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Artificial rupture of membranes (AROM), also known as amniotomy, is a procedure performed by a midwife or obstetrician to rupture the amniotic sac. The procedure is typically carried out to induce or accelerate labour, monitor the baby's heartbeat, check the colour of the amniotic fluid, or prevent the baby from aspirating the contents of the amniotic sac during birth. While AROM can be performed using different techniques and tools, such as an amnihook or amnicot, it is important to ensure that certain criteria are met before proceeding, including the absence of contraindications for vaginal delivery and confirmation of labour or indication for delivery.

To induce labour or augment uterine activity

Inducing labour or augmenting uterine activity is a process that involves starting labour artificially. This can be done through various methods, including the use of tablets, gels, or other medications to initiate contractions. Inductions are typically carried out when there is a risk to the mother's or baby's health, or when a pregnancy goes beyond its due date.

One method of induction is the use of prostaglandins, which can come in the form of a tablet, gel, or controlled-release pessary. Prostaglandins work by preparing the cervix for labour and stimulating contractions. The tablet/gel regimen involves a first dose followed by a second dose if labour does not start within 6 hours. The pessary regimen involves a single dose over 24 hours, with a recommended maximum of one cycle in 24 hours.

Another method is an amniotomy, or artificial rupture of membranes (ARM), where the membranes are ruptured artificially using an instrument called an amnihook. This procedure is usually performed when the cervix is deemed ripe, and it can help expedite labour by releasing prostaglandins. It is often accompanied by an infusion of artificial oxytocin to increase the strength and frequency of contractions.

Additionally, a membrane or cervical sweep can be performed to increase the likelihood of spontaneous delivery and reduce the need for a formal induction. This procedure involves inserting a gloved finger through the cervix and rotating it against the fetal membranes to separate the chorionic membrane from the decidua, thereby releasing natural prostaglandins.

Inducing labour can also be done through medication that imitates the hormones that initiate labour, such as misoprostol, dinoprostone, or oxytocin. Misoprostol can be taken orally or vaginally, while dinoprostone is administered as a vaginal suppository. Oxytocin is given intravenously and can lead to faster labour progression, especially in first-time mothers. However, it carries a risk of fetal distress and may require an emergency C-section.

It is important to note that inducing labour carries some risks, including increased chances of a C-section, uterine rupture, and fetal distress. The decision to induce labour should be made in consultation with a healthcare professional, taking into account the risks and benefits for both the mother and the baby.

To monitor the baby's heartbeat

Doppler Monitoring

Handheld Doppler devices are often used during prenatal visits. A gel is applied to the mother's abdomen and a probe is placed on the gel, picking up the baby's heartbeat and displaying the readout on a screen. This is also how ultrasounds are performed, which can be used to hear the baby's heartbeat before it can be detected by a Doppler.

Continuous Electronic Monitoring

During labour and delivery, healthcare providers may opt for continuous electronic fetal monitoring. This involves holding an ultrasound device in place on the mother's belly with an elastic strap, with a second strap holding an instrument that measures contractions. The wires from these instruments are attached to a monitor that provides a continuous readout of the baby's heart rate.

Internal Monitoring

Internal monitoring involves attaching a wire to the baby's head to continuously track the heart rate. This method is more precise and is used during labour and delivery when external monitoring is unreliable or when closer monitoring is required. However, it can only be done if the amniotic sac has broken and the cervix is open.

Fetal heart rate monitoring is especially helpful for high-risk pregnancies, such as when the mother has diabetes or high blood pressure, or when the baby is not developing or growing as expected. It may also be used to check how preterm labour medicines are affecting the baby.

Risks of Fetal Heart Rate Monitoring

While fetal heart rate monitoring is generally safe, continuous monitoring can restrict the mother's movement and increase the risk of an unnecessary C-section or assisted delivery. Internal monitoring can increase the risk of injury to the baby's scalp and asphyxiation, as well as the transmission of certain infections.

To check the colour of the amniotic fluid

The colour of the amniotic fluid can indicate the health of the baby. Normally, amniotic fluid is clear or a pale yellow. However, if the fluid is tinted brown or green, it means the baby has passed meconium (their first faeces) in the uterus. Meconium in the amniotic fluid can cause complications if the baby breathes it in, potentially leading to meconium aspiration syndrome, which requires immediate treatment after birth.

During an amniotomy, a practitioner will use a specialised tool, such as an amnihook or amnicot, or their finger, to puncture the amniotic sac and release the fluid. The colour of the fluid at the time of rupture is noted, and the practitioner must be cautious to avoid potential cord prolapse, which is one of the most common complications of the procedure.

After the procedure, a nurse will monitor the mother's temperature and watch for any signs of infection. They will also monitor the baby's heart rate and communicate any findings to the healthcare provider.

To avoid the baby aspirating the amniotic sac contents

When considering the timing of an artificial rupture of membranes (AROM), it is essential to prioritize the well-being of the baby and avoid potential complications. One of the primary concerns is to prevent the baby from aspirating the contents of the amniotic sac. This can occur if the baby inhales amniotic fluid, which can lead to severe consequences, including respiratory distress and, in rare cases, aspiration pneumonia. To avoid this, healthcare providers typically wait for the baby to reach an appropriate station before performing AROM.

So, what station should AROM occur to minimize the risk of the baby aspirating the amniotic sac contents? Generally, it is recommended that AROM is performed when the baby has reached a station of +2 or beyond. This means that the baby's head has descended into the birth canal and is at least two centimeters below the plane of the mother's ischial spines. At this station, the risk of aspiration is significantly reduced because the baby's head is lower than the level of the amniotic fluid.

Waiting until this advanced station helps ensure that the baby's airway is protected. As the baby's head descends, the airway becomes more compressed, reducing the likelihood of aspiration. Additionally, at this stage of labor, the baby's head may act as a "plug" in the cervix, further preventing the ascent of amniotic fluid into the baby's airway. This position also indicates that the baby is likely in a favorable position for birth and that the labor is progressing well.

In some cases, healthcare providers may opt to perform AROM at an earlier station, but this is typically done with caution and only in specific circumstances. For example, if the labor is not progressing as expected or if there are concerns about the baby's heart rate, a provider may carefully consider performing AROM earlier. However, they would take extra precautions to avoid aspiration, such as using a small incision and slowly releasing the amniotic fluid to allow for a controlled flow away from the baby's airway. Overall, the decision of when to perform AROM requires a careful balance between facilitating labor progress and ensuring the baby's safety and well-being.

To relieve pressure on the mother's vagina

When considering an assisted vaginal delivery, the position of the baby's head and the progress of labor are crucial factors. The decision to use instrumental assistance, such as forceps or a vacuum, is typically made when the baby has descended to a particular station, which is a measurement of the baby's progress through the birth canal. This station indicates the ideal time for an assisted vaginal delivery, often referred to as an operative vaginal delivery (AVD) or assisted reproductive delivery (AROM).

Now, to relieve pressure on the mother's vagina during an AVD, it is important to ensure that the procedure is carried out at the appropriate time and with careful technique:

Proper Positioning and Technique:

Ensuring that the mother is in the correct position is vital. Typically, the mother will be guided to push in a semi-sitting or lithotomy position, which provides better access for the delivery and helps reduce the pressure on the vagina and perineum. The healthcare provider should also apply gentle traction, pulling the baby's head in the direction of the birth canal, in synchronization with the mother's contractions and pushing efforts.

Perineal Support:

Applying counter pressure to the mother's perineum can help reduce the strain on the vagina and surrounding tissues. A warm perineal compress can also provide comfort and aid in relaxing the perineal muscles, making more space for the baby's head to descend.

Slow and Controlled Delivery:

A controlled delivery ensures that the baby's head emerges slowly, reducing the risk of vaginal tearing and excessive pressure. The operator should apply gentle traction between the mother's contractions, guiding the baby's head to rotate and descend gradually.

Episiotomy:

In some cases, performing a minor incision called an episiotomy may be necessary to create more space and reduce the pressure on the vagina. This is usually done as a last resort, as it can increase the risk of perineal trauma and post-partum discomfort.

Instrumental Assistance:

Forceps or a vacuum extractor may be used to assist in the delivery, providing more control and reducing the duration of pushing. This can help minimize the pressure on the vagina and the risk of severe tearing. However, the use of these instruments requires skill and careful judgment to avoid potential complications.

By following these measures, the pressure on the mother's vagina can be relieved during an assisted vaginal delivery, helping to ensure a safer and more comfortable birth experience. Proper technique, positioning, and support are crucial to achieving a positive outcome for both the mother and the baby.

Frequently asked questions