Intact Membranes
The significant benefits of intact membranes are the maintenance
of an even hydrostatic pressure to the whole fetal surface during labour
and a reduced likelihood of infection. Fetal hypoxia is less likely
because retraction of the placental site and thus impairment of the
uteroplacental circulation will not occur (Henderson). Fetal heart rate
abnormalities were less common in the amniotomy group in a study by
Barrett et al., but there was no difference in this study between the
amniotomy and nonintervention groups in regard to the method of delivery,
condition at birth and postpartum pyrexia.
Fraser reviewed six trials (Wetrich; Stewart; Franks; Fraser; Barret;
Fraser et. al.) that examined amniotomy in spontaneous labour. The main
conclusion of this meta analysis was that at the present time there
is no evidence that one policy of rupturing the membranes or leaving
them intact has a clear advantage over the other. Of course the most
important views of amniotomy are those of women who experience this
intervention. A large trial conducted by the National Childbirth Trust
found that the great majority of women found labour harder to cope with
following amniotomy and felt their physiology had been disturbed. Another
study (Robson and Kumar) made the unexpected discovery that maternal
affection was more likely to be lacking after delivery if the mother
had a forewater amniotomy, experienced a painful unpleasant labour,
and had been given more than 125 mg of pethidine. In this study most
mothers had developed affection for their baby within a week of the
birth and no further adverse effects were noted.
- Mayes' Midwifery, 12th ed., Betty R. Sweet, ed.
References:
Barrett, JFR et al. (1992). Randomized trial of amniotomy versus the
intention to leave membranes intact until the second stage. Br. J. Obstet.
Gynaecol. 94: 512-517.
Franks, SP. (1990). A randomized trial of amniotomy in active labour.
J. Family Pract. 30: 49-52.
Fraser, WD. (1988). A randomized controlled trial of the effect of amniotomy
on labour duration. MSc thesis. Alberta, Canada: University of Calgary.
Fraser, WD et al. (1991). The Canadian multicentre RCT of early amniotomy.
J. Perinat. Med. 2.
Henderson, C. (1990). Artificial rupture of the membranes. In Alexander,
J., Levy, V., & Roch, S. (eds) Intrapartum Care-A Research Based
Approach. Hampshire: Macmillan Education.
National Childbirth Trust. (1989). Rupture of the Membranes in Labour:
Women's Views. London: National Childbirth Trust.
Robson, KM and Kumar, R. (1980). Delayed onset of maternal affection
after childbirth. Br. J. Psychiat. 136: 347-353
Stewart, P. (1982). Spontaneous labour, when should the membranes be
ruptured? Br. J. Obstet. Gynaecol. 99: 5-10.
Wetrich, DW. (1970). Effect of amniotomy upon labour. Obstet. Gynecol.
35: 800-806.
====
E-News asked readers, What are the fetal benefits to labor
with intact membranes?
I have made it a practice with all my laboring moms to never artificially
rupture membranes. This is a result of a birth that I attended nearly
10 years ago. It was the mom's first homebirth; at her two previous
births her membranes had been ruptured during early active labor; she
felt it was a necessary part of her labor and it helped her progress.
She wanted me to rupture the bag this time. I really didn't want to,
but it was her birth so I agreed. At 6 cm there was not enough of a
bulge to the bag to allow the amnihook to snag it, so I backed off.
When she was 8 cm, I made my second attempt. Nothing! I looked carefully
at the hook and realized there wasn't a beak on it. I thought, I am
not supposed to break this bag.
About 45 minutes later a nice big baby boy was born. When my mentor
examined the placenta she said, "This baby is truly a miracle baby."
Coursing through the membranes were many vessels from the placenta (vasa
previa) and a velamentous insertion of the cord--the Wharton's jelly
didn't continue to surround the vessels of the cord all the way to the
placenta. The vessels looked like bare wiring the last eight inches
to the placenta. If I had been successful in rupturing the membranes,
the baby would have been in danger of bleeding to death.
After this experience, I never rupture membranes. I feel the benefits
of intact membranes are many: the amniotic fluid protects the cord from
compression and prevents fetal distress. It protects the baby's head
from the pressure of the birth canal and the bulging bag helps dilate
the cervix and birth canal as it presents before the baby's head and
opens up a space for the babe to come into. The baby continues to have
its watery environment during the labor to continue drinking and breathing
the fluid. I believe this helps the baby prepare for life outside the
womb.
Leaving the membranes intact also allows the baby to change positions
with greater ease, which prevents asynclitic and other cephalic positional
challenges from occurring. If the mother's labor stalls or stops, there
is no time constraint because the membranes have ruptured. This intervention
is irreversible and leads to more interventions and complications. I have seen many babies born in the caul and it is a truly amazing sight.
I have seen many bags full of fluid crowning before the baby's head,
with vernix swirling around inside it, looking like a picture of the
earth from outer space with the clouds moving upon its face.
- Cynthia Luxford, LDM-CPM
I helped with two births where one baby was born with completely
intact membranes and the other baby was born where the membranes had
ruptured approximately 4-6 hours before the birth. The baby without
the intact membranes had tiny, broken blood vessels all over his face,
caused by the pushing effort, whereas the baby with intact membranes
did not.
- Stephanie Bryant, aspiring midwife
Lumberton, MS
Intact membranes are a marvelous protection for the baby.
One incident made me realize exactly how beneficial they are. One of
my mothers gave birth to a frank breech baby at home. As everyone knows,
when a breech is born, the presenting part gets severely bruised and
swollen since it is soft tissue. This breech baby was born in the caul
(with the membranes intact). I had to tear open the bag after the buttocks
were born. She had absolutely no bruising or swelling as a result of the birth and had a 10-10 Apgar. I firmly believe the intact membranes
are what protected the baby from the bruising that normally occurs.
I believe that intact membranes provide the same cushioning protection
for the head as well.
- Judy Jones, CPM
From my own observations it seems women who labor with intact
membranes can have more spurious labours than ruptured membranes. I
would imagine that having intact membranes can only be of benefit to
the baby inasmuch as they act as a cushion against the pelvic floor,
protecting the presenting part to some degree. I also wonder if having
intact membranes aids cervical dilatation by gently holding open the
cervix when they are bulging. Certainly you see this in pre-term threatened
premature labor or malpositions when there may be a question of cervical
incompetence or ripeness.
In (small only) defence of ARM or even relief at SROM, having ruptured
membranes with regular liquor leakage may be the only indicator of general
fetal well being if EFM is not being done (there's no mistaking meconium
stained liquor).
Recently a client was in reasonable labour but experiencing severe pain
and requested an epidural. Her blood pressure had been rising but she
was generally asymptomatic. EFM revealed type 1 intermittants but increased
fluid and position changes generally controlled these. She became febrile/
in pain/ ctg EFM questionable/membranes intact. This lady was transferred
to theatre for a cesarean. She had an epidural for delivery (platelets
later came back at 40), proceeded to a postpartum haemorrhage of 2 litres
and the baby had thick meconium liquor and APGARs of 1, 4 and 6. It
was one of the most distressing deliveries I have been to and I think
had her membranes been ruptured as we would have liked to do I feel
we could have acted earlier than we did and maybe had a better outcome.
- Anon.
If the presenting part is uniformly applied to the cervix,
the forewaters apply steady pressure to the whole cervix with each contraction,
allowing it to dilate uniformly, preventing uneven dilation that can
lead to lips of cervix remaining. These can lead to a longer labour.
Early artificial rupture of the membranes has not been found to help
other than to shorten labour.
The bulge of forewaters also acts as a cushion to protect the fetus's
head and to absorb the contraction as it travels along its body. If
the membranes rupture early or are ruptured prematurely, the fetal skull
will receive the direct pressure of the dilating cervix. This leads
to the formation of caput succedaneum.
If the membranes remain intact until dilation is completed they will
usually go as there is lack of support from the cervix. This is also
emphasised with the action of relaxin upon the placental membranes.
If the membranes rupture upon full dilation then the amniotic fluid
released acts as a sterile douche of the vagina. The membranes may be
resistant enough for the baby to be born in the caul which is thought
to be very lucky.
- H.H.
UK
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To share your thoughts and experience, go to Midwifery Today's Forums.
Question of the Week
A friend suffered with obstetric cholestasis in first pregnancy from
32 weeks and baby was delivered at 36 weeks, fit and well. Now on her
second pregnancy it has returned at 16 weeks. At present although she
has high phosphate levels, bile salts are not being deposited in areas
causing risk to the baby. Does anyone have previous knowledge of this,
and any advice, comfort to offer?
- Mags
Send your responses to:
Question of the Week Responses
Q: I have a client who has been
diagnosed with varicose veins in her vulva. Can anyone give me suggestions
on how to help her with this?
- Chrys Holland, doula/massage therapist
A: Speaking from experience--support hose. I used prescription
support pantyhose. They were a Godsend! They cost about $100/pair nine
years ago and were worth every penny. Insurance will cover the cost.
- Edie, midwife
Wisconsin
A: I have seen some pretty bad vaginal and vulvar varicosities,
but have never had any problems from them. First, I never encourage those
gut-busting breath-holding pushes like I've seen some people do, but for
varicosities, I stress a side-lying position and gentle pushes. Also,
prenatally, I encourage vein-strengthening herbs. Underwater delivery
also eases pressure on the veins. If this is not feasible at least use
hot witch hazel/comfrey compresses and a lot of lubrication like vitamin
E oil, K-Y jelly or Astroglide (my favorite) on them as the baby comes
out.
- Marlene
A: I have seen this only once. The client had a large varicosity
on her labia minor, about the size of a sausage. The advice given was
to use Tucks or a witch hazel periwash for itching/discomfort, wear support
hose, and support with her hand during bowel movements. During labor she
was advised to allow her body to push and to support the varicosity with
her hand.
- Pam Martin, MS, DONA CD, CM, PMT
A: With some, this condition can get quite uncomfortable as the
pregnancy progresses. Others have no discomfort at all. I recommend applying
witch hazel compresses, wearing maternity support pantyhose, and using
hamamelis homeopathically. When it comes time for delivery the tub offers
good support of the vulvar tissues. If delivering on land, having the
mom lie on the unaffected or less affected side and supporting the vulva
during crowning and delivery of the head seems to be sufficient. I've
never had a problem at delivery.
- Liza McKinney, CNM
A: Is there a diagnosis of kidney problems? Of course you know
that varices are caused by pressure. So bottom up several times of the
day will release the pressure. For giving birth: one of the signs that
she will be in labor soon is when the veins become smaller.
- Mary Schefffer
The Netherlands
Coming E-News Themes
1. COMPOUND PRESENTATION: What do you do?
2. An E-News reader submitted the following description of her concern
for hospital-birthing women. Please share your thoughts on this issue,
and let's get some problem-solving dialogue going:
I AM A MIDWIFE WHO ATTENDS TO THE NEEDS OF WOMEN BIRTHING IN THE HOSPITAL.
I find that many "modern" (i.e. dot.com) American women and
a large percentage of my Chinese immigrant women have difficulty recognizing
and validating their strength and power in the process. I think the midwives
who attend the [Midwifery Today Eugene] conference probably identify the
same problem, especially those whose clients have the good fortune of
being cared for by midwives by virtue of showing up at a clinic that midwives
attend and having no knowledge of the issues of philosophy, etc.
I would find it useful and interesting to include "ways to inspire
confidence and a sense of the inherent power and brilliance" of women
into the section on women who care for women in the hospital. I work hard
at this endeavor every day, but because our presence is diluted by all
the non-midwives who work in the "institutions," I find it draining.
Your conferences are restorative and invigorating. However, I also feel
a sense of disappointment or frustration because I don't attend homebirths
and the most glorious stories usually are from homebirths. I fully support
homebirth and would love to see a movement to take normal birth out of the hospital and into the home. There are women who don't have a home
suitable for homebirth--they live in what the Chinese call "pigeon
houses" where many families share a common bathroom and kitchen,
are often alone and unsupported. I hope there will always be midwives
willing to attend these women in the hospital.
There is a strong need to remind midwives why they are midwives and ways
of bringing those midwives back to the fold.
- Zora
Send your responses to:
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so, please forward this issue of Midwifery Today E-News to one or two
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QUESTION OF THE QUARTER for Midwifery Today magazine
Issue No. 57 (Theme: Cesarean Prevention/VBAC) How do you
prevent cesareans?
Deadline: Dec. 15, 2000
Send your response to:
Switchboard
I am a student midwife in Chile, where there really isn't
any midwifery in existence at all. In this pioneer journey I am calling
for educational information IN SPANISH about natural support and care
during prenatal, birth, postnatal, breastfeeding, but most of all about
menopause and climateria, having to do with natural menopause support
as well as information about hormonal treatment with scientific basis
and the dangers for health, etc. It is an alternative during the menopausal
years. (For the latter, in English would be acceptable, but preferable
in Spanish.) Any support, connections, books, authors etc, will be very
helpful. The more information in Spanish I find, the less I will have
to translate, which is very time consuming.
- Megan Aiyana Gregori
Reply to: ayunklo3@surfree.com
Editor's note: The Midwifery Today Forums includes a Spanish section.
Visit our forums and click on "Espanol." Introduce a topic!
====
Dear TLK from Canada [Issue 2:47]: I have had what was called prediabetic
problems. I found the book Protein Power by Michael and Mary Eades to
be helpful. Diabetes is talked about starting on page 307, but I think
the whole book is worthwhile. There are also helpful herbs I have not
used, but I'm sure you could find them with some research.
- Francie Smith
South Dokota
====
I tore out an inguinal hernia [Issue 2:47] during my fourth pregnancy.
I already had an umbilical hernia from previous pregnancies. Inguinal
hernias usually only appear in women if there is a family history. I felt
the hernia tear when I was carrying my sleeping five-year-old up the stairs.
You need to be careful and not carry heavy things or strain unnecessarily.
I delivered my baby without any problems at all after a three-hour labor.
The only warning my doctor gave me was to not carry heavy things and get
it repaired before I got pregnant again. I did that (both hernias at the
same time) and had two more babies after that without event.
I am also a midwife and have cared for one mom who also developed an inguinal
hernia during her pregnancy. Her delivery, though longer than mine, was
uneventful and she had her hernia repaired between pregnancies.
- Judy Jones, CPM
====
I am considering becoming pregnant and want a midwife-attended birth.
I have previously been diagnosed with Group B strep. I am wondering about
the possibilities of having this now or when I deliver, and what can be
done for it when pregnant, aside from intrapartum IV antibiotics (i.e.
can I use acidophilous to help treat it? I have used it in the past and
once had a Pap done when on it and the only thing that came back when
cultured was heavy normal flora.). I am not sure on home or hospital birth
yet (this would be my first child and I am going to be 32 very soon) but
I want as few medical interventions as I can, but want to also make the
best decisions for my baby and me.
- M. Irvine
Reply to: tatiana-o@home.com
====
I think you should stop calling PROM premature rupture of membranes and
call it prelabour rupture of membranes. Presumably from the point of view
of the physiology of the woman to whom it is happening it is prelabour,
though not necessarily premature.
- C.R.
====
In response to Dianant-Sheida [Issue 2:47]: The concerns about longer
second stage are a major contributing factor to the high c-section rate
in the areas where it exists. Funny that in general the obstetric community
does not even acknowledge the dangers of an extremely fast second stage,
so long as a doctor is there to catch. From reading and workshops on birth
trauma there are also real dangers as far as birth trauma from a fast
delivery and also from a c-section as well. Women left to their own pace
of delivery push for an average of two hours for a first-time mom. Could
it really be that this is dangerous if it is the average if just left
alone? Why is it that even shorter time for second stage is allowed for
the woman who has birthed before? Yes, it is likely that she will push
for a shorter time the second time, but does it really put baby in danger
if she takes as long as the first-time mom the second time? I know of
several cases of moms who have pushed for four or more hours with perfectly
healthy babies. I have seen damage to baby and mom from pushing, but it
is much more likely when the pushing is directed by the doctor or nurse
rather than the mom's body, and when the mom is instructed to push beyond
the point of comfort and hold her breath and push to a count of ten or
more.
- Anon
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