baby are unique, every birth will be unique. We cannot always control the cards we are handed, and the important thing is to be able to trust both your instincts and your practitioners. In theory, I would love to have an unmedicated hospital birth (home birth is not in the cards for me), but I have also made peace with the idea that it might not happen. I may need/want the epidural. There may be good reasons why I end up needing a c-section. I am doing my best to prepare myself for the fact that I can only control so much of what happens to me once it’s time for this baby to make an appearance. In the meantime, I’m making sure that I trust the trust the people who will be in the room with me with both my life and my baby’s life. In my particular case, I think it helps that I experienced so much medical intervention just to GET pregnant. My experience has made me so much more comfortable with medicine in general, because I wouldn’t be carrying this baby if it wasn’t for doctors and drugs. For me, it’s just a matter of it being the right doctors and the right drugs at the right time.

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    • Having a relationship with your care provider(s) that has a solid foundation, one which experience after experience tells you that you can trust them when the going gets tough, is one of the most vital things missing from almost every traumatic birth story I hear. Birth is a time we’re at our most vulnerable, so it’s not surprising. From what you’ve said, you’re setting yourself up as best you possibly can for your labor and birth!

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  2. I had all those interventions, plus was induced so I got way more than a whisper of pitocin. I never cared to have a natural birth, and I trusted my ob to guide me thru the experience. I mean, he delivered babies pretty much all day every day, he delivered 6 on the night I gave birth! I think people should do what they want, but this badge of courage some women feel they have for their birth is silly.

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  3. I don’t get why OBs refuse to follow informed consent rules. This blows my mind. We shouldn’t have to turn to books and the internet to learn about birth interventions. OBs and midwives need to take the time to do their jobs and build that trust. I think what needs to happen is a push for a change in maternity care to respectful evidence based practice. I am glad these topics are getting more exposure but wish it weren’t at the expense of women. It took me a bit to come to terms with my birthing experience and I still feel the interventions I had were not necessary and I did not want them. I made the best decisions I could in the situation I found myself due to the resources I had available. My baby is fine, and besides the traumatic experience of pitocin (glad yours wasn’t!), I am also okay. I have learned a lot and will stack the deck differently next time.

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    • I agree. I’ve heard it come from both sides about how a caregiver has either not listened to requests, or done things without consent, from breaking water to administering drugs to performing episiotomies. Birth is a big deal and the woman going through it should be treated as capable, competent human beings.

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  4. shawnsorcade says:

    Thank you so much for this. I’m having a very hard time processing the guilt I feel over my perceived failed home birth and feeling weak for resorting to pain relief.

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    • I spent weeks going over what happened during my labor and delivery. I’m still processing it. Hearing other stories that are similar can still bring me to tears. You did not fail. You did exactly what you needed to do. Every decision you made was the right one, because *you* made it. And as my midwife (who also had a posterior baby) said, the work we do to push those babies out would have birthed 3 babies if we’d been birthing a baby in a more standard position.

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      • shawnsorcade says:

        I hate that I’m replaying it so often but I hope I get to a place of comfort that you have found yourself in 🙂

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  5. I’ve read a lot of dismissive comments about birth plans (i.e. “the only birth plan you need is deliver a healthy baby.”) But for me the birth planning process was really educating myself about the different interventions, talking with my doula about them, and then emotionally preparing myself for what interventions I would be okay with and for what purpose. I completely agree with your post, perfectly worded.

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  6. It sucks when your birth plan goes out the window for sure!!! From our experience, the twins were head down through 90%of the pregnancy and we were all ready for a natural delivery. Unfortunately, the last 3 weeks, Levi turned and went transverse and that was the end of it! C-section it was and Callie was brokenhearted. Ultimately in the long run, what’s most important is that mom and baby are safe…and if people started realizing that those decisions are made based on that, then there would be lest shaming and more congratulating ans supporting. This is a great post!

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