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How to pierce the amniotic sac. Bladder puncture before childbirth: indications, technique, reviews

Birth culture shapes practices and absorbs established rituals. There is now a popular movement from hospital birth to natural birth with a midwife; this comes as women and birth professionals re-evaluate some of the practices and interventions typical of hospital births. Amniotomy is a long-standing practice that is considered acceptable to reduce the length of labor. There are practically no publications about the effect of amniotomy on a child. This article explores the pros and cons of amniotomy, its role as a ritual for birth attendants, and its possible psychological effects on the baby.

Puncture of the membranes, or amniotomy, is a common, if not routine, practice in North American birth culture. Amniotomy is perceived as a useful technique to improve labor if labor becomes weak (1). During pregnancy, amniotic fluid is the baby's natural habitat. In the aquatic environment, the child masters his first movements, learns to breathe and swallow; all this prepares him for extrauterine life. During childbirth, amniotic fluid serves as a “safety cushion” for the baby during labor and during passage through the birth canal (2). The decision to pierce the bladder or, conversely, to wait for the natural rupture of the membranes is an important part of the birth plan. But since amniotomy has long been a common practice and is perceived as such even in circles of supporters of natural childbirth, this issue is often completely overlooked.
When a doctor or midwife decides to perform an amniotomy, the puncture is performed using a special hook-like instrument; the instrument is inserted into the birth canal, the membranes are picked up and pierced. As a result, it is assumed that the baby's head will put pressure on the dilating cervix, which will speed up the dilatation and the birth itself. Some studies (3-6) have found that amniotomy does not speed up labor too much, by an hour or two at most. Another study (7) suggests that amniotomy makes contractions more painful and interferes with maternal bonding immediately after birth, as many women feel that the natural course of labor has been disrupted (8). However, in some women, especially multiparous women, amniotomy reduces pain during the second stage of labor (9). There are virtually no contraindications to amniotomy in cases of fetal distress (10). Amniotomy is routinely used to access the fetal head when distress is suspected to confirm or refute this assumption (11). Puncture of the amniotic sac helps doctors examine the waters for the presence of meconium or blood. An amniotomy also allows monitor sensors to be attached directly to the baby's head if there are signs of distress. However, there is limited scientific evidence on the advisability of puncture of the bladder in the early stages of labor for the purpose of testing amniotic fluid when fetal distress is suspected. Early amniotomy can increase distress as it reduces the amount of water, which can lead to partial compression of the umbilical cord, reducing the supply of oxygen to the baby, often resulting in the need for an emergency caesarean section.

Spontaneous rupture of membranes
Spontaneous rupture of membranes before the onset of labor occurs in approximately 12% of cases (12). Premature rupture of water can create a critical situation, as there is a risk of umbilical cord prolapse. If the umbilical cord is pressed against the bones of the maternal pelvis, then there is a risk of fetal hypoxia. If labor proceeds without intervention, two thirds of women in labor with a healthy full-term pregnancy achieve good dilatation with an intact membrane (13). In an online obstetrics discussion, one midwife states that out of 300 uninduced labors without intervention, approximately 15% of women had an intact bladder until almost the end of the second stage of labor (14). One of the advantages of trusting nature and waiting for the spontaneous rupture of the membranes is that in this case the entire body of the child experiences only hydrostatic pressure and thereby receives protection during contractions, and the head does not change its configuration so much when passing through the pelvic bones (15 ). In addition, intact membranes reduce the chance of intrauterine infection.
The presence of meconium in the water does not necessarily mean an increased risk for the child. A full-term healthy baby can pass meconium in utero and even swallow it (16). Routine piercing of the bladder “just in case” is unwise and unethical (17, 18). On the other hand, some studies show that sometimes the presence of meconium in waters lowers their pH and then the child's APGAR score. Dr Marsden Wagner says: " Early bladder puncture as a routine procedure is not scientifically proven"(19). Amniotomy is a procedure that takes away part of the woman's birth experience and reinforces the subconscious belief that childbirth is unnatural (20).

Hormonal, chemical and physiological adaptation During childbirth, biochemical and hormonal adaptation of mother and child to each other occurs. The baby's pH level is influenced by the mother's pH and changes during labor (21). The pH value measures the acidity of the environment (acidic, neutral or alkaline) and determines the body's ability to get rid of waste products. A neutral pH of 7 is optimal, and the body works to maintain the pH at this level. Blood levels of catecholamines (adrenaline and norepinephrine) increase with the stress that accompanies normal labor and facilitate its progress (22). Optimal changes in hydrostatic pressure and pH (downwards) have a beneficial effect on the child’s cardiac activity and his cardiovascular system, preparing adaptation to extrauterine life. However, excess stress and anxiety raise hormone concentrations above the functional limit, which causes a decrease in pH and slows down labor. The second stage of labor is marked by changes in the pressure, position and position of the baby as it emerges from the aquatic environment, unbends and experiences gravity.
The level of anxiety and stress a woman experiences during childbirth depends on the birth culture of a given society. Women need accurate, unbiased and complete information so they can become active participants in their births. Women who do not have such information often behave passively and are afraid (23). The medical model of childbirth places more trust in machines than in the woman's body, and in this model there is a greater chance of interventions and unnecessary procedures. Ultimately, women are not involved at all in decision-making during childbirth, and all they can do is worry about what happens to them and their children.

Functions of amniotic fluid
There is a huge amount of research studying the chemical composition of amniotic fluid and its role in fetal ripening, as well as during childbirth. Although the hormonal, chemical and physiological mechanisms of adaptation of mother and child have been largely studied, the composition of amniotic fluid, its changes during the first and second stages of labor and how the baby uses amniotic fluid during such an important period for its development as childbirth are all this has not yet been fully studied (24). There is recent research about the carbohydrates, proteins, fats, electrolytes, enzymes, and hormones contained in amniotic fluid and how these relate to the baby's birth weight, onset of labor, and pregnancy (25).
The study suggests that early spontaneous rupture of the bladder may be related to the composition of the amniotic fluid. Another study indicates an increase in the concentration of prostaglandins in the amniotic fluid, suggesting that this increase triggers labor; this postulate contradicts the generally accepted view that prostaglandin concentrations increase as a consequence of the onset of labor (26). Other studies (27, 28) have examined the relationship between the presence of one of the parathyroid peptides (PTHrP) in amniotic fluid and its effect on labor and membrane function in late pregnancy (29). Another study (30) examines the role of interleukin-2 in the maternal-fetal immune system during early pregnancy and possibly during labor. Amniotic fluid, the baby's natural habitat, is taken for granted and manipulated without a full understanding of its function in childbirth. Research points to the need for more research into the chemical changes in amniotic fluid composition during labor and the impact of these changes on the baby's birth experience. Although everyone knows that amniotic fluid creates a protective layer for the baby during childbirth, puncture of the bladder continues to be a routine procedure. It is quite possible that there are still important, but not yet known to us, functions of the amniotic fluid that help the child adapt to new living conditions after birth.

Rituals surrounding birth The birth process is reflected in the culture of every society, and every culture uses various rituals to overcome the fear of the unknown. Childbirth can be unpredictable and carry elements of spiritual mystery. With the help of rituals, it is possible to avoid dangers and come to a good ending. Medical interventions, explains anthropology of childbirth researcher Robbie Davis-Floyd, give clinicians a psychological sense of control over the forces of nature and help relieve fears (31). The ritual includes symbolic objects (for example, a hook to puncture a bladder), ideas (for example, “amniotomy speeds up labor, which is good for the woman”) and actions, such as taking responsibility, explaining the meaning of the procedure. The imagery associated with amniotomy suggests forces that "release water and bring life" in the hands of the person delivering the baby. Such rituals convey an unconscious message that the woman feels rather than consciously perceives. The effect is unusually powerful. Hospital birth culture relies on technical symbols and procedures that attempt to transcend nature and individuals, as if to tell us that women's bodies are imperfect and that by using tools, doctors can control nature.
The obstetrician, who mobilizes the strength of the woman in labor, allows the natural process to develop independently; he understands that the woman’s body itself knows what to do (including the moment when it is time to be freed from amniotic fluid). This obstetrician accepts the fact that amniotic fluid helps dilate the cervix by pushing outward in the bladder, working like a wedge, using hydrostatic pressure to gently and evenly dilate the cervix (32). This is progress that mother and child achieve together, and not the hasty mechanical intensification of labor that is caused by amniotomy and which robs mother and child of the birth experience that rightfully belongs to them.

Types of influences and behavior
Childbirth is a biological milestone. Recent studies on the prenatal causes of adult disease note that more changes occur during the fetal and early postpartum periods than during any other age period. By examining the body's interaction with its environment during critical periods of development, the study concludes that the baby makes compensatory efforts in utero that increase its susceptibility to disease (33). The researchers also found that this type of reprogramming can be passed on from generation to generation. One cannot help but wonder whether the sudden change in the child’s living conditions when the bladder is punctured is the reason for the increase in the number of children with sensory integration difficulties, who then receive such neurological diagnoses as “hyperactivity and attention deficit disorder” (this diagnosis is more often given to boys of preschool and early school age ). There is a hypothesis that the consequences of puncturing the bladder in girls appear later, since the eggs in her body register this intervention at the level of cellular memory, and when she grows up and becomes pregnant, this will change the properties of the membranes in her children. From a prenatal and perinatal point of view, it is known that the way our heredity manifests itself and our personality traits depends, among other things, on the events surrounding conception, intrauterine life and birth (34). The influence of amniotomy on early psychological development, unfortunately, is not taken into account, while the ritual of puncturing the bladder in order to enhance labor is flourishing everywhere. Amniotomy is routinely used to hasten labor and to diagnose fetal distress, while the amniotomy itself promotes an irregular fetal heart rate (which is a sign of distress!) by reducing the amount of water in the uterus, thereby compressing the umbilical cord and reducing access of placental blood and oxygen to the baby. When the membranes are not touched, the baby experiences much less heart rhythm disturbances during labor. Part of the irregular heart rate is caused by labor itself, and this is natural (35). It is likely that amniotomy is used to diagnose fetal distress far more often than is actually necessary. Amniotomy forces the child to urgently adapt to the fact that his body is subjected to strong mechanical compression, and his head passes through the bony ring of the maternal pelvis without any protection. The sudden drop in hydrostatic pressure and unexpected compression of the head in the bone ring that the child experiences in connection with the amniotomy is perhaps too much stress on the child’s body. When the bladder is punctured, it experiences symbolic, physiological, and psychological loss (36). When the environment surrounding the child - the amniotic fluid that protects and nourishes it - is suddenly drained, the child instantly experiences a feeling of irrevocable loss. He passes through the birth canal on command, this is his first “loss of self.” " Stress Matrix” is a conceptual model that helps us better understand the shock and trauma that a child experiences during childbirth (37). As the shock physiologically increases, the changes may be unbearable and excessive for the child. Shock is a “sudden disturbance of psychological equilibrium” (38) and it certainly affects behavior. The body will remember the birth experience at the motor, vestibular, emotional and social levels (39). Some physical signs that are observed in infants who experience stress during birth are twitching of the limbs, muscle hyper- or hypotonicity, anger, fear, or lack of response to the environment (40). Their condition is often explained as infantile colic, ignoring the trauma they suffered. While these signs need to be noticed and accepted, working with them, if we do not want them to become entrenched and affect the development of the individual throughout life.
Young children are often diagnosed with attention deficit hyperactivity disorder (ADHD) when their nervous system aggressively resists stimuli received from the environment. Or the child may be unresponsive, non-communicative - this is a reaction of “escape” from environmental stimuli. Such children are at risk of developing depression in the future, as teachers and parents often incorrectly assess their condition. As they grow up in the modern high-tech world, these children often isolate themselves from society and immerse themselves in computer games, which, of course, negatively affects their behavior. Technology influences a child's social life from the very beginning; it has such a strong influence that stressed children subsequently choose to communicate with the world through technology. In the worst case, the latent desire for human contact with oneself and with others (and rage at one’s powerlessness to establish these contacts) is fueled in such children by electronic games that glorify violence and murder. Accordingly, these contacts are carried out in the form of aggression directed at oneself or at others.

Psychology of early development
Amniotomy is rarely, if ever, mentioned as an intervention that has the potential to be psychologically damaging to the mother or baby. A sudden change in intrauterine conditions is stressful for the baby, and the mother may perceive amniotomy as a gross intrusion into the birth process. Without a doubt, a baby can be born in shock and no one will notice, so routine has this procedure become in our birth culture. One of the principles of early developmental psychology related to the development of human potential refers us to the capabilities of the infant, which include intellectual, sensory and energetic adaptation. It seems quite clear that the decision to perform an amniotomy will have many consequences for the child. From the very beginning of its nascent life, the baby is influenced by the thoughts and feelings of its mother, and during childbirth it is also influenced by the thoughts and feelings of those delivering the birth. The foundations for the growth and development of a child are laid during pregnancy and childbirth. He reacts to the sensations and emotions of his mother and her environment, and this affects his development. The behavior and thoughts of others during childbirth can have a lasting impact on him. Amniotomy means that an outsider appears with an instrument that grossly disrupts the child’s environment and causes sudden changes for which the child is completely unprepared. This is an invasive procedure that violates the child’s innate need for belonging, safety, and care. Puncture of the bladder makes contractions more painful for both mother and baby, and can disrupt their telepathic connection. The sudden changes caused by the rupture of water cause the release of stress hormones that affect the sympathetic nervous system, and this process can be reproduced whenever the child finds himself in a stressful situation throughout his life.

Strategies for solving the problem
To overcome the widespread use of amniotomy, it is necessary to open our minds to unfamiliar statements and break through stereotypes. We are moving forward because educational texts already indicate that amniotomy is not useful in reducing the length of labor (41, 42). It is also recognized that amniotomy “just in case” to assess the condition of the fetus is not justified. People working with children need to be educated and trained to recognize the symptoms of shock in infants, children and parents to facilitate recovery from its effects. It will take passionate people to bring this information to every child and every parent personally, and those who work with these children and parents will need many people to organize conferences and publish credible research. We need an environment that gives us a sense of security. It will be able to heal the trauma that we received in the early stages of development. As labor and delivery workers, we must slow down and reduce our activity to allow the baby's body to engage in self-regulation and adaptive mechanisms (43). Slowing down helps us establish contact." here and now” and form meaningful relationships. A calm state increases our empathy for infants and allows us to recognize their unique bodily manifestations of trauma.
We have a long way ahead - we have to create and maintain a gentler childbirth culture. This requires educating the public, pregnant women, childbirth educators and policy makers about the need for changes in childbirth to empower women. We must recognize the value of the art of midwifery and support it everywhere, as it makes our society better.

Verna Oberg received her master's degree from the Faculty of Prenatal and Perinatal Psychology of the Institute in Santa Barbara in 2010. She works as an early childhood consultant, tracking the developmental stages of newborns and young children, promoting the formation of parent-child attachments, and advocating that newborns and young children are full human beings with consciousness and feelings. Verna expresses her deep gratitude to Dr. Jean Rhodes for her assistance in writing this article.

Literature: 1. Goer, H. 1999. The Thinking Woman’s Guide to a Better Birth. New York: The Berkeley Publishing Group. 2. Simkin, P. 2001. The Birth Partner, 2nd ed. Boston: The Harvard Common Press. 3. Davis-Floyd, R., and C.F. Sargent, eds. 1997. Childbirth and Authoritative Knowledge: Cross-cultural Perspectives. 3rd ed. Berkeley and San Francisco: University of California Press. 4. Enkin, M., et al. 2000. A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. New York: Oxford Press. 5. May, K.A., and L.P. Mahlmeister, eds. 1994. Maternal & Neonatal Nursing, 3rd ed. Pennsylvania: J. B. Lippincott Company. 6. Wagner, M. 2006. Born in the USA. Berkley, CA: University of California Press. 7. Robson, K. M., and R. Kumar. 1980. Delayed Onset of Maternal Affection. Br J Psychiatry 136:347–53. 8. Mayes, M. 1996. Mayes Midwifery, 12th ed. Oxford: Bailliere Tindall. 9. Brenda. 2001. Artificial rupture of membranes: breaking the waters. Message posted to UK Midwifery Archives at http://www.radmid.demon.co.uk/arm.htm. Accessed 2 Jun 2010. 10. See Reference 6. 11. See Reference 4. 12. Childbirth Graphics. 1993. Directional Learning. Wasco, Texas: A Division of WRS Group, Inc. 13. See Reference 6. 14. Rehana. 2001. Artificial rupture of membranes: breaking the waters. Message posted to UK Midwifery Archives at www.radmid.demon.co.uk/arm.htm. Accessed 2 Jun 2010. 15. See Reference 2. 16. See Reference 5. 17. Ibid. 18. See Reference 6. 19. See Reference 3. 20. Davis-Floyd, R. 1987. Hospital birth routines as rituals: Society’s messages to American women. J Prenat Perinat Psychol Health 1(4): 276–96. 21. See Reference 5. 22. Ibid. 23. McKay, S. 1991. Shared power: The essence of humanized childbirth. J Prenat Perinat Psychol Health 5(4): 283–95. 24. See Reference 5. 25. Gotsch, F., et al. 2008. Evidence of the involvement of caspase-1 under physiologic and pathologic cellular stress during human pregnancy: a link between the inflammasome and parturition. J Matern Fetal Neonatal Med 21(9), 605-16. 26. Lee, S. E., et al. 2008. Amniotic fluid prostaglandin concentrations increase before the onset of spontaneous labor at term. J Matern Fetal Neonatal Med 21(2): 89–94. 27. Ferguson II, J.E., et al. 1992. Abundant expression of parathyroid hormone-related protein in human amnion and its association with labor. Proc Nati Acad Sci USA. 89: 8384-88. 28. Wlodek, et al. 1992. Abundant expression of parathyroid hormone-related protein in human amnion and its association with labor. Reprod Fertil Dev 7(6): 1560–13. 29. Ibid. 30. Zicaria, A., et al. 1995. Interleukin-2 in human amniotic fluid during pregnancy and parturition: implications for prostaglandin E2 release by fetal membranes. J Reprod Immunol 29(3): 197–208. 31. Davis-Floyd, R. 1990. Obstetric rituals and cultural anomalies: Part I. J Prenat Perinal Psychol Health 4(3): 193-211. 32. See Reference 12. 33. Nijland, M.J., S.P. Ford and P.W. Nathanielsz. 2008. Prenatal origins of adult disease. Curr Opin Obstet Gynecol 20(2): 132–38. 34. Odent, M. 2008. New Criteria to Evaluate the Practices of Midwifery and Obstetrics. J Prenat Perinat Psychol Health 22(3): 181–89. 35. Barrett, J. F. R., et al. 1992. Randomized trial of amniotomy versus the intention to leave membranes intact until second stage Br J Obstet Gynecol 94: 512-17. 36. Emerson, W.R. 1997. Birth Trauma: The Psychological Effects of Obstetrical Interventions. Petaluma, CA: Emerson Seminars. 37. Castellino, R. 2005. The Stress Matrix: Implications for Prenatal and Birth Therapy. Santa Barbara, CA: Castellino Prenatal and Birth Therapy Training. 38. Ibid. 39. Perry, B. 2009. On the brain: How we remember. CYC-Online (122) http://www.cyc.net.org/cyc-online/cyconline-apr2009-perry.html. Accessed 14 Apr 2009. 40. See Reference 37. 41. See Reference 3. 42. See Reference 6. 43. Glenn, M. 2002. The use of body-centered psychotherapy in working with prenatal and perinatal imprints within a group. Paper presented at the Third United States Association of Body Psychotherapy Congress and Emergence in Body Psychotherapy. http://www.sbgi.edu/cont_edu/glenn/glennceuя.html. Accessed 30 Sep 2009.

Artificial opening of the membranes, or amniotomy, often causes some concerns among women expecting the birth of a baby. Not every patient in the maternity ward understands the meaning of this procedure: why open the amniotic sac if the waters break on their own during labor? Let's try to reassure expectant mothers and answer this question.

Based on the objectives and timing of the procedure, amniotomy is divided into three types. Premature amniotomy is used to induce labor. During childbirth, there may be a need for early or late amniotomy.

Premature amniotomy

A so-called premature amniotomy is one way to end a pregnancy before spontaneous labor begins. The use of amniotomy for the purpose of inducing labor means the immediate onset of labor: once the membranes are opened, there is no turning back. During pregnancy, the obstetrician is forced to induce labor most often ahead of schedule, at different stages of pregnancy, including in the last week before the onset of spontaneous labor on the part of the mother and fetus - this induced labor. Indications for amniotomy may include:

severe form of late pregnancy, when edema, high blood pressure, changes in urine tests cannot be corrected with medications, the condition of the mother and fetus remains unsatisfactory, despite treatment;
maternal diseases (cardiovascular pathology, diabetes mellitus, liver disease, chronic lung diseases, etc.);
post-term pregnancy;
acute increasing polyhydramnios with symptoms of cardiopulmonary failure in a pregnant woman;
deterioration of the fetus for various reasons.

In other cases, premature amniotomy for the purpose of inducing labor is performed at term without medical indications, when the fetus has reached full maturity and there are no signs of spontaneous labor. Such preventive induction of labor with amniotomy during normal pregnancy is called programmed birth.

One of the possible conditions for the use of amniotomy for the purpose of inducing labor is the presence in a woman of optimally expressed signs of readiness for childbirth. In 70-80% of cases with full-term pregnancy, when the cervix is “ripe” (it is short, soft, slightly open, located in the center of the small pelvis), labor can be induced by amniotomy alone without the use of medications that stimulate uterine contractions (prostaglandins).

Premature amniotomy in the absence or insufficient expression of signs of readiness for childbirth does not always lead to the development of adequate labor - as a rule, labor is protracted, requires drug-assisted labor, there is a danger of an increase in the anhydrous interval, infection of the birth canal and fetus, asphyxia (cessation of oxygen access ) and birth trauma in the fetus.

Widespread in the 90s, programmed childbirth is now practiced less frequently due not only to possible complications (anomaly of head insertion, impaired contractility of the uterus, bleeding after childbirth), but primarily due to the tendency for the natural course of pregnancy and childbirth.

Early amniotomy

During childbirth, there may be a need for an early amniotomy - it is performed when the opening of the cervix is still small. Let us list the indications for its use.

Cases when acceleration of labor is necessary:
- with weakness of labor(there is a close relationship between the low level of uterine contractility and the slow progress of labor at any stage of the first and second periods). Early opening of the membranes leads to increased production and release of prostaglandins - special physiologically active substances. Prostaglandins cause uterine contractions and also contribute to increased uterine activity during labor;
- with a functionally defective amniotic sac(“flat” or “flaccid”). The usual volume of anterior waters located in front of the fetal head is up to 200 ml. If there is little anterior water, which happens with oligohydramnios, the membranes are stretched on the fetal head (“flat amniotic sac”). A decrease in the volume of amniotic fluid in most cases is associated with the presence of malformations of the fetal urinary system; during postmaturity, a decrease in the amount of amniotic fluid to 50-100 ml is also observed. In the case of leakage of water due to a lateral tear of the fetal bladder, the membranes hang “sluggishly”. Such a bubble (“flat” or “flaccid”) does not fulfill its function as a “hydraulic wedge” in dilation of the cervix, which is also the reason for the slow progress of labor;
- with polyhydramnios due to the large amount of amniotic fluid, the uterus is overstretched, its contractions are weak. More often than half of the cases, the causes of polyhydramnios remain unclear. Polyhydramnios is not only a disease of the amnion (fetal membranes) - it can be associated with maternal disease (diabetes mellitus, inflammatory diseases of the genitourinary system), with the development of fetal diseases (hemolytic disease or the presence of various defects and chromosomal abnormalities). The infectious nature of polyhydramnios is possible when the mother is ill with syphilis, influenza, etc. Early amniotomy for polyhydramnios reduces the volume of the uterus, as a result of which uterine contractions become stronger.
Use of amniotomy for therapeutic purposes on the day of achieving:
- hemostatic (hemostatic) effect during bleeding associated with partial presentation or low attachment of the placenta, that is, in cases where the placenta is attached close to the exit of the uterus. Placental tissue is not capable of stretching; during contractions, the membranes pull the edge of the placenta with them. As a result, a section of the placenta is torn away from the presenting wall of the uterus, which leads to disruption of the integrity of the vessels of the placental area and bleeding. After amniotomy, the wall of the lower segment of the uterus, along with the membranes and placenta, moves upward, the placenta no longer exfoliates, so bleeding stops. The presenting part of the fetus descending into the pelvic inlet presses the bleeding part of the placenta to the walls of the uterus and to the walls of the pelvis and thereby also helps to stop the bleeding;
- hypotensive effect- lowering blood pressure during labor in women in labor with late toxicosis (preeclampsia), as well as with hypertension. In this case, the reduced uterus after amniotomy puts less pressure on large vessels, and blood pressure decreases.
The presence of indications from the fetus, if additional examination methods during labor reveal signs that threaten the life of the fetus:
- detection of green amniotic fluid(with an admixture of meconium) during amnioscopy, examining amniotic fluid through the membranes with an optical device - this indicates that the fetus is experiencing a lack of oxygen;
- disruption of blood flow in blood vessels umbilical cord according to Doppler measurements;
- pathological type of fetal cardiotocogram curves, which does not require a caesarean section.

Delayed amniotomy

Sometimes, despite the complete opening of the uterine pharynx, the amniotic sac remains intact and the period of expulsion occurs with the anterior waters not receding. The reasons for this pathology may be the following:

excessive density of the membranes prevents their timely opening under the pressure of intrauterine pressure;
excessive elasticity of the membranes leads to the fact that the fetal bladder becomes thinner and fills a significant part of the vagina, and sometimes comes out of the vagina;
with a “flat” bladder with a small or negligible amount of anterior water, the membranes are stretched on the fetal head and cannot open on their own,

In these cases, the period of expulsion (the second, pushing period of labor) is prolonged. A non-opening amniotic sac interferes with the insertion of the head into the pelvis and pulls the overlying sections of the membranes along with it, the placenta begins to peel off from its bed - bloody discharge appears. In rare cases, a child may be born in the amniotic sac with a detached placenta (people say about such cases: “born in a shirt”), usually in a state of asphyxia. In order to prevent such complications, they resort to belated amniotomy already in the second stage of labor. After the opening of the membranes and the release of water, labor intensifies, and forward movements of the fetus begin along the birth canal.

Carrying out amniotomy. Progress of the procedure

After treating the external genitalia, the doctor inserts the index and middle finger into the uterine os of the cervix until it comes into contact with the cervix. During childbirth, this is usually done at the height of the contraction with the greatest tension in the fetal bladder during manual reception by pressing on the bladder from bottom to top or using an instrument with a sharp hook at the end, the membranes are opened, after which the obstetrician uses his fingers to spread the membranes apart. The manipulation is painless, because there are no nerve endings in the membranes.

At the time of amniotomy, the doctor evaluates the color of the water: this sign can be used to judge the condition of the fetus. Normally, the waters are clear, but if the waters are green, this indicates that the baby is experiencing a lack of oxygen, which, in turn, leads to relaxation of the intestinal obturator muscles, and the original feces mixes with the amniotic fluid. Yellow amniotic fluid indicates a disease that develops in the fetus when the blood of the mother and fetus is incompatible according to Rhesus or blood group.

Fortunately, serious complications from amniotomy are rare. However, this manipulation may be accompanied by undesirable consequences: pain and discomfort, infection, deterioration of the fetal heartbeat, prolapse of the umbilical cord or small parts of the fetus (arms or legs), as well as bleeding from the fetal vessels in the membranes, from the cervix or from the placenta insertion (partial) .

Opening the amniotic sac is used only when necessary; the manipulation is carried out with the consent of the woman. Since, as already mentioned, the amniotic sac plays a protective role, including protecting the fetus and uterus from infection, no more than a day should pass from the moment the amniotic fluid is released until the baby is born. Currently, time restrictions have become even more stringent, and it is believed that a more reliable protection against infection of the fetus and uterus is a water-free period of no more than 12 hours.

Why is the amniotic sac needed?
The importance of amniotic fluid is great. They prevent the formation of adhesions between the membranes and the fetus; protect the umbilical cord and placenta (baby place) from pressure from large parts of the fetus and uterine contractions during childbirth; make fetal movements possible and easy, which are necessary for its proper development; protect the fetus from shocks and bruises from the outside; influence the position and articulation of the fetus - the relative position of the limbs and torso; make fetal movements less noticeable for the pregnant woman; the integrity of the fetal bladder protects against infection, promotes the opening of the uterine pharynx during childbirth - during each contraction, the fetal bladder wedges into the cervical canal, facilitating the opening of the cervix. Normally, the opening of the membranes occurs when the cervix is more than 6 cm dilated.

Lyudmila Petrova,
Obstetrician-gynecologist of the highest qualification
categories, head of the maternity department
maternity hospital No. 16, St. Petersburg
Article provided by the magazine "Pregnancy. From conception to childbirth" N 03 2007

In what cases is the amniotic sac punctured, and what could be the consequences?

What is amniotomy

In the womb, the baby is surrounded by amniotic or amniotic fluid, which is located inside a dense amniotic sac. Artificial opening of the membranes is called amniotomy. During labor, when the bladder does not rupture on its own, it is opened by an obstetrician.

What happens to the amniotic sac during childbirth

With the onset of labor, the uterus opens so that the fetus can move along the birth canal. At the moment of maximum dilatation of the cervix, the amniotic sac ruptures and the baby comes out with the waters. This should ideally be the case, but it doesn’t always work out. Sometimes the membrane ruptures prematurely or does not break its integrity for a long time.

Indications for amniotomy

The amniotic sac is artificially opened for the following reasons:

Severe form of gestosis.
All deadlines for the onset of labor have passed.
Premature placental abruption.
Freezing of the fetus in late gestation.
Exacerbation of severe chronic diseases in a pregnant woman.
Prolonged labor.
The presence of Rh conflict between the mother and the unborn child.
The uterus opened, but the bladder did not burst on its own.
Weak contractions during childbirth.
Incorrect location of the placenta (low).
Excessive amount of amniotic fluid.
Insufficient amount of amniotic fluid inside the bladder.
The presence of two or more embryos.
A sharp increase in blood pressure in a woman in labor.

Sometimes the amniotic sac is opened to speed up labor when the uterus is dilated at least 5 cm.

How is amniotomy performed?

Typically, the opening of the amniotic sac is carried out according to the following scheme:

The expectant mother is given an injection of an antispasmodic, for example, Papaverine or another similar drug.
The woman is placed on a special gynecological chair.
The doctor inserts an instrument that looks like a hook.
After the integrity of the fetal bladder is broken, the woman is observed for about 30 minutes, listening to the heartbeat of the unborn child.

The main thing when performing an amniotomy is that the hole in the amniotic sac is small and the fluid flows out gradually, otherwise the umbilical cord or the baby’s limbs may come out along with the water.

Risks and consequences of puncturing the amniotic sac

If the procedure is carried out correctly, the risks are reduced to zero, but sometimes complications are possible in the form of:

Infections.
Disturbances in labor - too fast or too slow.
Deterioration of the baby's condition.
Loss of the umbilical cord or some parts of the baby.
Heavy bleeding.

Such violations occur extremely rarely and are rather the exception.

Does the woman feel pain during the procedure?

Since the amniotic sac is not closely connected to the woman’s body and has no nerve endings, there is no pain from a violation of its integrity. All that a woman feels is the leakage of fluid and the beginning of labor.

Scratches in a child after puncture of the amniotic sac

If the procedure is carried out according to all the rules, amniotomy cannot harm the child, but there are cases when scratches remain on the baby’s head. This happens when:

Too little amniotic fluid.
The baby's head is very close to the exit and when piercing the bubble, the instrument may touch it.
The water broke earlier, but the doctor did not pay attention.

In general, amniotomy is not a dangerous procedure and is widely used these days to speed up labor, even when there is no particular need for it. However, if there are wounds or scratches on the child’s body, consult a doctor for explanations and advice.

Ovchinnikova Olga
Obstetrician-gynecologist. Medical clinic "Gazprommedservice".

Many expectant mothers, even those who have never been to the maternity ward, have heard about such a procedure as amniotomy - the opening of the fetal bladder. Someone may have a logical question: why rush things and “help” the amniotic fluid flow out if this will happen by itself sooner or later? It turns out that this simple manipulation helps to avoid many troubles regarding the health of mother and baby.

A short excursion into physiology

Normally, labor begins with contractions. Contractions help open the cervix and move the fetus through the birth canal. The cervix smooths and opens due to contraction of the uterine muscles. The dilation of the cervix is also facilitated by the amniotic sac. During contractions, the uterus begins to actively contract, as a result of which intrauterine pressure increases, the amniotic sac tightens, and amniotic fluid rushes down. The lower pole of the bladder penetrates into the internal one and helps dilate the cervix.

Cervical dilatation occurs differently in primiparous and multiparous women. In first-time mothers, the internal uterine os opens first, the cervix smoothes and thins, and then the external uterine os opens. In multiparous women, the external uterine os is slightly open at the end of pregnancy. During childbirth, the opening of the internal and external pharynx, as well as the smoothing of the cervix, occur simultaneously.

The degree of cervical dilatation is determined in centimeters during vaginal examination. Dilatation of the cervix by 11–12 cm, at which its edges cannot be determined, is considered complete.

The first stage of labor is characterized by the occurrence of regular contractions and the advancement of the presenting part of the fetus (the part that first passes through the birth canal, and before birth is facing the cervix) along the birth canal. Most often, the presenting part of the fetus is its head. During normal labor, the waters break on their own. Typically, the membranes rupture when the cervix is fully or almost fully dilated, and the anterior amniotic fluid (they are so called because they are in front of the presenting part of the fetus) is poured out. Rupture of the membranes is a painless process, since there are no nerve endings in the membranes.

In 10% of women, the water breaks before labor begins. When amniotic fluid ruptures, about 200 ml of liquid is released at once, that is, approximately a glass. This cannot be ignored. But it also happens that the fetal bladder does not open directly near the exit from the cervix, but higher up, where it comes into contact with the wall of the uterus. In this case, water leaks from the genital tract drop by drop, and the watery spot on the underwear gradually increases.
When labor begins with the rupture of water, they speak of premature rupture of amniotic fluid. The release of water after the onset of labor, but with incomplete dilatation of the cervix, is called early release of water.

With premature rupture of amniotic fluid, the course of labor depends to a large extent on whether the woman’s body is ready for childbirth, and with early rupture of water - on the regularity and strength of labor and the location of the presenting part of the fetus. If a pregnant woman’s body is ready for childbirth, premature rupture of amniotic fluid will not become an obstacle to its normal course. Typically, labor in such cases develops 5–6 hours after the rupture of the membranes, but the first contractions may appear immediately after the release of water. However, often premature or early rupture of amniotic fluid leads to weakness of labor, protracted labor, fetal hypoxia, and inflammatory processes of the membranes.

Therefore, if your water breaks outside the maternity hospital, even in the absence of contractions, you must go to the maternity hospital immediately. In this case, it is necessary to remember the time of rupture of amniotic fluid and inform the doctor about it. Pay attention to the color and smell of amniotic fluid. Usually the waters are clear or slightly pink, odorless. A slightly greenish, dark brown or black color of the amniotic fluid indicates the release of meconium (original feces) from the baby’s intestines, which means that he is experiencing oxygen starvation and needs help. Amniotic fluid is colored differently, depending on the amount of discharge. If contractions do not begin soon after the water breaks, doctors resort to induction of labor.

It is not known exactly what causes early or premature rupture of water. However, in women who were prepared for childbirth, such cases are less common. This is largely due to the woman’s emotional state, her ability to relax and her general attitude towards a successful birth.
Very rarely, the amniotic sac does not rupture at all, and the baby is born covered with membranes. People say about such a baby that he was “born in a shirt.”

Indications for amniotomy

It happens that when the cervix is fully dilated, the fetal bladder remains intact. This may be due to its excessive density or elasticity, as well as a small amount of frontal water. Such births are characterized by a protracted period of expulsion of the fetus, slow progress of the presenting part, and the appearance of bloody discharge from the genital tract. There is a danger of premature placental abruption and fetal hypoxia. In this case, an artificial opening of the fetal bladder is performed for medical reasons.

Like any manipulation in medicine, amniotomy must be justified, since the amniotic sac performs certain functions: it protects the child from infection and makes childbirth less unpleasant, soft and natural. It allows the cervix to open smoothly and gradually. In addition, if an amniotomy is performed while the baby is in a high position, there is a risk of umbilical cord prolapse, which leads to serious complications.

Indications for amniotomy are:
Post-term pregnancy. This refers to the so-called true post-term pregnancy, when certain changes occur in the placenta, due to which it can no longer provide the required amount of oxygen to the fetus. Thus, the fetus is in a state of hypoxia (lack of oxygen). In this situation, amniotomy can serve as a way to stimulate labor.
Pregnancy gestosis. This condition is a syndrome in which the functioning of many organs and systems is disrupted. Develops as a result of pregnancy. Its main symptoms are: pathological weight gain, edema, arterial hypertension, proteinuria (protein in the urine), seizures and/or coma. Gestosis in pregnant women is not an independent disease; This is a syndrome caused by the inability of the mother’s body’s adaptive systems to meet the needs of the developing fetus.
Rhesus conflict pregnancy. Such a pregnancy can also occur with complications. If vaginal delivery is possible, amniotomy can be a means of stimulation.
Preliminary period. This is the name given to irregular and ineffective prenatal contractions that do not lead to dilatation of the cervix, sometimes lasting several days. They can also become an indication for opening the amniotic sac.
Weakness of labor. It is characterized by the presence of contractions that are weak in strength, short in duration and rare in frequency. During such contractions, the opening of the cervix and the movement of the fetus through the birth canal occurs slowly.
Increased density of membranes. When the cervix is fully or almost fully dilated, the membranes cannot rupture on their own; amniotomy is the only way to prevent the birth of a baby “in a shirt.” This situation is unfavorable because the baby cannot take a breath immediately after birth.
Polyhydramnios. The opening of the amniotic sac in cases of polyhydramnios is carried out because a large amount of amniotic fluid can cause weakness in labor, as well as prolapse of the umbilical cord when amniotic fluid is discharged on its own.
Flat amniotic sac. Sometimes (most often with oligohydramnios) there is very little or no anterior water in the amniotic sac - then the membranes become stretched on the fetal head, which can lead to abnormalities in labor and premature placental abruption.
Low location of the placenta. The onset of labor can provoke premature detachment, which is extremely dangerous for the fetus, since it stops the delivery of oxygen to the fetus. During amniotomy, the waters are poured out, and the fetal head presses the edge of the placenta, thus preventing its detachment.
Various pathological conditions associated with high blood pressure and impaired blood circulation - gestosis, hypertension, heart and kidney disease, etc. Amniotomy allows you to quickly reduce the size of the uterus due to the rupture of amniotic fluid. As a result, the pressure of the uterus on nearby large vessels is reduced, blood circulation improves, and blood pressure decreases.

Progress of the procedure

The opening of the amniotic sac is performed during a vaginal examination using a sterile hook-like instrument. This procedure is completely painless, since the amniotic sac is devoid of pain receptors. It is assumed that when the membranes are opened, the anterior waters pour out, and the fetal head presses on the cervix, mechanically irritating the mother’s birth canal.

Amniotomy is a painless procedure that, as a rule, proceeds without complications and does not affect the child’s condition in any way. If, despite the amniotomy, labor does not resume, the likelihood of infection of the uterus and fetus increases, which is now not protected by the membranes and amniotic fluid. In such situations, doctors resort to stimulation of labor, and if it is ineffective and in the presence of other indications, they decide on delivery by cesarean section.

taken here:

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Approximately 7-10% of women in the maternity hospital undergo an amniotomy. Pregnant women who hear about this manipulation for the first time are frightened by it. Natural questions arise: amniotomy, what is it? Is it dangerous for the child? Not knowing why this procedure is performed, many expectant mothers are negative in advance. Information about the indications, contraindications and possible consequences of amniotomy will help you understand whether your fears are justified.

Amniotomy is an obstetric operation (translated as amnion - water membrane, tomie - dissection), the essence of which is to open the amniotic sac. The amniotic sac and the amniotic fluid that fills it play an important role in the normal intrauterine development of the child. During pregnancy, they protect the fetus from external mechanical influences and microbes.

After opening or natural rupture of the amnion, the uterus receives a signal to expel the fetus. As a result, contractions begin and the baby is born.

The manipulation of opening the amniotic sac is carried out with a special tool in the form of a hook at the moment when the bubble is most pronounced, so as not to damage the soft tissues of the baby’s head. Amniotomy is a completely painless operation, since there are no nerve endings on the membranes.

Types of amniotomy

Opening the amniotic sac, depending on the moment of the manipulation, is divided into four types:

prenatal (premature) amniotomy - performed before the onset of labor for the purpose of inducing labor;
early amniotomy – performed when the cervix is dilated to 7 cm;
timely amniotomy - the amniotic sac is opened at a cervical opening of 8-10 cm;
belated amniotomy - opening of the amniotic sac on the birth table, when the head has already dropped to the bottom of the pelvis.

When is it needed?

Basically, an amniotomy is performed during childbirth if the fetal sac has not ruptured on its own. But there are situations in which urgent delivery is necessary. In this case, puncture of the amniotic sac is performed even in the absence of contractions. Indications for it are:

Post-term pregnancy. A normal pregnancy lasts up to 40 weeks, but if the period is 41 weeks or more, the question arises about the need to induce labor. During a post-term pregnancy, the placenta “grows old” and can no longer perform its functions in full. Accordingly, this affects the child - he begins to experience a lack of oxygen. If there is a “mature” cervix (the cervix is soft, shortened, and allows one finger to pass), the woman’s consent and there are no indications for a cesarean section at the moment, a bladder puncture is performed to induce labor. In this case, the fetal head is pressed against the entrance to the pelvis, and the volume of the uterus decreases slightly, which contributes to the occurrence of contractions.
Pathological preliminary period. The pathological preliminary period is characterized by long preparatory contractions for several days, which do not develop into normal labor and tire the woman. During this period, the child experiences intrauterine hypoxia, which resolves the issue in favor of prenatal amniotomy.
Rhesus conflict pregnancy. When the mother's blood is negative and the fetus's is positive, a conflict arises regarding the Rh factor. At the same time, antibodies accumulate in the blood of the pregnant woman, which destroy the red blood cells of the fetus. If the antibody titer increases and signs of hemolytic disease of the fetus appear, urgent delivery is necessary. In this case, the amniotic sac is also punctured without contractions.
Preeclampsia. This is a serious disease of pregnant women, characterized by the occurrence of edema, the appearance of protein in the urine and increased blood pressure. In severe cases, preeclampsia and eclampsia are added. Preeclampsia has a negative effect on the condition of the woman and the fetus, which is an indication for amniotomy.

If labor has already begun, with certain characteristics of the expectant mother’s body, you will also have to resort to opening the fetal sac. Indications for which amniotomy is performed during childbirth:

Flat amniotic sac. The amount of anterior water is approximately 200 ml. A flat amniotic sac is practically the absence of anterior waters (5-6 ml), and the membranes are stretched on the baby’s head, which prevents normal labor and can lead to a slowdown and cessation of contractions.
Weakness of generic forces. In the case of weak, short and unproductive contractions, the dilation of the cervix and the advancement of the fetal head are suspended. Since amniotic fluid contains prostaglandins that stimulate cervical dilatation, early amniotomy is performed to enhance labor. After the procedure, the woman in labor is observed for 2 hours and, if there is no effect, the issue of birth stimulation with oxytocin is decided.
Low location of the placenta. With this position of the placenta, as a result of contractions, its detachment and bleeding may begin. After amniotomy, the fetal head is pressed against the pelvic inlet, thereby preventing bleeding.
Polyhydramnios. The uterus, overstretched by a large amount of water, cannot contract correctly, which leads to weakness of labor. The need for early amniotomy is also explained by the fact that its implementation reduces the risk of prolapse of umbilical cord loops or small parts of the fetus during spontaneous rupture of water.
High blood pressure. Preeclampsia, hypertension, heart and kidney diseases are accompanied by high blood pressure, which negatively affects the course of labor and the condition of the fetus. When the amniotic sac is opened, the uterus, having decreased in volume, frees nearby vessels and the pressure decreases.
Increased density of the amniotic sac. Sometimes the membranes are so strong that they cannot open on their own even with the cervix fully dilated. If an amniotomy is not performed, the baby may be born in the amniotic sac with water and all membranes (in the shirt), where it can suffocate. This situation can also lead to premature placental abruption and bleeding.

Are there any contraindications?

Although in many situations opening the amniotic sac facilitates the birth of a child, there are contraindications to this procedure. Amniotomy during childbirth is not performed if:

a pregnant woman has genital herpes in the acute stage;
the fetus is in a leg, pelvic, oblique or transverse presentation;
the placenta is too low;
umbilical cord loops do not allow the procedure to be performed;
Natural childbirth is prohibited for a woman for one reason or another.

In turn, contraindications to natural delivery are the incorrect location of the fetus and placenta, the presence of scars on the uterus and abnormalities in the structure of the birth canal. They are also prohibited in case of severe symphysitis, heart pathologies and other diseases of the mother that pose a threat to her health and life or interfere with the normal birth process.

Technique

Although amniotomy is an operation, the presence of a surgeon and anesthesiologist is not required. The opening of the amniotic sac (puncture) is performed by an obstetrician during a vaginal examination of the woman in labor. The manipulation is absolutely painless and takes a few minutes. A puncture during pregnancy is performed with a sterile plastic instrument that resembles a hook.

The procedure consists of the following steps:

Before amniotomy, the woman in labor is given No-shpu or another antispasmodic drug. After its action begins, the woman should lie down on the gynecological chair.
Then, the doctor, wearing sterile gloves, dilates the woman's vagina and inserts the instrument. Having hooked the amniotic sac with a plastic hook, the obstetrician pulls it out until the membrane is torn. After this, an outpouring of water occurs.
At the end of the procedure, the woman needs to remain in a horizontal position for about half an hour. During this time, the child’s condition is monitored using special sensors.

The amniotic sac is opened outside the contraction, which ensures the safety and convenience of the procedure. If a woman is diagnosed with polyhydramnios, the water is released slowly to prevent prolapse of the umbilical cord loops or fetal limbs into the vagina.

Prerequisites

Following a number of rules allows you to avoid complications during manipulation. Mandatory conditions without which amniotomy is not performed include:

cephalic presentation of the fetus;
birth not earlier than 38 weeks;
no contraindications to natural delivery;
pregnancy with one fetus;
readiness of the birth canal.

The most important indicator is the maturity of the cervix. To perform an amniotomy, it must correspond to 6 points on the Bishop scale - be smoothed, shortened, soft, and allow 1-2 fingers through.

Complications and consequences

When performed correctly, amniotomy is a safe procedure. But, in rare cases, childbirth after puncture of the bladder can be complicated. Among the undesirable consequences of amniotomy are:

Prolapse of the umbilical cord or fetal limbs into the vagina of the woman in labor.
Injury to the vessels of the umbilical cord during its membrane attachment, which may be accompanied by massive blood loss.
Deterioration of uteroplacental blood flow after manipulation.
Changes in fetal heart rate.

There is also a risk that opening the amniotic sac will not give the desired result and labor will not become active enough. In this case, the use of drugs that stimulate contractions or a cesarean section will be required, since a prolonged stay of the child without water threatens his life and health.