Common Interventions 101

Some labor and births might need a little extra help to get things moving. In some cases, your care provider may recommend an intervention or two for the health of you and your baby. In fact, nearly 20% of births include the administration of a medication called Pitocin and more than 25% of births result in cesareans.

When a medical intervention is recommended, you are always within your rights to ask your care provider about the benefits, risks, and alternatives of the intervention. For example, if your care provider recommends an induction, you should ask if the recommendation is medically indicated or if waiting is an option as you consider the next steps. Some interventions may be offered for convenience and not because it is medically indicated. It is so important that you trust your intuition when consenting to an intervention - if you need more time to review your options, stand firm in that.

Let’s talk about common birth interventions and when they might come up during your labor.

Electronic Fetal Monitoring 

Electronic fetal monitoring (EFM) is a device used to evaluate the strength and duration of your uterine contractions as well as your baby’s response to the uterine contractions. Uterine contractions essentially “squeeze” your baby and encourage them to move lower in the pelvis. Depending on your hospital, you may have access to one or more types of monitors. External monitors involve two elastic belts - one will measure your contractions and the other will monitor your baby’s heart rate (see image). A handheld telemetry unit, also known as a fetal heart doppler, can be used for EFM and gives you the freedom to move around your birth space. Your care provider can place the handheld telemetry unit to your belly to hear your baby’s heartbeat. In some cases, a third type of monitor, an internal monitor, with a transducer may be attached to your baby’s head. This is done vaginally and is recommended if your care provider has concerns about the strength of your contractions or if other monitors, like the external monitor and handheld telemetry unit, cannot effective trace your contractions and the baby’s heart rate.

EFM tell us how your baby is tolerating labor. In some cases, low-risk birthing persons can request to be monitored intermittently, such as every 30 minutes. High-risk birthing persons may be monitored non-stop. Continuous monitoring has been connected to an increased risk of cesarean. It also limits your ability to move in and around your birth space. If your labor is induced with Pitocin, you have an epidural, or your baby’s heart rate decelerates frequently, your care provider will likely encourage continuous monitoring.

The American College of Obstetricians and Gynecologists (ACOG) believes that monitoring every 30 minutes during active labor is appropriate in lieu of continuous monitoring for low-risk birthing persons. If your hospital or birth center has a policy that does not support this, ask about alternatives to continuous monitoring, like handheld telemetry units. The latter will allow you to move freely in your birth space and keep you out of bed. Laboring in bed is associated with increased interventions so it is often best to minimize your time in that space.

Induction 

Induction is an artificial way to start your labor using medical and mechanical methods. In some cases, your body is not yet ready to go into labor even if you are at or past your due date.

1. Membrane stripping or sweeping occurs when your care provider uses their finger to separate your cervix from the amniotic sac. The act releases prostaglandins, a cervix-softening hormone. This can be uncomfortable and you may experience cramping and spotting after the process. Note that if a membrane sweep is successful, labor should begin within 48 hours. However, if it is your first time giving birth, membrane sweeps are less likely to be successful than if you have had children previously. For this reason, you should consider the benefits and risks of the intervention.

2. Artificial rupture of membranes (AROM) involves using a sterile hooked instrument with a blunted end. This process is also called an amniotomy. The blunted end of the hook is gently pushed into the amniotic sac, creating a small tear. This causes your amniotic sac to open and leak amniotic fluid (also known as your water breaking). The action gives your baby’s head the opportunity to move downward further as the amniotic fluid is no longer in the way, letting the baby’s head push against the cervix and encouraging dilation. Please note that AROM can increase your risk of infection and that research has shown that 7 or more cervical checks after ROM increase risk of infection significantly.

3. Cervical ripening with the cervical insertion of a prostaglandin medication such as Cervidil (also known as Dinoprostone, a long string with prostaglandin at the tip inserted vaginally) or Cytotec (also known as Misoprostol, a pill that can be inserted vaginally or taken orally). These medications are intended to ripen or soften the cervix. The cervix must soften to dilate.

4. Cervical ripening with the insertion of a balloon-like catheter. This option is available if your cervix is at least 1 centimeter dilated (opened). The catheter is inserted vaginally and its tip (which will go into your cervix) is filled with saline, water, or air, creating a balloon. The balloon portion puts pressure on your cervix, encouraging dilation and softening. The balloon essentially acts like your baby’s head in that way. Once the balloon falls out (usually once you are 3-4 centimeters and your cervix can no longer hold the balloon), it will not be reinserted. Depending on your labor progress, the balloon may be paired with another cervical ripening agent, like Cervidil, Cytotec, or Pitocin. Research has shown that pairing induction methods can be more effective than using any one alone.

5. Pitocin is a synthetic hormone administered through an IV. The medication is started at a low dose to stimulate contractions. Note that Pitocin administration should not be recommended unless your cervix is soft. Pitocin can only induce contractions - the cervix must be ready for this method before the contractions can actually be effective. For this reason, Pitocin use may be paired with a cervical ripener. After Pitocin begins entering your IV, your and your baby’s tolerance of it is monitored via EFM. Please note that Pitocin is the synthetic version of Oxycotin, the “love” hormone.

You may also consider non-medical induction methods, like acupuncture, visiting a chiropractor, sexual intercourse, nipple stimulation, and herbs. Before trying any of these options, however, check with your care provider to discuss the benefits and risks.

You may be wondering whether induction is necessary and how to avoid it if it is not. ACOG has recognized that there are some cases where induction is medically indicated, such as if there are concerns about the health and safety of the birthing person and their baby. Inducing for other reasons, such as to ensure your care providers attendance at your birth or because the baby is large (an estimated weight of 8 pounds or more) is not a medical reason to induce. In many cases, it is best to let labor begin on its own. When this occurs on its own, interventions are less likely to be needed. If an induction method is recommended, talk to your partner, care provider, and doula about the implications. If your care provider is recommending an induction because you are past your due date, please note that it is still possible for your body to go into labor spontaneously and naturally without such methods. Again, review your options before moving forward with an intervention.

Directed Pushing vs Trusting your urge to Push

If you have ever watched a birth, you may have observed that the birthing person’s birth team encourages taking a deep breath, holding it for 10 counts, and pushing through the contraction. The birthing person may be laying on their back with their knees bent, their chin to their chest, and their spine curled around their belly. This is called directed pushing. Though a common practice, it is very beneficial for birthing people to follow their own instincts when it comes to pushing. There is a risk of a longer pushing phase if you are relying on the cues of your birth team to know when to push. Instead, tell your birth team that you want to take the lead when it comes to your pushing. Use this time to relax and trust your body as your baby rotates and descends.

Having an epidural can impact how long you push. If you have an epidural, try to wait until your baby descends naturally so the urge to push is triggered by their positioning and not by external pressure from your birth team.

Forceps and Vacuum 

In some cases during labor, your care provider may use special tools, like forceps (which encircles the baby’s head, pulling them out) or a vacuum (which attaches to the baby’s head and uses a sucking pressure that draws the baby out) when you are pushing during a contraction. The care provider may make this decision if the baby is not descending as expected, if the baby is struggling to move through the vagina safely, or if it appears your baby is having difficulty breathing. These interventions may also be recommended if you have been pushing for some time or if your contractions have a significant gap between them, thereby rendering your pushing efforts less effective. Because there are risks of injury to the birthing person and baby, such as bruising and tearing, forceps and vacuum use should always be medically indicated and patients should consent prior to use.

Episiotomy 

An episiotomy is a surgical cut to your perineum. The perineum is the surface area between the vagina and the anus as well as the muscle between it. If your baby is in distress, an episiotomy may be recommended in very rare cases. Because research has indicated that episiotomies do not benefit the birthing person and may contribute to significant health problems related to your pelvic floor, episiotomies should be avoided.  You can include notes in your birth plan that you would like to avoid an episiotomy unless it is medically indicated.

Lubrication and Vaginal stretching

In some cases, your care provider may apply lubrication or oil to your vagina in an effort to shorten the pushing phase and minimize tearing. These lubricants or oils are intended to allow for the easier passage of your baby’s head and body via your vagina. Care providers may apply the liquids in addition to gently stretching the vagina and perineum manually with their fingers (see image). While this does not seem like an intervention, it is an external method intended to progress your birth by stretching your skin and muscles to accommodate your baby’s body. Please note that research indicates that this method does not necessarily shorten the length of time that you push.

Cesarean Section

Finally, let’s review cesarean sections, also known as c-sections. C-sections involve a surgical incision into your abdomen, its associated muscles and fat, as well as the uterus to deliver your baby. C-sections are considered an emergency intervention that may be recommended if the birthing person is in distress, which can occur with preeclampsia (pregnancy-related high blood pressure), or the baby is in respiratory distress. In some cases, a c-section may be recommended if your baby is in a breech position. Though c-sections occur in almost 30% of births, you can reduce your risk of having one by finding a care provider with a low c-section rate. Hiring a doula is also a helpful way to reduce the risk of cesarean.

There is an association between the use of interventions and the risk of cesarean birth. This is known as the “cascade of interventions”.

Before consenting to any intervention, talk to your care provider about how each intervention or pain relief option (like an epidural) increases your risk of having a cesarean. You are always worthy of an explanation! 

Please note: Aila Birth Village and the materials and information it contains are not intended to, and do not constitute, medical or other health advice or diagnosis and should not be used as such. You should always consult with a qualified physician or health professional about your specific circumstances.