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Contractions after puncture of amniotic sac. Rupture or puncture? When and why is the amniotic sac opened?

Normally, the water should break on its own during labor. But sometimes it happens that the contractions have already intensified and it’s getting close to pushing, but the water still doesn’t break. In this case, the doctor decides whether to puncture the bladder.

Contractions help the cervix open and the baby move through the birth canal. The cervix smoothes out and then dilates, all due to contraction of the muscles of the uterus. But the opening also occurs due to the amniotic sac: contractions cause the uterus to actively contract, the intrauterine pressure increases and the amniotic sac tenses, while the amniotic fluid rushes down, the lower part of the amniotic sac enters the uterine os (internal) and promotes the dilatation of the cervix.

Usually the bladder ruptures when the cervix is ​​fully or almost fully dilated. The anterior waters flow out first - they are located in front of the presenting part (most often this is the head). When the amniotic sac ruptures, the woman does not feel anything because there are no nerve endings in it.

For some, about 10% of women in labor, their waters break before labor begins. It’s hard not to notice, because about a glass (200 ml) of liquid immediately flows out. But it also happens that the bubble bursts not at the exit of the cervix, but at the point of contact with one of the walls of the uterus. Then the water simply flows drop by drop, gradually staining your underwear.

If your water breaks at home, you need to urgently go to the maternity hospital. Be sure to remember the time they leave and tell the doctor about it. It is worth paying attention to the nature of the waters – their color and smell. Normally, they should be transparent and odorless.

As you can see, the role of amniotic fluid for the normal course of labor is quite large. If the water does not break during childbirth, labor is delayed in time. In this case, we are talking about protracted labor, and in this case, artificial opening of the amniotic sac is necessary.

Indications for bladder puncture during childbirth

Puncture (opening) of the amniotic sac is necessary in a number of cases. Among them:

How is the amniotic sac pierced?

The procedure itself is absolutely painless, since, as already mentioned, there are no pain nerve endings in the amniotic sac. An autopsy is performed during a vaginal examination using a special instrument - a metal hook. After the bladder is punctured and the waters pour out, labor becomes more rapid, and soon the baby will be born.

Many women who are preparing to become mothers have heard that puncture of the amniotic sac is a very effective measure for inducing labor and accelerating the labor process. What this procedure is, to whom and when it is performed, we will explain in this article.

What is it?

Throughout pregnancy, the baby is inside the amniotic sac. Its outer layer is more durable; it provides reliable protection against viruses, bacteria, and fungi. In case of disruption of the mucus plug in the cervical canal, it will be able to protect the child from their harmful effects. The inner lining of the fetal sac is represented by the amnion, which is involved in the production of amniotic fluid - the same amniotic fluid that surrounds the child during the entire period of intrauterine development. They also perform protective and shock-absorbing functions.

The amniotic sac is opened during natural childbirth. Normally, this happens in the midst of active labor contractions, when the dilation of the cervix is ​​from 3 to 7 centimeters. The opening mechanism is quite simple - the uterus contracts, with each contraction the pressure inside its cavity increases. It is this, as well as the special enzymes that the cervix produces during dilation, that affects the membranes. The bubble becomes thinner and bursts, the waters recede.

If the integrity of the bladder is broken before contractions, then this is considered premature release of water and a complication of labor. If the dilation is sufficient, attempts begin, but the amniotic sac does not even think of bursting, this may be due to its abnormal strength. This will not be considered a complication, because doctors can perform mechanical puncture at any time.

In medicine, puncture of the amniotic sac is called amniotomy. Artificial disruption of the integrity of the membranes allows the release of an impressive amount of biologically active enzymes contained in the waters, which has a labor-inducing effect. The cervix begins to open more actively, contractions become stronger and more intense, which reduces the labor time by about a third.

In addition, amniotomy can solve a number of other obstetric problems. So, after it, bleeding from placenta previa can stop, and this measure also significantly reduces blood pressure in women in labor with hypertension.

The bladder is punctured before or during childbirth. Before a cesarean section, the amniotic sac is not touched; its incision is made during the operation. The woman is not given the right to choose, since the procedure is carried out only if indicated. But doctors must ask consent for amniotomy by law.

Opening the bubble is a direct intervention in the affairs of nature, in a natural and independent process, and therefore it is strongly not recommended to abuse it.

How is it carried out?

There are several ways to open the membranes. It can be pierced, cut or torn by hand. It all depends on the degree of dilatation of the cervix. If it is open by only 2 fingers, then a puncture would be preferable.

There are no nerve endings or pain receptors in the fetal membranes, and therefore amniotomy is not painful. Everything is done quickly.

30-35 minutes before the manipulation, the woman is given an antispasmodic in tablets or injected intramuscularly. For manipulations that do not necessarily need to be performed by a doctor, sometimes an experienced obstetrician is sufficient. A woman lies down on a gynecological chair with her hips apart.

The doctor inserts the fingers of one hand in a sterile glove into the vagina, and the woman’s sensations will be no different from a regular gynecological examination. With the second hand, the healthcare worker inserts a long thin instrument with a hook at the end into the genital tract - a jaw. With it, he hooks the fetal membrane with the cervix slightly open and carefully pulls it towards himself.

Then the instrument is removed, and the obstetrician expands the puncture with his fingers, making sure that the water drains smoothly, gradually, since its rapid outflow can lead to washing out and prolapse of parts of the baby’s body or the umbilical cord into the genital tract. It is recommended to lie down for about half an hour after amniotomy. CTG sensors are installed on the mother's belly to monitor the condition of the baby in the womb.

The decision to perform an amniotomy can be made at any time during labor. If the procedure is necessary for labor to begin, then it is called a premature amniotomy. To intensify contractions in the first stage of labor, an early amniotomy is performed, and to activate uterine contractions during almost complete dilatation of the cervix, a free amniotomy is performed.

If the baby decides to be born “in a shirt” (in a bubble), then it is considered more reasonable to carry out a puncture already at the moment the baby passes through the birth canal, since such births are dangerous due to possible bleeding in the woman.

Indications

Amniotomy is recommended for women who need to induce labor more quickly. So, with gestosis, post-term pregnancy (after 41-42 weeks), if spontaneous labor does not begin, puncturing the bladder will stimulate it. With poor preparation for childbirth, when the preliminary period is abnormal and prolonged, after the bladder is punctured, contractions in most cases begin within 2-6 hours. Labor speeds up, and within 12-14 hours you can count on the baby being born.

In labor that has already begun, the indications may be as follows:

  • the dilatation of the cervix is ​​7-8 centimeters, and the amniotic sac is intact; preserving it is considered inappropriate;
  • weakness of labor forces (contractions suddenly weakened or stopped);
  • polyhydramnios;
  • flat bladder before childbirth (oligohydramnios);
  • multiple pregnancy (in this case, if a woman is carrying twins, the amniotic sac of the second child will be opened after the birth of the first in 10-20 minutes).

It is not customary to specifically open a bladder without indications. It is also important to assess the degree of readiness of the female body for childbirth. If the cervix is ​​immature, then the consequences of early amniotomy can be disastrous - weakness of labor, fetal hypoxia, severe anhydrous period, and ultimately - an emergency caesarean section in the name of saving the lives of the child and his mother.

When is it not possible?

They will not pierce the bladder even if there are strong and valid indications for amniotomy for the following reasons:

  • the cervix is ​​not ready, there is no smoothing, softening, the assessment of its maturity is less than 6 points on the Bishop scale;
  • a woman has been diagnosed with an exacerbation of genital herpes;
  • the baby in the mother’s womb is positioned incorrectly - it is presented with its legs, butt or lies across;
  • placenta previa, in which the exit from the uterus is closed or partially blocked by the “baby place”;
  • the umbilical cord loops are adjacent to the exit from the uterus;
  • the presence of more than two scars on the uterus;
  • a narrow pelvis that does not allow you to give birth to a child on your own;
  • monochorionic twins (children in the same amniotic sac);
  • pregnancy after IVF (caesarean section recommended);
  • state of acute oxygen deficiency of the fetus and other signs of trouble according to the results of CTG.

An obstetrician or doctor will never perform an autopsy of the fetal sac if a woman has indications for surgical delivery - cesarean section, and natural childbirth may pose a danger to her.

Possible difficulties and complications

In some cases, the period following the amniotomy occurs without contractions. Then, after 2-3 hours, stimulation with medications is started - Oxytocin and other drugs are administered that enhance uterine contractions. If they are not effective or contractions do not normalize within 3 hours, a cesarean section is performed for emergency indications.

As already mentioned, mechanical puncture or rupture of the membranes is an external intervention. Therefore, the consequences can be very diverse. The most common:

  • rapid labor;
  • development of weakness of generic forces;
  • bleeding when a large blood vessel located on the surface of the bladder is damaged;
  • loss of umbilical cord loops or parts of the fetal body along with flowing water;
  • sudden deterioration in the child’s condition (acute hypoxia);
  • the risk of infection of the baby if the instruments or hands of the obstetrician were not sufficiently treated.

If the procedure is carried out correctly, and in compliance with all requirements, most complications can be avoided, but it is difficult to predict in advance how the uterus will behave, whether it will begin to contract, whether the necessary contractions will begin at the right pace.

According to statistics, at least 50% of women have their bladder pierced before giving birth. Many even believe that this is a routine procedure that is necessarily included in the delivery plan. Why do obstetricians resort to such manipulations? Does it hurt and could the child get hurt? How do former women in labor assess the need for such actions and their consequences?

Mandatory stage or last resort: why do an amniotomy?

Nature has programmed it so that the discharge of amniotic fluid during childbirth occurs without outside intervention. Normally, the bubble bursts when the cervix is ​​almost completely dilated and the baby is ready to leave the mother’s tummy. But in reality, many women undergo an artificial bladder puncture before giving birth. Such manipulations are usually resorted to if contractions are already in full swing, pushing will soon begin, but the water has not yet broken.

The intention to shorten the duration of delivery is the first answer to the question of why the bladder is pierced before childbirth. It is believed that amniotomy improves labor, makes it possible to do without stimulation, and examine the amniotic fluid for the presence of meconium or blood.

This practice flourishes in maternity hospitals, but it should be understood that this is an optional procedure. Amniotic fluid helps open the cervix, serves as a kind of “safety bag” for the baby - it softens the pressure and pain that he has to experience during contractions, facilitates movement through the birth canal (therefore the head is less deformed), and reduces the likelihood of intrauterine infection.

When is it really necessary?

The decision about whether to pierce the bladder should be made by a panel of doctors, but in practice it is often decided by one doctor or even a midwife. There are special medical indications for this procedure. It is necessary if:

  • the walls of the bladder are too strong, which is why the fetal membrane is not able to rupture on its own, even if the cervix is ​​fully dilated;
  • labor activity is very weak. Amniotomy will help strengthen contractions and increase their duration;
  • gestosis developed;
  • pregnancy with Rh conflict, and this led to complications during childbirth;
  • The woman in labor has polyhydramnios. If the fluid begins to drain on its own, the umbilical cord may fall out or the contractions will be too sluggish;
  • low attachment. The placenta may depart prematurely, which threatens to cause fetal hypoxia;
  • irregular and ineffective contractions that do not dilate the cervix. The woman in labor suffers for several days, but the end still does not come. Artificial opening stimulates labor;
  • flat bubble. If there are no anterior waters or there are too few of them, then the membrane tightly clasps the baby’s head, which is fraught with the development of premature placental abruption, and this is an emergency cesarean section;
  • high blood pressure;
  • the bubble burst at the site of its contact with one of the walls of the uterus, which caused a slow leakage of fluid.

Puncture of the bladder before childbirth without contractions to induce labor, according to many doctors, is an unnecessary and even harmful measure. Early amniotomy (up to 6-7 cm) does not prevent, but increases distress. This reduces the amount of water, which causes partial compression of the umbilical cord and a decrease in the amount of oxygen that the baby receives. But it is necessary if the woman is past her due date (the puncture will “start” labor).

Important! If the bubble does not burst on its own by the end of the first phase of labor (7-8 cm), then the staff is obliged to open it, because at this stage it is simply in the way.

Who can't?

Contraindications to this procedure are: herpes on the perineum, complete placenta previa, foot, pelvic, oblique or transverse position of the fetus, an umbilical cord loop on the head, a weak scar on the uterus after cesarean section, tumors, narrowing of the pelvis, the baby’s weight is more than 4.5 kg, deformation of the vagina due to scar changes, high myopia, triplets, stage 3 fetal growth retardation, acute hypoxia.

Will it hurt?

For such manipulations, a special tool is used - a jaw, a thin metal needle with a curved end. Everything happens very quickly, under sterile conditions. The woman in labor is placed on a chair; during a vaginal examination, this hook is inserted into the vagina and the membrane is torn. The gynecologist inserts a finger into the resulting hole and releases the water. No painful sensations occur, because nature does not provide nerve endings in the sheath.

Did the puncture help you give birth faster: what do women say?

So is it necessary or not to puncture the bladder before giving birth? If we summarize the reviews, the conclusions will be as follows:

  • Usually no one asks a woman in labor whether she agrees to such a procedure, and the moment is not the most appropriate. Therefore, it is better to find a doctor in advance whose actions she trusts;
  • if the obstetrician insists that this is necessary, then it is better not to refuse. After all, she will not be able to determine on her own whether there is evidence for this. In addition, some women note that after the puncture the water was already green, so this was definitely a necessary measure. But some strongly disagree. They believe that they can challenge the obstetrician’s decision, ask what the threat is in this situation, and ask for another hour or two for spontaneous rupture;
  • a puncture speeds up the process and relieves pain (especially if this is not the first baby). Therefore, the help of doctors is necessary: ​​protracted labor exhausts a woman, and she may not have enough strength to give birth herself. But some write that the puncture did not speed up the matter. After such manipulation, 5-12 hours passed - and nothing. As a result, I had to give oxytocin;
  • It doesn’t hurt to get a puncture; you don’t feel anything at all;
  • the procedure is far from safe. There are reviews in which women report that the baby had a wound on the head after birth.

Why is amniotomy needed? Is it possible to do without it? Will it harm the mother or baby? Let's figure it out together with our expert - Yulia DREMOVA, an obstetrician-gynecologist at the Avicenna Medical Center.

According to statistics, amniotomy or, simply put, puncture of the amniotic sac is used in our country in approximately seven births out of a hundred.

Sibmama data based on surveys of women who have recently given birth ( ) , radically differ from official statistics: last year, puncture of the amniotic sac became the most common intervention in the childbirth process: it was least often resorted to in maternity hospital No. 2 (38% of cases), most often in the maternity hospital of the 25th medical unit (68% of cases).

In 2015, according to a new survey, amniotomy was performed on 541 women in labor out of 1,426 who completed (among them there are those who had a cesarean section, i.e. amniotomy is performed on at least every third woman).

What happens to the amniotic sac during childbirth

The amniotic sac, the baby’s first “home,” is a strong, thin and very elastic “sac.” It's full (in medical language they are called amniotic fluid): a warm (about 37 degrees) comfortable environment that reliably protects the baby from external influences: noise, pressure, ascending infections.

What happens to the amniotic sac when contractions begin? The muscles of the uterus begin to squeeze it with force. The amniotic fluid begins to move and part of the fluid (about 200 ml) moves down, forming a kind of “water cushion”, which with each uterine contraction presses on the cervix and helps it open. Normally, rupture of the bladder occurs when the cervix is ​​already wide enough - 4-6 cm. The lower part of the bladder penetrates deeper and deeper into the internal os of the cervix, the pressure increases, the bladder ruptures and the amniotic fluid that was below flows out.

From this moment on, the baby’s head begins to press directly on the cervix, dilatation accelerates, bringing the moment of the baby’s birth closer. This occurs not only due to increased pressure, but also because the rupture of the bladder is accompanied by the release of biologically active substances - prostaglandins, which stimulate uterine contractions.

Why amniotomy is needed

“Why open the amniotic sac at all if the waters break on their own, what if this stimulation disrupts the natural course of labor?” - many women in labor express similar concerns. But the fact is that when childbirth occurs naturally and without complications, the need for amniotomy does not arise. Simply put, if you can do without puncturing the amniotic sac, then doctors are happy to do so.

The procedure may be required when the condition of the child or mother requires urgent delivery, or when labor is weak. Also, a puncture is a solution in some cases when the natural sequence of the birth process is disrupted. The membranes may be so strong that they do not tear and a puncture is required; another common reason for amniotomy during childbirth is the so-called “flat bladder”, when there is no fluid in its lower part and the membranes tighten around the baby’s head and interfere with its advancement and opening cervix.

However, it is not at all harmful to remember the indications for which this procedure is performed, so that if it is necessary, you can clearly understand what is happening.

Expert commentary

Indications for amniotomy:

  • induction of labor during post-term pregnancy;
  • weakness of labor;
  • , ;
  • “flat” amniotic sac (the membranes are stretched over the fetal head, preventing its movement through the birth canal);
  • complete opening of the uterine pharynx, if the fetal bladder has not opened on its own (dense membranes);
  • in case of multiple pregnancy, after the birth of the first fetus, an amniotomy of the second amniotic sac is performed;
  • suspicion of fetal hypoxia and premature placental abruption;
  • the condition of the pregnant woman does not allow further prolongation of pregnancy;
  • It is advisable to perform an amniotomy before labor anesthesia using the prolonged method .

From the moment the integrity of the bladder is broken, there is no turning back - the clock counts, because the anhydrous period cannot last indefinitely (usually doctors recommend limiting the time period from the moment the bladder opens to the onset of labor to 10-12 hours, but this issue is resolved in each case individually).