Aromantic? Navigating The 'When' Of Arom-Ing

Amniotomy, or artificial rupture of membranes (AROM), is a procedure in which the amniotic sac is manually ruptured to induce or expedite labour. It is typically performed to augment stalled labour, allow for internal monitoring of the baby, or facilitate a forceps- or vacuum-assisted delivery. While AROM can speed up labour and increase the likelihood of spontaneous vaginal delivery, it carries risks such as injury to the fetus, bleeding, and prolonged rupture of membranes. The effectiveness of AROM is debated, and the American College of Obstetricians and Gynecologists (ACOG) recommends delaying the procedure in low-risk pregnancies.

To induce labour, often with an oxytocin infusion

To induce labour, amniotomy (or artificial rupture of membranes (AROM)) can be performed, often in conjunction with an oxytocin infusion. During AROM, a thin, sterile, plastic hook is brushed against the membranes just inside the cervix, causing the baby's head to move down against the cervix. This usually causes contractions to become stronger and releases a gush of warm amniotic fluid from the vagina.

AROM is performed to induce labour when the amniotic sac has ruptured but labour hasn't started within 24 to 48 hours. It can also be performed when there is a prolonged pregnancy (beyond 42 weeks) and there is a possible risk to the baby from a decrease in nutrients from the placenta.

The benefits of AROM include:

• Shortening the labour process by about an hour.
• Allowing the doctor to examine the amniotic fluid for meconium, which may be a sign of fetal distress.
• Allowing for the monitoring of the fetal heart rate.

However, there are also disadvantages and risks associated with AROM, including:

• The baby may turn to a breech position, making birth more difficult.
• The umbilical cord may slip out first, leading to a prolapsed cord.
• Infection may occur if there is a prolonged time between rupture and birth.
• There is a risk of injury to the fetus or surrounding tissues, bleeding, non-reassuring fetal testing, and cord prolapse.

The effectiveness of AROM is debated, and the American College of Obstetricians and Gynecologists (ACOG) recommends that it is used cautiously and only when necessary.

To speed up labour, especially in low-risk pregnancies

If you are experiencing slow progress in labour, your doctor or midwife may suggest two ways to speed it up:

Breaking your waters

Breaking the membrane that contains the fluid around your baby (your waters) is often enough to make contractions stronger and more regular. This is also known as artificial rupture of the membranes (ARM).

Oxytocin drip

If breaking your waters does not work, your doctor or midwife may suggest using a medicine called oxytocin (also known as syntocinon) to make your contractions stronger. This is given through a drip that goes into a vein, usually in your wrist or arm.

Other ways to speed up labour

• Nipple massage, if appropriate, to help your body naturally release more oxytocin, which encourages stronger contractions.
• Taking a warm bath to relax.
• Changing positions often or taking a walk.
• Using breathing exercises, massage and having a warm bath or shower to ease pain.
• Moving around and staying active.
• Relaxation techniques.

When to seek medical help

If you think you are experiencing precipitous labour, call 911 if you think your baby's arrival is imminent. If you are alone, call your partner or someone nearby to be with you. Call your doctor or midwife, and doula if you have one. Lie down on your side until help arrives and try to stay calm. Use breathing techniques to help you through the contractions.

To allow for internal monitoring of the baby

Internal monitoring of the baby's heart rate is used to check the rate and rhythm of the heartbeats. It looks for any increases or decreases in the baby’s heartbeat and how much the baby’s heart rate changes. The average fetal heart rate is between 110 and 160 beats per minute. The fetal heart rate may change as the baby responds to conditions in the uterus. An abnormal fetal heart rate or pattern may mean that the baby is not getting enough oxygen or there are other problems. An abnormal pattern may also mean that an emergency cesarean section (C-section) delivery is needed.

Internal fetal monitoring is used when the external monitor isn't picking up well (which sometimes happens if the mother is moving around a lot or is obese) or if the doctor has concerns and wants a more accurate reading. An internal heart rate monitor is connected to a wire electrode that is inserted through the mother's cervix and placed onto the baby's head.

Internal fetal monitoring can only be done if the amniotic sac is broken and the cervix is partly open (dilated). There may be a slight risk of infection with internal monitoring. The scalp electrode may also cause a mark or small cut on the baby's head, but this often heals quickly.

Internal monitoring is considered the most accurate way to measure a baby's heart rate during labour. It is also used if it's hard to hear the baby's heartbeat or if there may be a problem with the baby's heart rate.

To allow for a forceps- or vacuum-assisted delivery

• The mother has been unsuccessfully labouring for a prescribed length of time (one to four hours, depending on their health conditions).
• The baby has descended to the halfway point in the birth canal, where it can be accessed.
• The mother's health is at risk, or they are exhausted and unable to push.
• The baby's heart rate indicates fetal distress, and they need to be delivered soon.
• The baby is in an awkward position, such as lying facing upwards or to one side.
• The baby is premature, and forceps can help protect their head.
• The mother requires an epidural for pain relief during labour.

Before performing a forceps- or vacuum-assisted delivery, the obstetrician or midwife should discuss the reasons for the assisted birth, the choice of instrument, and the procedure with the mother. Informed consent is required, and the mother should be made aware of the risks and benefits of the procedure.

To check for meconium, which may indicate fetal distress

Meconium is the first faeces, or stool, of a newborn. Meconium passage during labour is generally considered a sign of fetal distress. The presence of meconium in the amniotic fluid is called meconium-stained amniotic fluid (MSAF) and is usually a marker of antenatal distress.

Meconium aspiration syndrome (MAS) occurs when a newborn breathes a mixture of meconium and amniotic fluid into the lungs around the time of delivery. It is a leading cause of severe illness and death in newborns, occurring in about 5% to 10% of births. MAS is defined as respiratory distress in a neonate born through MSAF, with symptoms that have no alternative explanation.

The most accurate test to check for possible meconium aspiration involves looking for meconium staining on the vocal cords with a laryngoscope. Other signs of meconium aspiration syndrome include bluish skin colour, a slow fetal heart rate, abnormal breath sounds, and limpness in the infant at birth.

If there are signs of fetal distress, the newborn's mouth should be suctioned as soon as the head can be seen during delivery. Further treatment may be necessary if there is thick meconium staining and fetal distress.

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