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Melanie Jackson is mother of two, Midwife in private practice, PhD graduate, part-time blogger, obsessed veggie patch owner and even more obsessed crocheter

Monday, 21 November 2011

Intervention Management of birth and its association to maternal morbidity

*Reader warning - this one will need a good cup of tea and a little time, but well worth the read*

This essay aims to define and analyse ‘intervention management’ of labour and birth, followed by the subsequent impact of intervention management on maternal morbidity. The definition of Intervention management will be derived from literature surrounding the concepts of obstetric fear, perception of risk, the medicalisation of childbirth and definitions of ‘normal’ and ‘abnormal’ labour and birth which stem from biomedical philosophy. Research has found that 43% of women experience some kind of morbidity beyond what would be normally expected in childbirth (Danel, Berg, Johnson & Atrash, 2003, p.28). Maternal morbidity will be defined in terms of a mothers ‘illness or abnormal condition’ (Harris, Nagy & Vardaxis, 2006, p.1127) relating to labour and birth and not specifically as a statistical measure of illness or abnormality. The focus of this analysis is on iatrogenic maternal morbidity relating to intervention management in labour and not morbidity associated with pre-existing poor maternal health.   

This analysis acknowledges that morbidity can be long or short term and can be physical or psychological in nature (Weaver, 2004, p.11). The psychological morbidity associated with intervention management will be examined followed by physical morbidity caused by various interventions. It is proposed that intervention management produces iatrogenic effects which compound as a result of the ‘cascade of intervention’ and thus produces an increase in avoidable maternal morbidity. Each intervention will be discussed in an approximate order of its place on the cascade chain to examine maternal morbidity. Interventions discussed include, coming to hospital, admission cardiotocography (CTG), artificial rupture of membranes, continuous CTG, restriction of food and fluids, maternal position, epidural use, episiotomy, instrumental delivery and caesarean section.

In order to fully analyse and define ‘intervention management’, the philosophical assumptions behind it must be explored. Thus, the notion of risk, which has bred a culture of fear surrounding childbirth, will be examined. What logically flows from this analysis is the obstetric philosophy of birth being pathological and the subsequent medicalisation of child birth. The medicalisation of childbirth gives way to the defining of ‘normal’ and ‘abnormal’ by medicine and thus creates a market for modern obstetrics to manage the risk of childbirth by intervening.

The concept and notion of risk is used by modern society to make decisions about and to come to terms with the possibility of outcomes which may entail loss, damage or death (Murphy-Lawless, 1998, p.12). During childbirth there is always the possibility that a woman or her baby may be disabled or die. Since illness and death are considered the domain of medicine it is the obstetric argument that childbirth is risky and dangerous and requires a medical expert to oversee it (Murphy-Lawless, 1998, p.22). Obstetrics argues that its account of birth is authoritative and that intervention is the most certain way to avoid death. Thus, medicine has marketed the message that childbirth can result in death and that death can be escaped by submitting to medical management (Murphy-Lawless, 1998, p.10). By presenting childbirth alongside the discourse of risk, modern obstetrics has created and marketed a need for itself and thus persuaded society to accept their perception of birth, therefore securing birth as their domain (Johanson, Newburn & Macfarlane 2002, p.893 Murphy-Lawless, 1998, p.10). The idea of risk is that the probability of a certain event occurring can be calculated and quantified. Because the complications of labour and birth consistently escape the systems of risk perception and calculation, there is an obstetric tendency to define every aspect of labour and birth in terms of risk in an attempt to explain and predict all possible eventualities (Murphy-Lawless, 1998, p.21). In this sense the labouring female body has become risk laden as the possibilities for something ‘going wrong’ proliferate.

 The use of risk discourse in association with birthing creates fear around the events of labour and childbirth. If an event is perceived as risky, then it is also perceived as scary. By the use of risk discourse, obstetrics has perpetuated the myth that childbirth is to be feared and thus convinced mothers to conform to obstetric management to avoid something ‘going wrong’ (Murphy-Lawless, 1998, p.18). Obstetrics cannot predict and prevent all the possibilities of things that can go wrong, yet have succeeded, with the use of risk discourse to sustain control over the birthing woman (Ballard & Elston, 2005, p.228; Murphy-Lawless, 1998, p.22). Murphy- Lawless states that, ‘the general drive towards intervention, gathered its credibility from the notion of identifiable risk factors and the hope that obstetrics could prevent death by responding to risk factors’ (p.172). Thus the discourse of risk and the resultant fear surrounding childbirth paved the way and provided justification for interventions during labour and childbirth, under the guise that they would prevent death and avoid something going wrong. The obstetric fear of birth combined with the discourse of risk, have led to the assumption of pathology for each labour and birth. Thus, as a matter of biomedical philosophy, birth can only be judged as normal in retrospect because it is always potentially pathological, therefore labour is managed to keep it within the bounds of the medically defined ‘normal’ to make it less risky (Murphy-Lawless, 1998, p.198).

The use of risk discourse has paved the way for obstetric intervention in childbirth which allowed for the process of medicalisation. The term ‘Medicalisation’ applies when a problem is created or taken over by the apparatus of medicine and gives definition to the ways in which medicine has extended its jurisdiction over normal life events (Ballard & Elston, 2005, p.228). The theme of medicalisation implies the extension of medical authority beyond a legitimate social boundary (Rose, 2007, p.700, 702) whereby social phenomena come to be defined and treated as disease (Ballard & Elston, 2005, p.228; McLellan, 2007, p.627). ‘Medicalisation should be understood as a manifesting and ongoing shift in social control processes in modern societies’ (Ballard & Elston, 2005, p.229). Medicalisation occurs when the medical profession uses power gained through their knowledge and expertise to define and control what constitutes health and illness (Ballard & Elston, 2005, p.230). Once medicalisation has occurred, practitioners demonstrate their control by redefining what is considered ‘normal’ and ‘abnormal’ within their newly acquired social process or event (Ballard & Elston, 2005, p.228; Rose, 2007, p.701). Through the process of defining what is ‘normal’, medicine can define what is considered ‘abnormal’ or pathological (Ballard & Elston, 2005, p.228; Rose, 2007, p.701). From a Foucaultian perspective, conformity to the medically defined norm is seen as good behaviour while pathology is seen as deviance and is not socially or medically accepted (Ballard & Elston, 2005, p.231). This is expressed by Parsons who identified ‘the sick role’ which describes the socially accepted role of the ‘sick’, which is to seek treatment and resume their role within society. Failure to conform to this expectation and refuse medical treatment is deemed as deviant and socially unacceptable (Maher, 2003, p.142). By developing a conceptual difference between abnormal and normal the medical profession have secured a large and growing market for their services in perpetuity by the creation of false needs and then catering to these newly perceived needs (Ballard & Elston, 2005, p.230).

As we can see by the social process of ‘problematising’ or medicalising birth, modern obstetrics can justify ‘managing’ labour and birth by ‘intervening’ to make each individual labour and birth conform to the obstetric definition of normal. Thus, by defining what is constituted as a normal birth, obstetricians have monopolised control over events which occur outside the norm under the guise of risk management. ‘By defining the parameters of abnormality and establishing the routine use of medical monitoring and intervention during pregnancy and childbirth, obstetricians have placed undue emphasis on probability of abnormality and thus on the need for all women to be dependent on medical care’ (Ballard & Elston, 2005, p.230). Under the guise of knowledge and expertise, medicine has proceeded to define all aspects of labour, in particular, the parameter of time. The use of medically defined times for labour and birth have justified the use of intervention to ensure each labour fits into the ‘normal’ time a labour should take according to doctors. If a labour is to long it is described as ‘failure to progress’ which is ‘abnormal’ and requires ‘treatment’ (Maher, 2003, p.145). A combination of strict timing criteria for ‘normal’ birth and the perception that childbirth is potentially pathological have encouraged the use of intervention which speeds up the process of birth. This leads to the use of manipulative interventions such as induction, augmentation, forceps, vacuum extraction and rupturing membranes (Murphy-Lawless, 1998, p.200). Just as what is normal can be defined as dangerous, that which is dangerous can be normalised over time (Murphy-Lawless, 1998, p.201) which is what has occurred with intervention during childbirth.

Based on the above stated discussion, the approach of ‘intervention management’ for labour and birth will be defined as, ‘a method of labour and birth care which assumes childbirth is pathological, thus requiring treatment. Using an intervention management approach, birth is controlled by a series of interventions, including pharmacological, instrumental and mechanical to ensure that labour and birth remain within the medically defined boundaries of normal. It is thought that these interventions reduce the risk of childbirth and thus prevent maternal and foetal mortality’. The remainder of this analysis aims to discover and discuss the subsequent impact that ‘intervention management’ has on maternal morbidity.

The use of intervention management to control labour has resulted in increased development and use of technological aids during childbirth which help to monitor birth to identify deviance and risk. When technological aids and intervention are routinely and unnecessarily used, they disturb the normal instinctive and physiological responses within the mother which help to make labour effective and successful. Each intervention has iatrogenic side effects which often require management with an additional form of intervention; this sets up a process which is defined as the ‘cascade of intervention’. The cascade begins with the first intervention and can roll on to the end point of an instrumental or operative delivery (Weaver, 2004, p.19). ‘Inch employed the term ‘cascade of intervention’, to produce a diagrammatic account of possible outcomes, beginning with artificial rupture of membranes which leads to other routine interventions like oxytocin induced induction, epidural, episiotomy and forceps delivery. She built up a picture of how labour goes wrong for women because obstetrics cuts across a woman’s labour in order to prevent a possible outcome which may never arise’ (Murphy-Lawless, 1998, p.204). This analysis proposes that intervention management produces iatrogenic effects which compound as a result of the cascade of intervention and thus produce an increase in avoidable maternal morbidity. To begin, the psychological morbidity associated with intervention management will be examined then each intervention will be discussed in an approximate order of its place on the cascade chain to examine physical maternal morbidity.

When a mother loses control over her birth experience due to intervention management, this can produce emotional and psychological effects of which can be long lasting and affect parenting and future pregnancy and birthing decisions. It is supported in the literature that obstetric intervention during birth produces negative reactions from mothers and can be associated with long term psychological morbidity (De Costa & Robson, 2004, p. 438). Operative and instrumental delivery including caesarean delivery, forceps and vacuum extraction is linked with considerable psychological maternal morbidity including, disappointment, anger, depression, guilt, regret, loss of self esteem, grief reactions, feelings of violation and dissatisfaction with care (Smith, Lumley, Donohue, Potter  & Waldenstrom, 2000, p.1043). In Oakleys ‘Transition to motherhood’ study, she compiled a technology score based on fifteen different forms of intervention that were accepted obstetric practices and found that an outcome of depression in the women who formed her study group strongly correlated with medium to high technology scores, which included the combination of induction, epidural and forceps (Murphy-Lawless, 1998, p.204). Similarly, Porter et al (2003) comment that many women report having more marital adjustment problems, have more problems bonding with their babies and difficulty establishing breastfeeding after caesarean compared to women who have vaginal deliveries. They also found that for some reason having a caesarean discourages women from having further children; women who had caesareans were afraid of further deliveries and as a result had fewer children. Inglis’ study found that there is growing recognition that the effects of a woman’s birth experience can negatively affect her transition to parenthood and that as a result of events occurring during labour, women needed debriefing to recover from being psychologically traumatised by their birthing experience (Inglis, 2002, p.368).

As previously discussed, intervention management stems from obstetric fear and has become mainstream as childbirth has been medicalised. The medicalisation of childbirth requires women to be cared for during labour within the hospital setting. Thus, the first in the chain of the ‘cascade of intervention’ is, going to hospital to experience labour and birth (De Costa & Robson, 2004, p. 438). It is understood that stress and clinical procedures intervene with the physiological process of labour and the stress of transferring to hospital during labour can slow labour and thus create pathology (Maher, 2003, p.141). Sheilds et al (2007) found that women presenting to hospital in the latent stage of labour undergo an increased number of obstetric interventions and that avoiding early admission for women not in active labour reduces the risk of receiving augmentation of labour or an epidural by more than half (Sheilds, Ratcliffe, Fontaine & Leeman, 2007, p.1673). The idea that intervention is more likely to increase with early admission during labour, links well with the previously discussed notion of the ‘normal’ labour time expected by doctors.

A management approach which often accompanies presentation to hospital is an admission CTG. This intervention is often performed routinely on all women presenting in labour to monitor how the baby is coping with labour and allows the staff to determine how to best manage the labour and what interventions are to be employed during the labour to reduce risk (Impey, Reynolds, MacQuillan & Gates, 2003, p.465). Impey et al performed a randomised control trial to assess the neonatal and maternal outcomes in the CTG group and intermittent auscultation group. They hypothesised that there would be a 50% reduction in neonatal morbidity for the CTG group, but instead found that there was no difference between the groups for either maternal or fetal outcomes. They concluded that admission cardiotocography, at the start of a labor in a pregnancy judged to be normal, cannot be justified’ (p.470). In a similar study by Mires et al, it was found that while admission CTG did not improve fetal outcomes it did increase medical intervention with increases in both instrumental deliveries and caesarean section in a low risk population and made a similar conclusion to Impey et al  (Mires, Williams, Howie & Goldbeck-Wood, 2001). These studies support the proposal that intervention management of labour leads to increased intervention and subsequent maternal morbidity in low risk women.

Within the approach if intervention management of labour, interventions are employed to ensure that the length of labour remains within the ‘normal’ limit. In addition to this, as previously mentioned, if birth is seen as pathological, practitioners are eager to have it over and done with as soon as possible. To assist with this, the intervention of artificially rupturing the membranes (amniotomy) is often employed as it is thought speed up the progress of labour (Smyth, Alldred & Markham, 2007, p.2). Murphy-Lawless quotes Nihell who states that ‘the deliberate premature discharge of waters was a very blameable practice, one that all capable midwives reprove and forbid, as it is robbing the part of the most natural and necessary lubrication for facilitating the launch in due course of the foetus’ (Murphy-Lawless, 1998, p.201). Although amniotomy is considered a simple procedure within the intervention management model it does carry risks. It can cause an increase in variable heart rate decelerations in the baby because of cord compression, cord prolapsed and is thought to worsen the pain of contractions (Sheilds, Ratcliffe, Fontaine & Leeman, 2007, p.1672; Smyth, Alldred & Markham, 2007, p.4). While amniotomy doesn’t directly cause maternal morbidity, it is a link in the chain of the cascade of intervention and can lead to continuous CTG. Immediately after amniotomy it is considered good practice to listen to the fetal heart to assess if the intervention has impacted upon the health of the baby (Smyth, Alldred & Markham, 2007, p.4). If decelerations in the heart rate are heard, continuous CTG is warranted as the fetus may be compromised. Thus, if amniotomy leads to the intervention of continuous CTG, it puts a further time limit on labour as doctors will argue that the longer decelerations are present, the more the fetus may be compromised and become distressed which may be an indication for assisted delivery (Gabay & Wolfe, 1997, p.387). The above stated chain of events may give some insight as to why amniotomy is associated with higher rates of caesarean and instrumental delivery then if membranes spontaneously rupture (Sheilds, Ratcliffe, Fontaine & Leeman, 2007, p.1672). Thus, the intervention of amniotomy can indirectly contribute to maternal morbidity due to resultant intervention management to remedy the iatrogenic effects of previous intervention.

          If fetal distress is diagnosed resulting in continuous CTG, the mother will often be advised not to take any oral fluid or eat. Restricting oral food and fluid intake of women in active labour in hospitals is a strongly held obstetric tradition based on the historical concern related to risks of gastric content regurgitation and aspiration into lungs during general anaesthesia. Thus the thought is that if the baby is distress, the mother may require a caesarean delivery and if she did, then she may need a general anaesthetic (GA) and if she did then there is a risk of Mendelsons syndrome which is a result of aspirating stomach contents during GA (Singata & Tranmer, 2002, p.unknown). Thus the philosophy behind intervention management dictates labour management and perpetuates and compounds risk as each intervention is performed. Restricting food and fluid during labour is not only unsubstantiated and unnecessary according to recent literature but predisposes women to dehydration, ketoacidosis, slowed labour (dystocia) and increased maternal stress. Intravenous therapy instead of oral hydration has become common practice, but this has been shown to predispose women to immobilisation and doesn’t ensure adequate fluid and nutrient demands for labour (Singata & Tranmer, 2002, p.unknown). It is evident then that the use of CTG can be combined with the use of intravenous fluid administration (in response to fluid and food restriction), which can both have the side effect of reduced maternal movement and mobilisation during labour and predisposes women to a semi-recumbent position. Women who adopt an upright or lateral position have reduced duration of second stage and incidence of instrumental birth compared with supine or lithotomy positions (Homer & Dahlen, 2007, p.88), highlighting the importance of mobilisation and freedom of movement during labour. Not only do the above stated interventions rob the mother of the freedom to move and control over her labour but they are also associated with the perception or experience of increased pain. Restricted movement means that mothers will often lie or sit on the bed which can result in a reduction in the mother’s ability to manage labour pain and use pain relief methods such as a shower, bath and massage. This can result in mothers requesting an epidural to cope with labour pain. 

          ‘Current pain-relief methods pose a dilemma for obstetrics because they entail sequale to which it must respond with further techniques that also up the odds of something going awry’ (Murphy-Lawless, 1998, p.58). The use of epidural anaesthesia to deal with labour pain is associated with additional intervention due to the effect it has on the maternal mechanisms of labour and alteration of the pelvic floor. The lower body muscle weakness resulting from an epidural inhibits normal fetal rotation which increases the incidence of fetal malpresentations among women who receive epidural anaesthesia (Cammann, 2005, p.719). The use of epidural analgesia early in labour contributes to the creation of fetal malpresentation by relaxing the pelvic floor before the presenting part is flexed and in a favourable position for rotation and descent (Klein, Grzybowski, Liston, Spence, Le, Brummendorf, Kim & Kaczorowoski, 2001, p.245). In addition to fetal malpresentation, epidural anaesthesia has a tendency to prolong the second stage of labour due to reduced maternal ability to push and malrotation of the baby. ‘Strong evidence from 11 trials involving 3280 women shows the association between epidural use and longer second stage’ (Homer & Dahlen, 2007, p.88). These factors increase the incidence of instrumental deliveries (Murphy-Lawless, 1998, p.41). Homer & Dahlen (2007) found 17 trials involving 6162 women which showed that the risk of an instrumental delivery was increased with the use of epidurals. Instrumental birth leads to overall increase in pelvis floor morbidity with increased perineal trauma (Homer & Dahlen, 2007, p.88).

A study by Klein et al (2001), shows the connection between epidural use and the subsequent cascade of intervention which ultimately results in higher rates of maternal morbidity. The objective of the study was to determine if family physicians overall approach to maternity care, as measured by average use of epidural analgesia, was associated with maternal and fetal outcomes. Physicians were separated into cohorts based on their level of epidural use (low, medium or high). The results showed that low versus high epidural users were admitted at a later state of cervical dilation, received less CTG monitoring and oxytocin augmentation, sustained fewer fetal malpresentations and had fewer caesarean deliveries. They concluded that high use epidural analgesia is a marker for a style of practice characterised by fetal malpresentations leading to dysfunctional labours and higher intervention rates, leading in turn to excess maternal morbidity (Klein, Grzybowski, Liston, Spence, Le, Brummendorf, Kim & Kaczorowoski, 2001, p.243). The authors of the above study hypothesised that those physicians who used epidural analgesia often might be creating iatrogenic conditions that lead to a cascade of interventions culminating in caesarean and concluded that high epidural use appears to be a marker for a style of practice characterised by higher intervention rates and excess maternal morbidity (Klein, Grzybowski, Liston, Spence, Le, Brummendorf, Kim & Kaczorowoski, 2001, p.244).

In addition to the cascade of events associated with epidural use during labour, the epidural itself poses a risk to the mother and is a cause of maternal morbidity including a dangerous drop in blood pressure which can have ramifications for organ perfusion and fetal health and may lead to emergency interventions and infection of the epidural site (Britt, 2002, p.78). In addition to the above stated complications, Klein et al observed that epidural use resulted in the need for labour augmentation (Klein, Grzybowski, Liston, Spence, Le, Brummendorf, Kim & Kaczorowoski, 2001, p.245). Due to an epirdurals effect on contractions, augmentation is often required to strengthen contraction and remedy the prolonged first and second stage of labour (Decca, Daldoss, Fratelli  & Lojacono, 2004, p.119). Thus in summary ‘Women receiving epidurals are more likely to require oxytocin augmentation in the first stage of labour, have longer second stages, have persistent Occipito Posterior fetal malpresentation and undergo operative vaginal delivery’ (Sheilds, Ratcliffe, Fontaine & Leeman, 2007, p.1673). Therefore epidural use serves as a link in the cascade of intervention resulting in interventions which increase maternal morbidity.

Women who undergo operative vaginal deliveries or instrumental deliveries are more likely to report sexual problems including painful intercourse and perineal pain compared to women who had unassisted deliveries (Thompson, Roberts, Currie & Ellwood, 2002, p.88). Furthermore, urinary and anal incontinence can be a consequence of instrumental deliveries as a result of damage to surrounding tissues (Johanson, Newburn & Macfarlane 2002, p.893). The morbidity relating to instrumental deliveries can be associated with the use of episiotomy when performing these deliveries. Episiotomies contribute more to anal sphincter disruption and severe perineal trauma then unassisted deliveries; therefore there is an increased risk of incontinence of faeces and flatus (Homer & Dahlen, 2007, p.87)

The culmination of the cascade of intervention and the ultimate management of birth is the complete detour of the birthing passage by surgical extraction of an infant through the abdomen of it’s mother. The World Health Organisation has estimated that almost 15% of women develop complications serious enough to require rapid and skilled intervention with the use of caesarean delivery (Johanson, Newburn & Macfarlane 2002, p.892). There are three major reported justifications for caesarean section; labour dystocia, fetal distress and breech presentation (Weaver, 2004, p.4). Since this analysis focuses on the iatrogenic causes of maternal morbidity, the ways in which intervention management can lead to caesarean delivery. Thus we can conclude that a caesarean section can be an intervention required to remedy the side-effects of the previous intervention in the management of a labour. It had been estimated that serious maternal morbidity occurs in 9-15% of women delivered by caesarean (Weaver, 2004, p.11).  The morbidities associated with caesarean at the time of surgery can include hysterectomy, anaesthetic complications, accidental extension of incision and haemorrhage requiring transfusion (Armson, 2007, p.475). The short term morbidities include wound, uterine and urinary infections, severe abdominal pain and local trauma to bladder, ureters and bowels (Grobman, 2002, p.20; Weaver, 2004, p.11). More serious short term morbidity associated with abdominal surgery in general includes thrombo-embolic complications and paralytic ileus (Weaver, 2004, p.11). It is estimated that 20% of women develop fever after caesarean due to iatrogenic infections (Wagner, 2000, p.1678). Furthermore, thromboembolic disease is approximately 5 times more common after caesarean then a vaginal delivery and can lead to anticoagulant associated major morbidity including post-thrombotic chronic pain syndrome and recurrent thromboembolic disease (Grobman, 2002, p.20). A 14 year study, as explained by Armson, found the overall risk of severe maternal morbidity associated with planned caesarean was 3 times higher than vaginal delivery. This included the risk of postpartum cardiac arrest, wound haematoma, hysterectomy, major puerperal infection, anaesthetic complications, venous thromboembolism, haemorrhage requiring hysterectomy or transfusion, uterine rupture, intensive care admission, postpartum readmission to hospital, problems with subsequent births including reduced fertility, ectopic pregnancy, miscarriage and placenta previa, complications of repeat caesarean birth and increased cumulative costs (Armson, 2007, p.476; Thompson, Roberts, Currie & Ellwood, 2002, p.88). Thompson found that, compared with women having unassisted vaginal births, women who had caesareans were significantly more likely to report exhaustion or extreme tiredness and at 24 weeks postpartum and were more likely to report other urinary problems when women having unassisted vaginal deliveries (Thompson, Roberts, Currie & Ellwood, 2002, p.88).

 In the longer term, caesarean delivery is thought to cause an increase in morbidity rates relating to, miscarriage, ectopic pregnancy, sub fertility, infertility, abdominal adhesions causing intestinal obstruction, placenta abruption, placenta previa, placenta acreta and antepartum haemorrhage (Abu-Heija, El-Jallad & Ziadeh, 1999, p.7; Grobman, 2002, p.21; Murphy, Stirrat, Heron & ALSPAC study team, 2002, p.1914; Porter, Bhattacharya, Tijlingen & Templeton, 2003, p.1983; Wagner, 2000, p.1678). Studies have consistently demonstrated that one caesarean is associated with a 2-4 fold increase in the occurrence of placenta previa, and the risk increases with each additional caesarean. It is suspected that due to the uterine scar, fertilised ovum that would normally have not implanted and been passed out, get caught on the scar and implant there (Abu-Heija, El-Jallad & Ziadeh, 1999, p.7). These cases of placenta previa tend to be more morbid then those that occur independent of prior caesarean and are associated with a significantly greater need for transfusion and hysterectomy (Grobman, 2002, p.21). The underlying mechanisms for an association between caesarean and subsequent sub fertility and infertility are unclear and may relate to infection, adhesion formation or placental bed disruption. These mechanisms seem plausible in the light of the associations between caesarean and subsequent ectopic pregnancy, placenta previa and placental abruption. (Murphy, Stirrat, Heron & ALSPAC study team, 2002, p.1916). Thus it is obvious that the risks and morbidity of an initial caesarean are not limited to the immediate post operative period but continue to accrue during future pregnancies (Grobman, 2002, p.21).

In conclusion, this analysis has defined intervention management of labour and birth as, ‘a method of labour and birth care which assumes childbirth is pathological, thus requiring treatment. Using an intervention management approach, birth is controlled by a series of interventions, including pharmacological, instrumental and mechanical to ensure that labour and birth remain within the medically defined boundaries of normal. It is thought that these interventions reduce the risk of childbirth and thus prevent maternal and foetal mortality’. This definition is based on the analysis of literature relating to obstetric fear of childbirth, the notion of risk, the medicalisation of childbirth and subsequent definitions of what is normal and abnormal in labour. Intervention management has led to the majority of women birthing their babies in hospital where they are under the control of medical staff who promise reduced risk during child birth. Risk is reduced by intervening to ensure labour and birth remain within the medically defined bounds of normal. This essay proposed that these interventions produce a cascade of other interventions in an attempt to manage the risk of the previous intervention. Each intervention carries risks and side effects which compound the possibility of maternal morbidity and increase the likely hood of further intervention. The cascade culminates at instrumental or caesarean delivery which carry a substantially higher risk of maternal morbidity then spontaneous vaginal delivery. Therefore, this analysis concludes that intervention management of labour and birth has the subsequent impact of increasing maternal morbidity in the short and long term. These morbidities are both physical and psychological.  

(references available on request)

Thanks for reading!

Kind regards
Melanie Jackson (homebirth midwife)

For more information on Melanie or her midwifery services please visit www.ellamaycentre.com