Some medical professionals in our country believe that if amniotic sac sac stays intact during giving birth, it needs to be artificially broken at least at cca 8 cm of cervical opening during the first stage of labor. They believe pushing with intact membranes can otherwise CAUSE placental abruption, which is dangerous for both mother and a child. What is the origin of this claim ? Is there any evidence supporting or refuting it ?
(I have seen a Cochrane review, which does NOT recommend a routine amniotomy during first stage of labor. Frustratingly, though, in that article, amniotomy is framed only as a measure to speed up labor. Placental abruption is not among the outcomes. )
I think it is one of the line of the management of abruption but it has no preventive role
In Russia we have the same classic approach to perform amniotomy after 8 cm of dilation, but I've never seen placental abruption in case of pushing with intact membranes in multiparous women and never seen some evidence base statements about need of artificial rupture of sac.
Best regards, Artem.
@Artem Romanovsky, that is interesting. Have you seen a placental abruption in women giving their first birth, though, which could be interpreted as a result of pushing with intact sac ?
In my own practice never. But several times I successfully use amniotomy as treatment options in case of marginal abruption with moderate bleeding in the end of first period of labour.
@Artem Romanovsky, it seems like you are saying the same as @Ishag Adam, that amniotomy is treatment after the abruption, not prevention. Thank you both.
Amniotomy may hasten Labour progression by allowing fetal axis pressure to come into play early and hasten the release of prostaglandins , all which may impact positively on Labour progression but not necessarily Labour outcome has been well documented.
Similarly amniotomy is a well documented integral and cardinal component of management of placental abduction but not it's prevention. Of crucial significance is the fact amniotomy should be performed in a controlled fashion in order to prevent sudden decompression of intrauterine pressure particularly in cases of uterine overdistension due to e.g. polyhydramnios which may then predispose to placental abduction.
The last 2 words in the 2nd paragraph should read 'placental abruption ' and not 'placental abduction'.
Kindly read my amniotomy review available on Researchgate:
https://www.researchgate.net/publication/258375672_The_less_studied_effects_of_Amniotomy
In the course of my research for this project of finding the rate at which amniotomy CAUSES cord prolapse, I read extensively on the subject of amniotomy and am confident there is no evidence that amniotomy has ever prevented placenta abruption. The opposite is more logical. After the birth of the baby, the shape of the uterus is changed and as a result the placenta immediately abrupts off the wall of the uterus and starts coming down if the woman is upright. Except for adherent placentas, in squatting, all placentas are not only separate but delivered by 5 minutes. In the case of vaginal birth of twins, often both placentas abrupt off the wall after Twin A delivers, which is why you have 15 minutes to deliver twin B, without incurring brain damage to Twin B. The placenta abrupts when there is a quick change in the contents of the uterus. Therefore, where there is ample amniotic fluid, amniotomy could result in sudden decrease in size of the uterus, which is the cue to the placenta to separate, ie. abrupt. Amniotomytherefore is a risk factor for placental abruption. Try asking the people who practice this protocol to provide evidence that it is effective. In my homebirth research, I found not a single case of placenta abruption during labor at homebirth. Placental abruption during labor is the result of Prostaglandin and Pitocin induction and augmentation. Vaginal exams can tear the cervix. The amni hook which is a sharp needle- can easily tear the cervix or uterus or leave a cut in the baby's head.
https://www.youtube.com/edit?o=U&video_id=6azE5n3nPGo
https://www.youtube.com/edit?o=U&video_id=4jN6r-cWVB8
Amniotomy has no benefit, since it has not even been shown to speed up labor more than 9 minutes.
I have now attended 900 homebirths. Without the practice of amniotomy, 5% or 45 babies were born in the sac, which was only removed after the head head or the whole body was born. It is a small sample, but I did not experience a single case of uterine abruption.
Controlled amniotomy or guided amniotomy is a measure to prevent abruptio placenta in patients with Polyhydramnios
In my experience those days, amniotomy was done early to hasten labour progresion as Akinwunmi Femi Akinsanya rightly puts it.
But I understand it is not done nowadays perhaps more in line with Judy Slome Cohain of inavented cervical or fetal head injury cum introduction of infection.
However, it was not intended to prevent placenta abruptio.
However, the risk of sudden decompression in polyhydramnios is strife.
If you are not continuously monitoring labor using cardiotocogram, delaying amniotomy has the risk of missing the diagnosis of fetal distress. late amniotomy may carry the risk of umbilical cord prolapsus. An inexperienced finger may not palpate the pulsations of the cord in front of the fetal presenting part. (proximal to the presenting part referring to the observer). This is even more important in breech deliveries, more in complete than frank breech, for obvious reasons.
In my practice, if the patient is not polyhydramniotic, which may predispose to placental abruption in some patients, I would prefer an amniotomy when the patient enters active labor. Earlier than active labor, amniotomy may predispose chorioamnionitis.
Delivering twins in a primipara even in head- head presentation carries plenty of obstetric risks, especially if they are preterm. So vaginal delivery should be weighed against cesarean section, before considering amniotomy.
On the other hand, after long years of practice, I have never seen a placental abruption following an amniotomy myself.
The American College of Obstetricians & Gynecologists (2017) came up with new recommendations for low intervention births which included not rupturing membranes is the labor is progressing normally. They do recommend amniotomy for fetal monitoring if there is concern about the fetal status and there is a need to apply internal fetal monitors. I have never seen that rupturing membranes is known to be preventive for abruption. I think its important to screen for risks of abruption and manage those risk factors. In doing more than 1000 births, I have not seen a correlation between intact membranes and amniotomy. The abruption I have seen have been related to cocaine use or hypertension/preeclampsia. Hope this information is helpful.
https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Approaches-to-Limit-Intervention-During-Labor-and-Birth
Amniotomy was applied to expedite labor in mother’s with placental abrupt ion.. In cases of polyhydramnios hind water rupture is considered (to prevent abrupt ion because of sudden decrease in intrauterine pressure - a contributing factor to the third stage of labor) avoid
@Michele R Davidson , you mean you did not see correlation between intact membranes and abruption, right ? Sorry for asking the obvious, but I might need to show this discussion to a medical professional in Slovakia.
Ambiotomy has a role in labour management for induction, augmentation in abruptio placenta but in prevention only in case of polyhydromnios by contrlled amniotomy. Definitely not by routine amniotomy.
The Cochrane review found amniotomy to speed labor by 9 minutes on average, and therefore found no place for amniotomy . My research found 1 cord prolapse caused for every 250 amniotomies performed. Cord prolapse is more common than that when there is polyhydramnious, which is reason not to break the sac. If the placenta is completely abrupted, you need a fast cesarean. If it is partially abrupted, my published review found no reason to take any action at all. Even 2 weeks of waiting had good outcomes.
My viewpoint is that amniotomy would give information about the colour and the maturity of the amniotic fluid which would be determining factors on the mode of delivery. Drainage of amniotic fluid in this manner makes the presenting part of the foetus - mostly cephalic - to get well applied to the cervix and also the reduction in the height of the uterine fundus. These would hasten the labour process in the first stage. In my experience cord prolapse is often found in cases of spontaneous rupture of membrames than with amniotomy. Placental abruption has other causes.
Amniotimy does not prevent abruption, it may facilitate abruption in cases of polyhydramnios.
Babies born in the caul for not have worse outcomes than those born through ruptured membranes.
Amniotomy can increase the risk of abruption (especially with polyhydramnios due to the sudden change in pressure in the uterus), the risk of rupture of vasa praevia, as well as possibly increase the risk of Caesarean section . It is associated with an increase in chorioamnionitis and can be associated with an increased incidence of variable decelerations of the fetal heart rate due to cord compression. As per the Cochrane review June 2013, “amniotomy is not recommended as part of standard labour management and care”. ACOG also state in their committee opinion, Feb 2017: “For women with normally progressing labour and no evidence of fetal compromise, routine amniotomyneed not be undertaken unless required to facilitate monitoring”
The most important reasons for Amniotomy in Abruptio placenta:
1. To decrease intrauterine pressure, extravasation of blood in to the myometrium; and entry of thromboblastic substances in to the circulation
2.To enhance the progress of labor
Amniotomy can be done for facilitating labour,(as it is one of the surgical methods of induction and augmentation of labour).
In my view, doing Amniotomy in abruptio placenta can not add for preventing the degree of placental detachment and to decrease bleeding, but it can be helpful for initiation of labour this makes contraction of uterine muscles and to decrease bleeding,
- Badges
- Science topic