Midwife Monday: Interventions during labor associated with increased cesarean risk in nulliparous women

Hooray Monday! A Friday Five did not happen around here (see spouse working the weekend; start of graduate school; and need for sleep). And although sleep and playing with the littles happened, not much else did. But…Sunday showed us some blue sky patches after a long week of fog and rain. And the snow has just about melted at sea level (the snow doesn’t melt from the mountain tops through June-ish). It was so nice to walk outside on dry roads…now if the street sweepers will get to it to pick up all the rocks off the road. Did you guys know Alaska doesn’t salt their roads? They use gravel….which is not so good for the windshield… and also why our car insurance is super high!

Anyways, I was catching up on some reading in journals this weekend and came across an article that just has to be discussed. Published in the Journal of Midwifery & Women’s Health, Iobst, Bingham, Storr, Zhu and Johantgen (2020) performed a retrospective observational study of 26,259 women that were nulliparous (first time pregnancies), full term (>39 weeks), singleton babies, with vertex (head down/presenting), that presented in spontaneous labor. The study examined this population of women and looked to see if the interventions of oxytocin use, epidural anesthesia and amniotomy (breaking the bag of water) increased a woman’s chance for a cesarean section.

The study found:

  • Only 10% of women received no intervention
  • 79.9% of women received an epidural
  • 47.8% of women received an amniotomy
  • 44.1% of women received oxytocin augmentation
  • 27.8% of women received any one intervention, while 43.0% received any two interventions
  • The following interventions were shown to increase the risk of cesarean birth (OR = odds ratio):
    • Amniotomy only (OR 1.57)
    • Epidural analgesia only (1.18)
    • Oxytocin augmentation only (OR 1.50)
    • Amniotomy-epidural analgesia (OR 1.76)
    • Amniotomy-oxytocin augmentation (OR 1.89)
    • Epidural-oxytocin augmentation (OR 1.87)
    • Amniotomy-epidural analgesia-oxytocin augmentation (1.83)

Here’s my take: As discussed in the article, low risk women are not generally studied. The study had a number of limitations, and overall, more research is needed (especially in regards to when oxytocin was started and why)…BUT, it was one of the first studies to look at interventions in spontaneous labor! The study also collected data from 2002 to 2008 and some practice patterns may have changed since then.

Midwives recognize that spontaneous labor comes with a host of hormones released in the body that continue to support labor’s progress. When interventions are performed, this can affect or slow down what the body was already doing on it’s own. To us, we sound like a broken record player: “Let labor happen on its own!” But, I find every day that we still have to wave the flag of midwifery and protect normal, active, spontaneous labor.

What do you guys think? Do you the three most common interventions (other than an IV and electronic fetal monitoring) are associated with an increased cesarean section risk? How do your facilities practice? I’m curious to hear your points of view!



Iobst, S., Bingham, D., Storr, C., Zhu, S. & Johantgen, M. (2020). Associations among intrapartum interventions and cesarean birth in low-risk nulliparous women with spontaneous onset of labor. Journal of Midwifery & Women’s Health, 65(1), 142-145. doi:10.1111/jmwh.12975

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