Updated: September 2023
Artificial rupture of membranes (ARM) aka ‘breaking the waters’ is a common birth intervention. However, an ARM should not be carried out without a good understanding of how the amniotic sac and fluid function in labour. Women need to be fully informed of the risks associated this intervention before agreeing to alter their labour in this way.
This post will discuss how the ‘waters’ work during a physiological labour and the implications of breaking them. Please note that this post is not about induction. An induced labour is not physiological and usually involves an ARM as part of the process.
Anatomy and physiology
By the end of pregnancy the baby is surrounded by around 600mls of fluid. This is mostly made up of urine and respiratory tract secretions produced and excreted by the baby. The amniotic fluid is constantly being produced and renewed – baby swallows the fluid; it is passed through their gut into their circulation; then sent out via the umbilical cord through the placenta. This process continues even if the amniotic membranes have broken. So, even when the amniotic sac has a hole in it, there is still some fluid present, there is no such thing as a ‘dry labour’. You can read more about amniotic fluid volume in this post.
The amniotic sac is made up of two membranes – the amnion (inner) and the chorion (outer). At the end of pregnancy there is around 200mls of amniotic fluid and mucous between these two layers. After the birth of the placenta the two layers stick together because this fluid has gone. However, you can still tease the layers apart.
During pregnancy
The amniotic sac protects and prepares baby by:
- Cushioning any bumps to the abdomen.
- Maintaining a constant temperature.
- Assisting the baby’s movements which are essential for muscle development.
- Creating space for the baby to grow.
- Protecting against infection – the membranes provide a barrier + the fluid contains antimicrobial peptides.
- Assisting lung development – baby breathes fluid in and out of the lungs.
- Taste and smell – the baby tastes and smells the fluid, which is similar to colostrum = helps to find their mother’s nipple after birth.
After 40 weeks gestation, around 20% of babies will pass meconium into their amniotic fluid as their bowels reach maturity and begin to work. This is perfectly normal and is not a sign of distress.
During labour and birth
Around 80-90% of women start labour with their membranes intact. This is probably because the amniotic sac plays an important role in the physiology of childbirth.
General fluid pressure
During a contraction the pressure is equalised throughout the fluid rather than directly squeezing the baby, placenta and umbilical cord. This protects the baby and their oxygen supply from the effects of the powerful uterine contractions.
When fluid is reduced (by escaping through a hole in the membranes), the placenta and baby get compressed more firmly during a contraction. When the placenta is compressed blood circulation is interrupted reducing the oxygen supply to baby. In addition, the umbilical cord may be in a position where it gets squashed between baby and uterus with contractions. When this happens the baby’s heart rate will dip during a contraction in response to the reduced blood flow. A healthy baby can cope with this intermittent reduction in oxygen for hours (it’s a bit like holding your breath for 30 seconds every few minutes). However, this is probably not so great for an extended period of time, or if the baby is already compromised through prematurity or a poorly functioning placenta.
Forewaters and hindwaters
The sac of amniotic fluid is described as having two sections – the forewaters (in front of baby’s head) and the hindwaters (behind baby’s head). A ‘hindwater leak’ refers to an opening in the amniotic membranes behind the baby’s head. Often this is experienced by the woman as an occasional light trickle as the fluid has to run down the outside of the sac and past baby’s head to get out.
During labour, forewaters are formed as the lower segment of the uterus is pulled upwards and the chorion (the external membrane) detaches from it. The well flexed baby’s head fits into the cervix and blocks off the fluid in front of the head (forewaters) from the fluid behind (hind waters). Pressure from contractions cause the forewaters to bulge downwards into the cervix and eventually through into the vagina. This protects the forewaters from the high pressure applied to the hindwaters during a contractions and keeps the membranes intact. The forewaters transmit pressure evenly over the cervix which helps with dilatation. When the baby is in an OP position the head may not flex as well to block off the hindwaters and pressure is able to move into the forewaters and they may rupture. Early rupture of membranes is often a feature of an OP labour.
Lubrication
The forewaters usually break when the cervix is almost fully open and the membranes are bulging so far into the vagina that they burst. This ‘fluid burst’ lubricates the vagina and perineum to facilitate movement of the baby and stretching of the tissues.
Born in the caul
It is fairly common for a baby to be born in the amniotic sac when labour is left to unfold without interference. Particularly during a waterbirth where the pressure on the amniotic sac is altered by the fluid in the pool. The photograph at the beginning of this post is my lovely friend Holly birthing her baby in his caul.
Historically, being born in the caul was considered good luck for the baby. It was also believed that a baby who was born in the caul would be protected from drowning. Midwives used to dry out amniotic membranes and sell them to sailors as a talisman to protect them from drowning. You can find out more about the social history of the caul in an old journal article by Forbes (1953).
How does birth in the caul influence the baby’s microbiota?
I don’t know the answer to this question. However, increasingly research is identifying the importance of intestinal microbiota for health, including immune development and function. I have written about this topic in more detail in another post. During a vaginal birth the baby is colonised by microorganisms as they pass through the vagina. So, this raises questions about what happens if the baby does not come into contact with vaginal microorganisms because the amniotic sac is intact. In theory, during a waterbirth the pool water is likely to contain microorganisms from the mother, therefore the baby could become colonised. But on land, I don’t know.
C-section and the amniotic sac
There are photos circulating on the internet of babies in their caul during a c-section (google caul+caesarean or cesarean). I would like to know the background stories to these photographs. There has been a study supporting this practice for preterm babies (Wang, et al. 2013). However, there is no research supporting this method for full term babies.
Artificial rupture of membranes (ARM) aka amniotomy
Breaking the membranes with an amni-hook is a common intervention during labour. It is usually the second step in the induction process, and is also done in an attempt to speed up spontaneous labour. In an induced labour, intact membranes can prevent the artificially created contractions from getting into an effective pattern. There is also the theoretical risk of an induced contraction (that is too strong) forcing amniotic fluid through the membranes/placenta and into the mother’s circulation causing an amniotic embolism and maternal death. So an ARM is recommended before a syntocinon/pitocin infusion is started (although this may not be a worldwide practice).
In a spontaneous labour the rationale for an ARM is that once the forewaters have gone the hard baby’s head will apply direct pressure onto the cervix and open it quicker. This is a relatively new idea. It appeared during introduction of O’Driscoll’s Active Management of Labour protocol into maternity hospitals in the 1970s.
Prior to the 1970s textbooks included explanations of the function of the amniotic sac as I describe above. They also included warnings about ARM. For example, A Short Practice of Midwifery for Nurses by Henry Jellett (1926) states that rupturing the membranes “…may result in various complications, the commonest perhaps of which is the prolongation of labour owning to the loss of the normal dilating power of the bag of membranes” and that “if the entire quantity of liquor amnii escapes, the foetus will be subject to an undue pressure during labour that may prove dangerous to it.”
As ARMs were introduced in the belief that they could speed up labour, Emanuel Friedman (famous for the 1950s research used to create the partogram) criticised the practice: “There is a generally accepted clinical impression that amniotomy stimulates labor in progress. The experimental evidence to support this contention just does not exist. Nevertheless, the conviction with which it is held is almost unshakable” (1978).
Fast forward to 2013 and a Cochrane review of the available research confirms Friedman’s findings, concluding that “the evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged.” There has been no research to date refuting these findings.
There are also known risks associated with an ARM:
- It increases pain which can result in the woman feeling unable to cope and choosing an epidural.
- The baby may become distressed due to compression of the placenta, baby and/or cord (as described above).
- Fok et al (2005) found amniotomy altered fetal vascular blood flow, suggesting there is a fetal stress response following an ARM.
- The umbilical cord may be swept down as the fluid drains out. If it ends up wedged next to the baby’s head or washout out into the vagina, this is called a ‘cord prolapse’ and is an emergency situation. The compression of the cord interrupts or stops the supply of oxygen to the baby, and the baby must be born asap by c-section.
- If there is a blood vessel running through the membranes and the amni-hook ruptures the vessel, the baby will lose blood volume fast (another emergency situation).
- There is a slight increase in the risk of infection but mostly for the mother (not baby). This risk is minimal if nothing is put into the vagina during labour (ie. hands, instruments etc.).
It seems that an ARM is often performed during labour without consent. The requirement for consent to be valid includes providing adequate information about the procedure. Have any readers been given the information above prior to agreeing to an ARM?
Summary
The amniotic sac and fluid play an important role in facilitating physiological birth and protecting the baby. There is no evidence that rupturing this sac will reduce the length of labour. While every intervention has its place, including ARM, midwives need to carefully consider the risks before offering it to women. Also, women must be fully informed of the risks before choosing an ARM during their labour.
If you found this post interesting, you can find more of my work in the following resources:
- Dr Rachel Reed YouTube Channel
- The Midwives’ Cauldron Podcast
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- Reclaiming Childbirth Collective
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A beautiful post Rachel. You have done the ‘waters’ credit. A great resource for students and childbearing women. Thanks.
Great clear blog post.
Thanks for visiting!
Thank you for the very informative post!!
This article is VERY informative! This is one of the reasons I will stay home as long as possible before going to the hospital to birth my 4th baby! Really wish I could have had a homebirth this time!
Hi Taci, have you looked into homebirth in your local area? There are quite a few public hospital group practice midwives that are doing homebirth now as well as the independent midwives. Wishing you a beautiful birth for your babe x
Great post! I’d love to hear your take on PROM, too.
Watch this space…
great post! How many times do we see membranes artificially ruptured to “speed” a labour up!
I once knew a girl who had a c-section due to blood being in the waters when they broke them. I wonder now if they had knicked a blood vessel in the membranes. Nothing was wrong with the baby for the blood to be in the water. This is very interesting and informative. Thank You!
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I think this is an awesome blog post. I too know a woman who had to have an “emergency c-section” BECAUSE of having her water broken. She was only 3 cm and already on pitocin when they did it. This was my sister in law. My mother in law told me “they are going to break her water now”. Immediately, I knew she was going to have c-section. They broke her water, then about 3 minutes after they broke it, they were rushed into surgery because the baby’s heart rate was going extremely high, then extremely low. I am so grateful you wrote this blog because I can now show it to other pregnant women, so they know the true risks of having their water broken.
The same exact thing happend to me when i had my daugher! only got to 3cm & never went anywhere but the OR (and her to the NICU). 16months later when i had my son w/ midwives i got to 10cm before i made the decision to do a C section.
Hi my daughter has just had a baby and went to the hospital to get checked as she had small leakage. When she got there all was good but the doctor broke her waters and then the babies heart rate went up crazy so then told her she would have to have a c section. She hadn’t even started big contractions. He seemed to just want her to have a c section. Don’t let them do it now looking into investigating the whole process. This was at Kilmore hospital
Your daughter should complain to the hospital. And if the doctor did not gain consent (with adequate information about the risks) to break her waters then you can notify the registration board: https://www.ahpra.gov.au/Notifications/Make-a-Notification.aspx
Your daughter shouldn’t have to investigate – her care provider is legally and professionally obliged to provide full information about the risks of a procedure in order to gain consent to do it. I am sorry that this was her experience of the maternity system.
Beautiful work that clearly demonstrates that ‘…the less we do, the more we give”. We need to stop doing and let women birth. Thank you Rachel.
Dear Rachel, I was not sure where exactly to write my question so I replied to Annette’s “…the less we do”. I would greatly appreciate if you share your opinion about Amniocentesis even though it is not exactly related to birth, but still concerns the baby and the women well being. Thank you for your work and the knowledge you share with us.
Hi Katarina
Amniocentesis is a diagnostic test offered to confirm the presence of a congenital ‘abnormality’. There are risks associated ie. miscarriage and sometimes those risks outweigh the chance of having an effected baby. Like all interventions women need to make their own decisions about what they want based on their own individual circumstances.
Now why aren’t doctors taught this is school? No one is ever going to break my water again! Thanks so much Rachel!
Are you saying that they always break the waters before they induce someone? (Or that they should?) Because I know my sister was induced and they didn’t break her waters until delivery . . . she had contractions 3 mins apart for hours, they forgot about her, finally remembered, broke her waters, found the baby posterior, used forceps and got him out. (I am having a homebirth!)
The waters must be broken before a syntocinon/pitocin drip is started. It sounds like your sister had been given the prostaglandin gel (or tablet) to ripen her cervix ready for the drip. That can be enough to kick start labour on it’s own if the body Is ready. I really hope they didn’t start a drip and forget about her with intact membranes.
I am a labor Doula and I’ve seen quite a few mom’s who have had a pitocin drip with intact membranes… I hadn’t realized that was the theory for Amniotic fluid embolism.
I have also heard so many times from women, “They had to break my water”, or some variation, of “my water wouldn’t break on it’s own, so the Dr. had to break it”. They have no idea that this is not ‘normal’! It drives me crazy!
I loved this post. Tons of good information.
I do question who it is that sets out the AROM before induction with pitocin though… as I would say definitely more than half, of the people I know who’ve been induced or augmented with pitocin have had intact membranes. In fact not rupturing them is a common choice so as not to start the “clock” of 18 or 24 hours before baby “must” be delivered because of infection. This is people both online and in my own city… I’m in Canada but the women I talk to are from all over this country as well as the US and a few from other countries as well.
Is there an official recommendation somewhere?
Hi Alison
AROM before syntocinon (pitocin) is the standard practice in the UK and here in Australia. The recommendation comes from the respective Obstetric Colleges and is reflected in hospital guidelines/policies for induction. I have even seen women have a c-section because their cervix would not open enough to have an AROM with prostaglandin treatment. I think the theoretical danger of fluid embolism is fairly unlikely. The recommendation seems to be based on the fact that syntocinon is not very effective on it’s own and if you have decided to induce you need to do it the best way. Remember when you are inducing labour you are saying the baby is in danger if it stays in the uterus therefore you need to make sure induction is successful. You can spot intact membranes during an induction by the CTG trace – it is classic. The contraction pattern is all over the place and uncoordinated and the cervix does not dilate well. Usually this prompts a vaginal examination and once an AROM is performed the contractions coordinate and labour progresses. Remember ‘progress’ is important when we are medically managing labour.
Also the prolonged rupture of membranes requiring antibiotics is rubbish and I will be posting on this phenomena at some point.
I am guessing that in the US and Canada the practice is different and maybe pitocin is being routinely used without AROM?
“I am guessing that in the US and Canada the practice is different and maybe pitocin is being routinely used without AROM?”
yes, i know that happens often around here (southern us). as soon as i walked into the hospital and was checked the nurse came back in with a bag of pitocin the ob had ordred for me. :-/
after 2 days of labor i asked my ob to break my waters and my baby was born within the hour.
Who says the waters have to be broken prior to pitocin drip, this is not true, there is no need to rupture membranes at all, unless a medical reason says so, such as the need to scalp monitor the fetal heart rate. Pitocin is often started with intact membranes, and should be, membranes should not be broken before labor has started as far as I am concerned.
Hi Irene
If you read some previous comments you can see that rupturing the membranes is often not done as standard in the US. In the UK it is because it makes the induction more effective and reduces the risk of a fluid embolism occurring. I have seen many inductions where the pitocin contractions were uncoordinated and just would not get into a pattern… until it was realised that the forewaters were still intact. Rupturing them = coordinated and effective contractions. If you are intervening I think you should do it in the most effective way possible.
Is there evidence based research/practice to support the theory of ARM leading to more effective contractions and reducing the risk of fluid embolism? If so, could you guide me in the direction of this research?
Not sure. The UK obstetric guidelines and practice were based on this (Australia too) and as I have said, anecdotally I noticed a difference with intact membranes. Here are the NICE guidelines along with references: http://www.nice.org.uk/nicemedia/live/12012/41255/41255.pdf The main focus of debate is over the importance of prostaglandin before any other step. There is an increased risk of fluid embolism during an induction (http://pubget.com/paper/20410762/Incidence_and_risk_factors_for_amniotic_fluid_embolism?institution=) and the theory behind this is the force of induced contractions on intact membranes. There is no research directly supporting this claim due to the rare nature of a fluid embolism… unfortunately research in all areas of birth is limited by a number of factors.
Birth practice is culturally/experientially based rather than research based in most cases. We tend to do what we are comfortable with and what we believe works.
My first labour was induced by a pitocin drip, and they didn’t break my water until I was in full labour either. Thankfully I didn’t have any complications!
I personally had three pitocin inductions with my amniotic sac intact before wising up and doing homebirths. (One in Illinois in 1996, and two in Virginia at two different hospitals in 1998 and 2004.) But even with my first homebirth, my midwife did break my water to help get things going. My bp had been rising and she had been trying to “naturally” induce me for 5 days. I was 8 cm dilated and not in labor when she broke my water! She had just found protein in my urine and said that I was 24 hours from transferring my care to an OB. A few hours later I was finally in active labor. Less than 4 hours after that, I had a healthy baby in my arms. I was VERY aware of the risks I was taking in allowing her to break my water and chose to do it because of the situation I was in. But yeah, in some places it isn’t a requirement to break the water before starting the pitocin.
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This is such a “lightbulb” post for me. I delivered my twin boys vaginally and have always thought I had a fairly “normal” labour, all things considered, but the more I read, the more I can see the effects that my induction had on the outcome.
I was induced at 37+5, with ARM & syntocin (I think you guys in the northern hemisphere call it pitocin? I am in Australia). After 10.5 hours of labor, with an epidural that was administered by staff choice at 4cm (I was borderline PE, BP was skyrocketing and I had agreed to have one put in at “the latest possible stage” in case my second twin needed manual repositioning as they were mono-di and sharing a placenta), I gave birth to two relatively healthy boys. My firstborn had gone into distress during my labor and was delivered in a rush by forceps, suctioned and then spent 48 hours in SCN on light O2 and for observation. My secondborn was pushed out 7 minutes later with ventouse assistance and was screaming beautifully.
I now believe my firstborn went into distress because:
– My syntocin kept being pushed up because one of the newer midwives was not satisfied I was “in labor” because my ECG patterns weren’t to her liking (until the head of mid came down and told her to look at ME not the ECG and that I was laboring just fine, thank you!)
– This increased the intensity and frequency of my contractions artificially fast
– AND I now know, that having had my waters broken on Twin 1’s amniotic sac, my poor baby was feeling the full pelt of each contraction.
It explains to me also, why Twin 2 came through the same labor so much better, with his amniotic sac intact right up until I was pushing him out, he would have been much better equipped to deal with my contractions than his brother.
I had always thought ARM was a relatively “minor” intervention and blamed the synto solely for Twin 1’s distress, but I can see now that the ARM was also a big part of it.
Lovely, informative article. Thanks so much – I’ll be sharing it!
Why must you never start a pitocin drip with intact membranes? I know I was on a drip for about 2-3 hours prior to ARM with my 2nd pregnancy…
Hi FoxyKate
See the reply to Alison below.
I wish I’d had this information before I had my second child. My doctor was “allowing me” (his word, not mine) to continue to labor naturally even though I’d been in labor “so long” (his words). I’d been in active labor for 13 hours, no where near as long as my first child (total labor time 27 1/2 hours). At the 8 hour mark my doctor told me I’d been in labor too long and the only way he’d let me continue naturally was if I agreed to him doing the ARM. Otherwise, he said (threatened) he was going to start me on pitocin.
With my first I’d labored for 20 hours at home, went to the hospital and labored the last 7 1/2 hours and had a successful vaginal birth.
This was the SAME doctor and suddenly 13 hours was too long. He broke my water, I was at 5cm and 100% effaced. My son was born 9 hours later.
So I never felt that the ARM sped my labor along…still over 20 hours of labor. And luckily I still had a successful vaginal delivery, but it has always been my belief that the difference in my doctor’s attitude was that the first time I remained open to an epidural if I needed one, the second one I had made it very clear I would not get one. Also, with my first I stayed in my bed nearly the whole time I was in the hospital (since I labored so long at home)…with my second I used the tub, and frequently went outside to take a walk around the maternity center. I also used the birthing ball and various relaxation cd’s and techniques. I honestly feel they didn’t like that I was going about laboring “my way” and just wanted me to hurry up and “be done.”
Great post!
You said at the end that every intervention has its place ,I am just curious what reasons you WOULD consider ARM to be a prudent intervention 🙂
Ohh difficult question Christine. I guess if a woman is aware of the risks and still want me to do it, I would. Some women who have birthed babies before are adamant that they want this intervention and who am I to argue? For some women it does speed up labour. I would probably suggest they try to do it themselves first – with their finger. Definitely for an induction of labour – if you are going to intervene and manage labour you need to do it the most effective way.
The last time I did it was at a homebirth (which I am always extremely reluctant to do). This mother was having a VBAC (OP) and had ‘stalled’ at 7-8cm which was what happened in her previous birth. Normally this is not a problem, but psychologically it was for her. We worked through it and she wanted to try an AROM hoping to bring baby’s head further into the pelvis to rotate. We did and she birthed – probably made no difference at all but she felt good about it. Interesting the membranes were the thickest I have ever seen – you could hardly see through them.
Thanks for sharing this. I’ve had 2 water births and during my second had a AROM. I was 8cm and delivered <15mins later with no complications and babe was completely healthy. I think I would do it again (at that later point) but this is really great information to have for that kind of decision.
Thank you so much!
This post, and this response were both great to read. I went into labor with my second babe while only having had an hour of sleep the night before. I was running low on steam by hour 8 (am I a baby or what?? i know women who labor for 36 hours, and I was exhaustion after 8…) My midwife and I discussed it, and I felt good about trying ARM. My son was born half an hour later. This post has been good food for thought, though. I’m so grateful for my midwife. She was very cautious about whether to do it or not. I love that she gives me information and let’s me choose. Also, after reading this her cautiousness makes me love her more!
I think I marveled more at the hands-off approach of the midwife than the birth itself. My third child was born this way – odd feeling – like he was wrapped in cling-film! I remember making out his ear as I waited for his shoulders to follow.
It is always inspiring to see footage free of fear and inhibition.
Thank you for this clip!
Rachel asked me for some comments, so here goes –
Nice article. I agree with some of the commenters that amniotomy is not required prior to starting pitocin. Amniotic fluid embolism is a super rare complication without clinically significant association to any particular intervention.
From an OB’s perspective –
* While some infants deliver en caul, the vast majority will spontaneously rupture prior to or during labor, so its hard to look at this intervention as being so significant. There are many papers that show amniotomy alone to be an effective induction method. We don’t use this a lot now because we have pitocin and cervical ripening agents, but it does work. I was once on a mission trip and saw a woman at 38 weeks with severe pre-eclampsia. We had no pitocin, no IV pumps, and no cervical ripening agent. We ruptured her membranes at about 10 PM and came back in the morning and the midwife had delivered her.
* AROM as a method of speeding up a labor is one of those things were the ‘data’ doesn’t seem to match up to what we see in practice. Cochrane says it doesn’t help, but I’ve seen a zillion labors that seemed stalled until amniotomy was done, and then suddenly the mother is rapidly progressing. I think it clearly helps in some cases, though those cases may be outliers. We have to remember that large studies statistically remove outliers. They do not say that the intervention does nothing in every case, they just say that in aggregate we cannot identify an effect.
* AROM does lead to cord prolapse in some rare cases, though for that to happen the cord likely needs to be presenting. It also increases the likelihood of cord compression during labor (whether it happens naturally or via AROM) for the reasons you mention.
* Regarding vasa previa (the vessels running through the membranes that you mention) – this is always talked about, but its hard to imagine somebody AROMing through vessels unless they are being pretty slack in their assessment. Vessels in the membranes, if they are in the strike zone of the open cervix, are going to be very palpable, given that they pulsate with the fetus’ heartbeat. If one felt these vessels typically we would go for a cesarean. In reality, this diagnosis is usually made postpartum, when the vessels are seen in the already delivered placenta. I’ve seen many placentas where the rupture, whether by AROM or SROM (spontaneous ROM) ripped right along the vasa previa. This is not surprising as the tear is going to go along the path of least resistance, and the vessels are going to provide more resistance than blank amniotic membrane.
* There was a time that inductions started with AROM, or it was done as soon as the cervix was open far enough to admit an amnihook. While I don’t have a huge anti-AROM feeling in my practice, this was a little extreme. It led to a high level of amniotic infection and probably increased cesarean rates as a result. Given our ability to get somebody into labor without AROM with other medications, this practice doesn’t make sense at this point.
* AROM is required for internal monitoring, which in some cases is a good idea.
* >> This risk (of infection) is minimal if nothing is put into the vagina during labour – This is a VERY good point. AROM does stimulate labor in inductions, but it is critical that if it is going to be employed that the doc or midwife not do a million cervical exams after AROM. I teach my residents that once they AROM, they should just wait until mom needs to push to check her again, unless there is some really good reason. There is little reason to do routine exams on a ruptured patient unless she is a way way way off the labor curve. AROM with or without pit and no exams seems to help labor along. AROM with lots of subsequent exams seems to cause infection.
* Overall, AROM is a useful thing with some potential downsides. I don’t subscribe to it being a fundamentally bad thing. It happens naturally in every labor at some point. Having it happen at the end of an amnihook rather than some natural shearing force in labor is not so different.
—
* When this happens (cord compression) the baby’s heart rate will dip during a contraction in response to the reduced blood flow.
Just a little physiology lesson here. This is partially right, but probably not why you think. The reason the heart rate drops is _not_ because of reduced blood flow _to_ the baby. It drops because of reduced blood flow _away_ from the baby. About 50% of fetal cardiac output goes out through the cord. If the cord is compressed, the afterload (blood pressure the fetal heart must pump against) shoots up. Little receptors in the fetal aorta and carotids sense the increased pressure and tell the fetal heart to slow down to return pressure to normal. This happens very fast (within a few heartbeats), which is why variable decellerations are so quick up and down. If the cord is compressed 100%, you will have about a halving of the fetal heart rate. Some worry that a variable deceleration could go down to 0 beats a minute, but this can never happen physiologically. As complete cord compression increases afterload by a factor of 2, the heart rate is divided by a factor of 2 to keep blood pressure the same. There is no reason for it to go lower.
Upshot of this is that the variable deceleration one sees with cord compression is a not a pathologic event. Its a healthy fetal response to cord compression.
Thanks for your input Nicholas.
There seems to be a different approach re. pitocin and ARM between Obs in different countries. As induction is outside the midwives scope of practice or expertise it is always good to hear the perspective of those responsible for the management of induction. Thanks for the physiology lesson – I kept the information simple but you have provided a more in-depth explanation. A variable deceleration is not pathological and is actually normal in the circumstance of cord compression. But over time more abnormal heart rate patterns can begin to develop.
As for AROM being the same as natural rupture – natural rupture usually takes place quite late on in the labour. I also agree that AROM does appear to speed labour up for some women despite the research. Then again we could head into the ‘adequate progress’ argument if we’re not careful ; )
Thanks again for your comment. It is only when midwives and obstetricians share respect and knowledge that women get the best care.
Thanks so much for this post. My labor progressed very well, and quickly, (4cm @6am, 9cm and pushing @9am) and so because I was ready to push, but my waters hadn’t broken yet so the nurse tried and couldn’t and the doctor had to come in and do it with his tool. Contractions stopped after he did that and they wanted to put me on the drip, even though I was 10cm! Fortunately contractions were going strong again before the drip got there. I had NO IDEA that wasn’t necessary!!! I’m going with a midwife, home birth next time around, for many reasons besides this one. Thanks so much for the great information!!
Adrienne
Thank you so much for this wonderfully clear post. Putting it in my Sunday Surf
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Loved it!! Thanks!!
I discovered your site through a friend and LOVE the info I am finding here! I am 6 months pregnant w/ my 3rd and have progressed from my 1st being an epidural @ 3cm, ARM, suctioned out after 17 1/2 hours of labor 9lb 2oz baby who was then placed into NICU (for 5 days) after 6 hours b/c the breathing didn’t calm down. 2nd was ‘au naturale’, I got to the hospital 2 hours before the baby was born & had a great DR/nursing staff! Also 9lb 2oz who stayed in the room w/ me & was extremely healthy. Now I would *love* to have a homebirth but my hubby is not okay w/ the idea b/c we live 40 mins away from the closest hospital, I’m not going to push him b/c my last experience was not ‘horrible’. I am hoping for another good labor & delivery but that I can also wait as long as possible before we head to the hospital!! I will continue reading up on what you have to say on here – it makes me feel like I can be more informed this time around!!
Good luck with the next birth Jai. Don’t leave it too long before heading to hospital!
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This a great blog. ARM seems to becoming routine in hospitals now. On the show “One Born Every Minute” when they were waiting for some poor woman to dilate enough so they could rupture her membranes, the woman asked the midwife “do you have to break someone’s waters”, the midwife responded “yes all the time”. My jaw nearly hit the floor.
It’s become so routine, that women generally accept it without questioning the implications or realising that it is in fact an intervention. I’m going to be giving this to mums that come on my classes as an example of why it’s important to ask the right questions every time they are offered an intervention. Thanks!
Women really need this information before they are in labour. Keep encouraging women to take hold of their power and ask for answers.
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With my 4th baby and 3 previous very satisfying births, I got to a stage where I felt I wanted to push but did not have the right feeling down there -can’t really explain it better than that, except to say, something didn’t feel right. I asked my midwife to examine me and ARM me if possible. She VE’d me and stated that she felt something that she thought was lumpy near the head and didn’t feel comfortable to ARM me – I was 7cm & at the spines. She got the Dr and she was unable to feel this and so progressed with the ARM. I went to the toilet and sat there for over an hour when I felt the urge to stand & balance on my (R) leg and shake my (L) leg just like a dog does for about 15 min. I told my midwife that I needed to dislodge something and there was nothing on view until suddenly I felt what ever it was move out of the way and out came the baby’s head with a mighty whosh. I truly believe that his little hand was in the way & that my body was telling me to shake it free so he could be born – it was an amazing birth and I felt so intune with my body like it was speaking to me from within – I just needed to listen. My midwife asked me later was I happy with the decision to have the ARM and I was completely happy because it was my decision, that was right for me at that point in time. I believe my baby was low enough but that feeling was not right because his little hand was in the way
This is such an interesting post! It reminded me of the funny thing that happened when my daughter was born at home last summer. I had a beautiful water birth; my midwife was marvelously hands-off. I was very calm and comfortable as I labored in the water, and reached down to feel my baby’s head as it was crowning. At first I totally freaked out, because I felt a very strange ridge on the top of her head — I imagined I was birthing a Klingon! “What IS that?!” I squealed. “Just the membrane, it’s okay,” my midwife replied calmly. Apparently it had sort of scrunched up right at the top of her head as my daughter moved down. Moments later I was holding my daughter and she was beautiful and perfect — NOT a Klingon. We all had a good chuckle!
Thank you so much for this. A year and a half later, I am in emotional recovery from a home birth turned “emergency” c-section and all that entailed. Your essay is illuminating and validating of my intuition. I had felt that my amniotic sac was strong and I had an intuition that my baby might be born in the caul. Due to prolonged labor where we were already considering transport to the hospital, my midwives suggested that we break the waters because it would expedite labor and because if we transported the hosptial would do that anyway. I really didn’t want to. I checked in with myself and felt the answer was ‘no’ and I checked in with my baby to ask permission and I’m not sure I got it, but I did consent to have the waters broken. And that in itself was Grief to me. It took a great deal of effort for the midwives to break the sac. They said it was a very strong one. Reflecting on that now, I see more how the sac didn’t want to be broken because it was meant to serve and protect. (And, sure enough, the labor picked up a bit and in my experience it became unbearable and a cascade of interventions happened but labor still didn’t speed up “enough” and so now my baby was unprotected by the caul and developed respiratory distress and needed resucitation after birth by c-section and spent 4 days in the NICU and bonding and breastfeeding were drastically affected. (Abbreviated story.) My regrets at not honoring my intuition are huge. Reading your essay helps me understand more physiologically and spiritually why it mattered to hold those waters as sacred and keep them undisturbed. I would welcome a response. Blessings to you.
I am pleased my post validated your intuition. I hope it helps you come to terms with how your birth journey went. It can help to debrief face-to-face with someone who can listen to your story and feelings. Do you have access to this? Every birth is unique and we learn important lessons about ourselves through our birth journeys – even those that did not go to plan. x
I gave birth to my first baby in January at 42w exactly following an induction.
My edd was adjusted at my 12w scan from 1/1/11 to 22/12/10, I came up with my original due date from lmp and extended cycle length whereas the scan edd agreed with lmp and normal cycle length. So when I gave birth on 5/1/11 I was 2 weeks over hospital dates, but only 4 days over my own. I was co-erred into an induction by my midwives, I always wanted a natural water birth in my local midwifery led unit (birth centre) and really wanted to avoid induction cos I was dreading the intervention roller coaster! But I was told that if I went to t+14 I would be allowed to go to the midwife unit I may as well have the induction, wasn’t overly happy about it, but I dd it anyway.
At my sweep at t+10 I was 2cm with membranes bulging, but cervix still really long. When I got to hospital 3 days later I was 3cm with a favorable cervix and so didn’t need the prostin. Was told my waters would be broken then placed on the drip. It wasn’t explained why the arm was necessary.
I was taken along to labour ward at 8.30am and she wanted to do the arm immediately I told her to wait until my partner arrived as I wanted him with me and he was due at 9, I fought to get her to wait. So she put me on the ctg and left me for 20 mins, and came back at ten to and told me that she was doing the arm right then as it needed doing, my partner was still 10 minutes away. I could not get her to wait and she proceeded.
It was the most painful thng I have ever experienced, I was crying and she was in there fo ages, when she finished there was blood on her Hand and my waters wer still only trickling. Was told it was difficult as the membranes were tight to baby’s head. Partner arrived after it had happened and was really upset that he wasn’t there for me. IN hindsight I am very glad he did not see it as I know he would have been horrified.
I then hadvto fight to be allowed to go for a walk to allow contractions to start naturally before being placed on the drip, I was allowed an hour and that was it. I am si thankful for that hour as i was able t walk down the 6 floors to outside for some fresh air and private time with my partner!
The drip was horrid, they doubled my dosage every 30 minutes instead of 60minutes. The ctg machine was not picking up my contractions even though they were horrid, ended up that the midwife had to physically record them by looking at my pulse and behavior. Within 3 hours I wax contracting for 60seconds every 75seconds and begging for an epidural, I was already flat on my back because pethidine was a bad idea, it did not agree with me at all. I was only 6cm by this point. They turned the drip off for the epidural and I went from screaming madwoman while the drip was on to blissful calm while it was off, didn’t even flinch as the epidural went in.
By 7pm I was fully dilated, was then told to rest for 2 hours before. Could start pushing so that baby could descend. Drip was lowered so I could nap. At half 8 the consultant registrar started making noise about intervention if pushing didn work so I was checked again and baby had descended and I was allowed to push. Pushed for an hour and nothing. Suddenly the room filled with people, baby was twisted and I needed forceps and possible c section. To be honest I’m not really sure wha happened, i was out of it. A consent form was shoved in front of me and I could barely see where to sign.
Rushed to theatre, massive epidural top up and was directed when to push as I couldn’t feel anything. Baby was born with keilands forceps just before midnight, luckily I had a ver experienced registrar, otherwise I would have had a c section.
It was very traumatic, recovery was horrid and as I was trying to breast feed, the only pain releif available was paracetamol and ibuprofen.
It took 4 days to get breastfeeding established as a resul of the birth trauma to baby and the combination of a tongue tie also.
I have read so much since then and am much more educated, next time I am resolutely avoiding induction and any possible interventions unless they are truly necessary
Than you for taking the time to share your story. It is a very familiar one unfortunately. Routine induction for post-dates needs to stop. I hope your next birth is a healing experience for you.
dear midwife, post dates can be dangerous , I went 5 weeks past due and baby almost died…
Wow 5 weeks is a long time! I have written a post on the risks of postdates vs induction you may find interesting: http://midwifethinking.com/2010/09/16/induction-of-labour-balancing-risks/ 🙂
Hi, just found your site from reddit. It’s not an article I would normally read, but I loved your perspective on it. Thank you for making a blog post worth reading!
Thanks for this post. I’ve recently come to realize how significant this seemingly small intervention can be.
One more risk is that once the waters have been broken, a hospital will not allow the mother to leave. It starts the arbitrary “clock” – some hospitals set it at 12 hours, some at 18, some at 24 – where once the waters have been released the baby must be born by that time or a cesarean will be done. (Based on the faulty belief that length of time since BOW broken leads to increased risk of infection.) As you noted, mom’s risk of infection is low as long as no fingers or instruments are inserted in the vagina, but how could they EVER keep from fiddlin down there!
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Thank you for all your wonderful articles. I am wondering what your opinion is on my situation. I am preparing for a VBAC (currently 18 weeks) but have been given till 10 days post dates before I will be induced via catheter and then AROM. As I am considered “high risk” of uterine rupture (not really if you read the stats but nonetheless) so cannot be induced via other methods. My only other option is a booked caesarean and I am definitely not going there again (1st baby was breech and I wish I knew what I know now). I am not interested in a home birth and am attending a clinic specifically for women wanting a VBAC so feel like I am I the right place but I still don’t want to be “on the clock” or poked and prodded continuously.
10 day post dates! Wow. VBAC women often go post dates (in my experience) probably due to anxiety and the pressure of ‘not going post dates’. I can’t give you any advice except get informed and remember that you don’t have to have anything done to you that you don’t want. Trust your instincts and your body.
Thanks. My previous Obs wouldn’t give me past 40 weeks and then straight to a booked caesar. A supposed VBAC friendly Obs would only give me till 41 weeks then a booked caesar. The main public teaching hospital will give me 10 days so that’s where I’m going.
Great blog entry! My question is about the meconium; my first they let me go to the beginning of 41 weeks. I was seeing a specialist at the time to keep an eye on my sons growth bc during the 20 sono they found to anomalies that they thought meant down syndrome. At 41 weeks they did a sono and my specialist realized he couldnt see my amniotic fluid (because there was meconium). My body was closed for business at the time, they gave me cervidil (sp) to get my cervix going, Praise God right as they were getting ready to hook me up to pitocin my water broke. 8 hours later I had a perfect, healthy baby boy! So my question is was he in any real danger from the meconium, because they made it seem as though he was in major danger?! Thank you
All I can say is that he was not in danger from the meconium alone. It can only be harmful if inhaled – which he would only do if he became stressed. It is interesting that the plan was induction which is know to increase the chance of the baby becoming stressed ie. would make the meconium more dangerous. Luckily you got yourself into labour without it. By the way ‘they’ don’t ‘let’ you go… remember it is your body and you call the shots. ‘They’ can give you information and should only give you recommendations if they want to take responsibility for you following those recommendations. No one can make you do anything. Enjoy your boy 🙂
Thanks for the info. I find it funny “the let me go” he was my first and that was almost 4 years ago. To be honest I was the woman that just wanted to go in and do what they told me and get my epideral and just wait for it to happen while being told what to do. Now after two kids, having had a spinal headache (that lasted 24 days-blood patch didnt work) with my 2nd. I have informed myself as to my options and I research everything almost to a fault (drives people crazy) 🙂 Anyways, with my 3rd (whenever happens) I have a whole different outlook and game plan. I would like a homebirth but if that wont work for us for whatever reason I will definately choose a birth center of the hospital and no pain meds this time. With meds I have push both of my babies out in just under 30 mins with 1 -2 stitches. So Im just thinking if I was actually in complete control just imagine what I could do.
Thank you for what you do informing women of their options. I didnt have access to the internet with my first and with my second I just didnt do enough research however. Now I am not the same woman or mother I was when I had my first 4 years ago.
Thank you sharing this information. It was very well done and informative that even I ( a women wanting to study soon) can understand it. Thank you again!!! The body is truly just amazing and with out a doubt the best made machine!!! Thank you again!!!!
Had first son in the hospital , my water had started leaking on its own and i was already having mild contractions (I could barely feel them) They gave me pitocin but did not do anything else…pretty much forgot about me and left me in my throw up for a hour with such painful unnatural contractions. I should have never let them give me anything but 1st time did not know any better.
My other 3 boys I had at home with a wonderful midwife. A very low stress natural delivery and much less painful. My 2nd and 4th babys would have been born in the “sac” but I could not handle the pressure. Once my 2nd had been crowning for about 3 contractions and after me climbing up the bed… i asked my midwife to break my water and it was good to feel that warm water come out and by the next contraction the baby just slide right out with almost no pain at all. My 4th.. well he was crowning and i could not ever feel it but remembering how much it hurt with trying to push with the sac intact, I asked her to break it after the next contraction and it was almost as if breaking the water at that point made him slide out on his own. That was a wonderful soothing feeling at that point in labor.
Thank you for the info I always love reading this stuff… even though we are done having babies
Random question but…Why is it that doctors worry so much if women go passed 42 weeks? Has it ever happened to where a mom really just doesn’t go into labor? I went 42 weeks with my last baby and through i was never going to go and he came out perfectly fine and look at a perfect “term” Why is it such a “big risk” to go to long?
Hi Kristen. Thanks for sharing your birth stories and re. your question… There is a theory that the placenta shuts down after 41 weeks. There is no evidence to support this. Babies are more at risk after 42 weeks but this may be associated with what is done to them to get them out. I’m pretty sure that before inductions women didn’t remain pregnant forever – labour would happen at some point. Our culture is very caught up on times and dates 🙂
In the book “Husband-Coached Childbirth” Dr Bradley cites a patient of his who was pregnant for a year. When the baby was born, he was a perfect at-term baby and the placenta was fine as well. He just needed that extra time. It’s important to remember that “term” is based on a bell-curve. The majority of women give brith between 37 and 42 weeks, but there are always others who give birth earlier or later than that. It’s not necessarliy dangerous – at least not as dangerous as most doctors would have you believe. My favorite quote from the book is “any doctor who thinks he knows when a baby is going to be born is going to fool himself into picking a green apple”.
My second birth ended in a transfer from home birth to hospital, because the midwife suspected that the baby has compressed the cord (baby’s heart rate was lower than usual and sometimes decelerated fast without contractions) and she wanted me to be in the hospital when the water breaks, because then the cord could get really compressed when the protection of water is lost. When I got to the hospital I was fully dilated, waters still intact. At the hospital the first thing they did was break the waters (well… actually they spent an hour asking me routine questions before even checking baby’s heartbeat, but that’s another story). And just after that the doctor started screaming – “get the monitor on, the cord is prolapsing!!!” Then she tried to get the cord back and the nurse tried to find a monitor that would pick up something. First one didn’t pick up anything so for 5 minutes I thought my baby is gone… At the same time nurses were shaving me for a CS and I even signed a consent. The next monitor they found picked up the baby’s heartbeat, the doctor managed to get the cord back behind my baby’s head and I managed to get a fairly routine hospital vaginal delivery (episiotomy, pitocin, immediate cord clamping, pulling on the cord to get placenta out, lost 2 liters of blood, manual revision of the uterus, antibiotics to save me from possible infection).
After this experience I am thinking that nature is clever. The cord was compressed so this time the waters would not break even at full dilation (my first birth started with rupture of membranes). And the waters probably would not have broken up until the last moment (I had 1,5 liters of waters so I doubt I could have managed birth in caul, but who knows) giving my baby the best chance of survival. I was surprised that the doctor was so shocked at the cord prolapse. When I transferred the homebirth midwife did tell hospital midwife all the reasons for transferring and we did suspect that something like this could happen if the waters broke before baby’s head was low enough. But probably the doctor was just arrogant and decided to ignore the thoughts and intuitions of a homebirth midwife. My intuition says that my baby would have been ok at home as well, but I am not a risk taker. If my midwife was not comfortable with the situation – I knew we had to transfer. Most important thing – both me and the baby are dong good – my son was doing excellent despite the circumstances. And now I have even deeper respect for the way birth works.
What is your take on the situation?
I agree with you – birth works in mysterious ways and we often don’t understand what is happening until afterwards. 🙂
Hi, thanks for your informative website. So, I am 37 6/7 days pregnant, had contractions 3 min apart, painful, for 5 hours, went to the hospital, confirmed contractions, dilated to 3 cm, 60 % effaced…after all the checking was done, I walked around for an hour, had an iv placed…declined epidural…and suddenly the contractions stopped. I was told I needed AROM by the nurse, I declined ( had AROM with my first, felt like it led to pitocin and the word csection being thrown about – which I refused and had vaginal delivery) and was discharged after being told to come back when I was ready to cooperate. I now have no clue when to go back to the hospital. I am afraid to go back because I think they think I am playing games. But I really dont want to give birth at home – I don’t know how to do that. Should I have let them do the AROM? I do have contractions now, but irregular, maybe 30 min apart at times.
I have been offline and moving house… I assume you have had your baby now and would love to know how it went.
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So I am wondering if maybe this is why my baby’s cord broke right after he was born. They broke my water and I was already at a ten….it hurt so horribly after that and I was so exhausted that I got an epidural so I could sleep for 2 hours before pushing baby out. When he came out the cord just burst. I was planning on waiting for it to stop pulsing before cutting the cord but those plans went out the window, and he got taken away from me right after he was placed in my arms. I was too exhausted to fight 🙁
Thank you so much for this post! I’m thrilled to learn more about the amniotic sac. I really suspect that my first baby would have been born in the caul. I was dilated to 10 and ready to push and she the sac was still intact. They broke it and she was born a little while later.
How does being born in the caul affect the baby’s first breaths? I’m 35 wks with my second baby and will be birthing with midwives this time. They’re very much supportive of my birth choices, but I want to be sure I understand what those all entail.
I’m so glad to have found your blog!
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Hi, I`m happy to find this page. I gave birth to my firth child 3 month ago and she was born in caul. It was spontanous 10 hours long labour on due date, not in water, with no pain relief. It was a wonderful experience and I hope for more like that. I`m just wondering if there is anything I can do for it! I`ve done a small research on the Internet and found that in many cases, when babies were born in caul, the mother was labouring and giving birth standing (like myself)… Maybe it helps, i will try it again:)
Oh, and I had a wonderful, very young midwife with me there, she was really superb with letting me do all the labour and birth in my way with the very minimum examinations and instructions.
Wow, amazing blog structure! How long have you been blogging for? you made running a blog glance easy. The full look of your web site is excellent, let alone the content!
Just a quick note to say I’m enjoying your blog very much and all the info on it. Also, the salemmidwife blog at wordpress.com was deleted, but I was able to see the in-the-caul pics at the first site. Neat photo with the blood vessel in the caul. Learning new things every day!
Thanks Becky. I have removed the link 🙂
I just wanted to say how valuable this blog article is. AROM for labour augmentation is such a common intervention in the UK and I make this compulsory reading for all mums in my classes and have done since you wrote it. You have a great way of writing a blog that is accessible, knowledgable and informative without dumbing down. Thank you!
Thank you 🙂
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Hi, thankyou for this information would you be able to tell me is there anyway any part of the waters could stay intact after the birth? after my 3rd pregancy i had a very quick delivery and 2 days after giving birth i had a very large gush of water, which i was told over the phone that no this was urine, but you can feel what area it comes out from and it definatly came out my vagina, is this possible?
thanks sam
I’ve never heard of this before. The bag of membranes that contains the amniotic fluid is part of the placenta. So, if your placenta was out – the membranes would also be out and any fluid they had contained. I really don’t know what the gush of water was… weird. Maybe someone else on here can come up with an explanation?
If it was clear amniotic fluid, it would have to be accompanied by a piece of sac which held the amniotic fluid inside the uterus. After birth the uterus contracts down to the size of a grapefruit, pushing out all the loose amniotic fluid. If the water was from the uterus / vagina and not urine, then it would have been red, mixed with the significant amount of bleeding that happens 2 days after birth. If it looked like water, and not in the sac or with a sac, then it was urine.
Thank you for the info. I was looking exactly for this. I just had a hospital water birth and when I was 8 cm, and after 8 hours of labor midwife offered to break the waters for me. I don’t know why I agreed to it, since I felt that I didn’t really need it, but she convinced me that it’s a good idea and that it will speed things up for me. After she broke the water, things did start to progress very quickly and way more intense. 10 mins later I started to push and in 20 more minutes I gave birth. The baby came out a little blue and the midwives though she was in distress and cut the cord right away (which I didn’t want to be done) and took her and put an oxygen mask. I strongly believe that breaking the waters was not needed in my case and even may have lead to the baby’s distress. I wish all the midwives were as informed as you are!!! 🙂
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I wish I knew more before I consented to having my waters artificially broken! Thanks for this blog post, and for your amazing blog. I will be reading your other posts and recommending it to my mummy and pregnant friends. I am so glad I found you.
I dont agree with the post of the obstetrician Nicholas Fogelson .
Artificial rupture of membranes increases the risk of Early Onset GBS disease of the newborn, prolapsed cord, difficult vaginal breech delivery, amniotic fluid embolism and perhaps even obstetric brachial palsy. AROM should be abolished wherever other options for induction (PGE and pitocin) are readily available.
The protocol to culture women prenatally for GBS and give high doses of prophylactic antibiotics to millions of full term, low risk, GBS positive women every year appears to be fueled by the antibiotic companies who are profiting hundreds of millions per year from this protocol. ** Where there is a sincere desire to decrease EOGBS among full term women that was not motivated by profit, the first plan of action would be to eliminate artificial rupture of membranes (AROM), perform digital vaginal exams rarely or never, and eliminate scalp electrodes, all of which increase infections rates (1,2,3). In decreasing order of significance, independent factors predicting neonatal infection are: clinical diagnosis of chorioamnionitis, maternal GBS colonization, number of digital vaginal examinations, and interval between membrane rupture to active labor. (1) The effect of digital vaginal examinations on chorioamnionitis became statistically significant at 3 examinations. (1) Scalp electrodes double the rate of GBS colonization. (3)
90% of women start labor with contractions, and usually have their membranes artificially ruptured. Only 10% of births that are not inductions begin with rupture of membranes. (4)
What happens in the absence of AROM? Usually when labor starts with contractions and the membranes are not artificially ruptured, and vaginal exams are not done, the membranes do not rupture until the final pushes, 5-10 minutes before giving the birth. In the absence of vaginal exams and AROM, 5% of births occur ‘in a caul’ without the membranes breaking at all.(5) This translates into 5% of full term babies having no risk of EOGBS, without any antibiotic prophylaxis by simply not doing any vaginal exams or AROM. Those babies are not at risk for GBS ascending to the uterus and are not exposed to the vaginal flora of the mother and therefore are at no risk of catching EOGBS from the mother. Since the length of the interval of ROM before birth is related to increased risk of EOGBS, it would appear that full term births without AROM, who’s membranes break minutes before the birth (95% of the 90%= 86%) have either a very low risk or no risk of EOGBS.
The rate of EOGBS at vaginal birth is in the absence of AROM has not been researched.
Because AROM is fairly routine, it is not known whether GBS bacteria always ascend thru the hole in the sac to infect the fetus, making ROM a necessary precursor to EOGBS or whether the fetus can gets the GBS in the last 10 minutes before birth from its momentary transit thru the vagina, seconds after the water breaks. It is known that birthing into water has the lowest documented rates of EOGBS. The rate of EOGBS reported at hospital births into water in the absence of GBS prophylaxis was 1/ 4,432 (6,7) which is 300% lower than the 1/1,450 EOGBS rate for hospital land births using antibiotic prophylaxis(8). We can only guess if restricted AROM was used at these water births, because the water birth studies failed to report use or non use of AROM.
EOGBS does not occur when the fetus is not exposed to GBS either by ROM or by passing thru the vaginal canal. At planned elective Cesareans in which the water is not broken before the delivery, EOGBS does not happen. A study of 550 births in Texas (9), born to GBS positive women, by cesarean surgery without ROM, and without antibiotic prophylaxis, demonstrated no cases of EOGBS disease, where one would expect 1/200 EOGBS cases for untreated GBS positive mothers if GBS crossed unbroken membranes. In vitro study has not been able to demonstrate GBS crossing membranes, even at concentrations of 1,000,000,000 CFU. (10) Further investigation into how GBS could cross intact membranes demonstrated that GBS failed to invade amnion cells under a variety of assay conditions (11) and fetal membranes demonstrated an inhibitory effect on GBS. (12). Rare cases of colonized infants born by elective CS in the absence of ruptured membranes could be explained as being cases of chorioamnionitis, particularly among premature babies for which membrane status is difficult to diagnose as well as any number of other vectors such as receiving GBS from surgical team. Despite the evidence that GBS does not cross intact membranes, the 2002 CDC protocols (13) makes unqualified statements including, “GBS can cross intact amniotic membranes.” This statement contradicts the research evidence, and therefore again supports the theory that the use of routine cultures and prophylactic antibiotics is profit based.
The simple obvious first line of defense against EOGBS, therefore is NOT to break the membranes. However, this is not mentioned anywhere in any of the CDC 1996, 2002, or 2010 GBS protocols. I welcome the CDC to give an explanation for this blaring omission.
AROM and CORD PROLAPSE
Rupturing the membranes should always be avoided for optimal outcomes. A recent case study was published in British J of Midwifery (14), described the following case:
Mary had booked for a homebirth and rang the delivery suite when she was 40 weeks gestation and had been contracting every 5 minutes for 4 hours. She was being supported by her husband. A senior midwife went to her home and performed the assessment. The woman lived on the top floor, with elevator access. The woman was found to be 8 cm dilated. The uterine contractions were occurring every 10 minutes and there was no change in dilation after 1 hour. The woman tried walking. The midwife suggested AROM to accelerate labor and the woman consented and during the procedure a cord prolapse occurred. The woman was assisted into the all fours position with her head down, and the midwife continued to put pressure on the baby’s head to prevent further occlusion of the cord. The father called the delivery suite. The second midwife arrived in 5 minutes and warm swabs were placed around the cord. The first ambulance crew arrived in 10 minutes. The ambulance trolley would not fit in the elevator and chair was contraindicated. A second ambulance crew assisted in transfer of Mary to ambulance. Sheila remained with her fingers applying pressure to the baby’s head to prevent occlusion of the cord. Mary was dragged on a blanket to the elevator and tranferred to the trolley on the ground floor. Once in the cold air, the cord collapsed, fetal heart fell to 40 beats per minute. The baby was delivered by forceps an hour after the cord prolapse. The Apgars were 1 @ 5 minutes. The baby was transferred to NICU and died 10 hours after delivery.
The conclusion of the article was not to have homebirths on top floors because transfer will be difficult. The death of the baby was not caused by the transfer, but rather by AROM. No matter how fast the transfer was, the cord would have collapsed when it hit the cold air outside. AROM was the cause of the problem, not the homebirth. AROM is ill advised unless you have an operating room ready next door and cesarean team all ready in the room and the woman has no contraindications for surgery. The article itself quotes research that half of cord prolapses result from interventions.(15) (Where membranes rupture themselves and a cord prolapse results, get the woman as quickly as possible into a hot bath or bucket of hot water, and deliver her into hot water where the cord will not contract from cold.)
AROM and VASA PREVIA : If there is a blood vessel running through the membranes and the amni-hook ruptures the vessel the baby will lose blood volume fast.
BREECH
Breech births progress slower than vertex births. The slow speed may be a good reason for a digital vaginal check, which will reveal the presenting part. Finding it to be breech, never rupture the membranes! Intact membranes allow the breech to descend more easily and protects against prolapsed cord, which is far more common at breech births. Intact membranes allow some footling breeches to convert to breech. With intact membranes, no one is aware of the thick meconium, lowering the tension level, improving outcomes.
AMNIOTIC FLUID EMBOLISM
Amniotic fluid embolism (AFE) is a rare complication which used to occur in 1 in 120,000 pregnancies, but now has been documented to occur in 1 in 50,000. 90% of AFE (38/43) had artificially or spontaneously ruptured membranes (16) and only 10% (5/43) had intact membranes, so eliminating AROM might lower the risk of amniotic fluid entering the maternal blood supply. Research lacks an explanation for how amniotic fluid would enter the maternal blood supply when the membranes are intact. (16)
OBSTETRIC BRACHIAL PALSY
The compression of the posterior shoulder against the sacral promontory is a possible cause of OBPP. Having the membranes intact would decrease the compression of the shoulder against the pelvic bones.
DECREASED PAIN
AROM may increase contraction intensity and pain which can result in the woman feeling unable to cope and choosing an epidural.
Conclusion: Midwives need to rethink AROM, delay doing it, delay some more and then reconsider doing it and then Not do it.
** This became apparent to me when the CDC representative prevented me from speaking at 2010 ACNM conference in Washington about my research into using garlic to kill vaginal GBS.
1.Seaward PG, Hannah ME, Myhr TL, et al. International Multicenter Term PROM Study: evaluation of predictors of neonatal infection in infants born to patients with premature rupture of membranes at term. Am J Obstet Gynecol. 1998;179:635–639.
2. P T Heath,1 G F Balfour,1 H Tighe,1 N Q Verlander,2 T L Lamagni,3 A Efstratiou Group B streptococcal disease in infants: a case control study. Arch Dis Child 2009 94: 674-680.
3. Keski-Nisula L, Kirkinen P, Katila ML, Ollikainen M, Saarikoski S. Cesarean delivery. Microbial colonization in amniotic fluid.J Reprod Med. 1997;42(2):91-8.
4. Zlatnik FJ. Management of premature rupture of membranes at term. Obstet Gynecol Clin North Am 1992; 19:353-64.
5. Cohain JS Top 10 reasons not to culture for GBS at 36 weeks. Midwifery Today Int Midwife 94:15.
6. Gilbert R.E. and P.A. Tookey. 1999. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ 319: 483–87.
7. Cluett, E.R. and E. Burns. 2009. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews (2) DOI: 10.1002/14651858.CD000111.pub3.
8. Phares C.R., et al. 2009. Epidemiology of invasive group B streptococcal disease in the United States, 1999-2005. JAMA 299(17): 2056–65.
9. Ramus RM, McIntire DD, Wendel GD, Jr. Antibiotic chemoprophylaxis for group B strep is not necessary with elective cesarean section at term [Abstract]. Am J Obstet Gynecol 1999;180:S85.
10. Kjaergaard N, Helmig RB, Schønheyder HC, Uldbjerg N, Hansen ES, Madsen H. Chorioamniotic membranes constitute a competent barrier to group b streptococcus in vitro. Eur J Obstet Gynecol Reprod Biol. 1999 Apr;83(2):165-9.
11. Winram SB, Jonas M, Chi E, Rubens CE. Characterization of group B streptococcal invasion of human chorion and amnion epithelial cells In vitro. Infect Immun. 1998 Oct;66(10):4932-41.
12. Kjaergaard N, Hein M, Hyttel L, Helmig RB, Schønheyder HC, Uldbjerg N, Madsen H. Antibacterial properties of human amnion and chorion in vitro. Eur J Obstet Gynecol Reprod Biol. 2001;94(2):224-9.
13. Centers for Disease Control and Prevention. (2002, Aug 16). Prevention of Perinatal Group B Streptococcal Disease. MMWR 51(RR-11). Page 11
Free internet access: http://www.cdc.gov/mmwr/PDF/RR/RR5111.pdf.
14. Richardson J. Supervisory issues: lessons to learn from a home birth. 2009. BJM 17:11:710-12.
15. Usta IM, Mercer BM, Sibai BM. Current obstetrical practice and umbilical cord prolapse. Am J Perinatol. 1999;16(9):479-84.
16. Clark SL, Hankins GDV, Dudley DA, Dildy GA, Porter TF. Amniotic fluid embolism: analysis of the national registry. Am J Obstet Gynecol. 1995;172:1158–1169.
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My water broke several hours BEFORE I went into labor. I’m curious if, in that situation, the same risks apply to mama and baby. I gave birth in a hospital-based birthing center, in water. My labor did stall for several hours after entering the HBBC, but in retrospect, I always believed that was a combination of going to the HBBC before it was necessary and trying to “manage” my contractions instead of letting my brain stem take over. Now I wonder if my labor did not progress because my waters had already broken. It had been a small gush followed by slow trickles.
Luckily I have a very decent OB/GYN (tough to come by in the USA) and two nice doulas, so it was never suggested to me to use medical interventions like IVs, episiotomy, etc. I had a wonderful birth, once I let go and let it happen. Just curious about those of us who have it break pre-labor on its own.
Hi Sarah
Not sure if you’ve found this post: http://midwifethinking.com/2010/09/10/pre-labour-rupture-of-membranes-impatience-and-risk/
When waters break physiologically before labour (ie. without intervention) there may be a good reason for it to happen – one that we don’t understand from the ‘outside’. The ‘risks’ may be the similar but the body/baby are not being forced into a situation… they created it themselves.
I had not but I did just read it. My labor started within 4 or 5 hours of my water breaking. I did end up with a uterine infection within a few weeks of giving birth, but also there were vaginal exams during labor, so that may have been why. Thanks.
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Very interesting readinv and most of which I was aware, I would be interested in having a look further into this and possibly consider writing my dissertation on this. Please would it be possible to have a look at your references? I would also like to gently question arm when on placement as I have seen this happen too often without any real informed consent, and also Im unsure as to what benefit this has given during labour.
If you click on the references in the text you will be taken to their source. I prefer this method to a reference list at the bottom because people can easily go to the article and get the details. I have included links where I have used research articles – the cochrane review will also cite their references. For the physiology bits – you can find this in any midwifery text book. Perhaps ask the practitioners who routinely do this to provide evidence to support their practice 🙂
Thanks for writing this; im very interested in writing about arm for my dissertation after seeing many performed without any real informed consent, just women being askes if it was ok. Would you please be able to share your references?
Thanks
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wow i had this done when i gave birth to my daughter but my midwife never told me why or what the risks were she just said she was doing it and did it i wasnt induced or anything and i think if i had read this before having my daughter i would have refused…
Hi Jessica
From a legal perspective your midwife committed assault and battery by undertaking a procedure without providing adequate information to you re. risks. Unfortunately this is fairly common 🙁
Hi, I feel I have been let down continually since I started my labour 3 days ago. I’m 21 and was 2 days early for my first child, I went into the labor ward at 3am after 4 hours of contractions, on my first check up she said I was 4cm and my cervix was nice and thin. 2 hours later and after a midwife change in shifts, she had a quick look and said I was about 5 cm and doing great but recommended I have my waters burst to speed things up, stupidly I agreed and was in imedidiate agony, my partner told me not to do it as I was progressing well. To cut a very long story short: I was told I was not allowed an epidural until I had my waters broke, then after 2 hrs waiting after they were broke I had a trainee administer one…several times. Then I need to have baby hooked to a heart rate monitor as he was ‘distressed’ then they said it was a faulty machine so they had to put an internal monitor on him, then they said ‘yes he’s definatelly distressed’ ‘we need to take his blood to test PH. That came back normal, so I avoided the caesarian, whilst applying the heart monitor to his head they noticed he was face up and ‘could have moved him if my waters was intact’. So in they came with vent house and foreceps which was agonising as my epidural was badly located and then to top it all off the male midwife said, and I remember so clearly ‘I don’t know why we are bothering, let’s get her in for a code red C’. I’m 21 and I am still in pain, I can’t believe I was treated this way. Does this seem familiar to anyone or is it normal and I’m making a fuss, but I feel a bit neglected and downright ashamed. I was inlabor for 12 hours and 6 of those I was doing well, progressing nicely. Surely 12 hours is to short for a first time labour, can anyone see where it went wrong.
Hi Chloe
You have been let down continually and neglected.You write “stupidly I agreed” – you were not being stupid. When offered without adequate information ie. “to speed things up” – many women agree. You had a procedure performed on you without consent (assault and battery). I am sorry that you were subjected to this poor standard of ‘care’. You have every right to be angry and upset. Don’t let anyone to tell you to just be grateful for a healthy baby – you can love your baby without accepting that your birth experience was OK. I suggest you find someone to help you process this experience (a friend, doula, midwife) who can let you feel what you feel and listen without judgement. If you are feel strong enough it would be great to let the hospital staff know your perceptions of the experience. Perhaps write a letter. Unfortunately this is so normal in the hospital system that staff are often totally unaware of their contribution to women’s pain. Take care x
Do you think that had I not had my waters broke and waited for ‘another 4 hours’ as she put it, things may have been different, what really annoys me is that the surgeon said if my waters were intact then he could most certainly have manipulated the baby into an agreeable position for vaginal birth. Thanks for the empathy x
No one really knows what could have happened if you had been supported to birth physiologically and not to meet someone else’s agenda. If your membranes had remained intact your baby may have been able to move/rotate without assistance. Unfortunately most of the time the staff genuinely believe that what they are doing is helpful. They don’t have knowledge or experience of another way of working. Then end up doing harm with the best intentions and often have no idea about the fall-out. This is why it would be good to let them know if you can… no rush as you have a baby to get to know 🙂
Hi Rachel,
I thought I might leave a comment about my own experience of having an ARM, just a few weeks ago with the birth of my second daughter. I had been having contractions during daylight hours for 7 days straight (I was 12 days past my ‘due date’) which were painless and regular, but always stopped when I lay down.
I had had a completely intervention-free labour the first time, (baby was born into water after a nice gradual build up and about 18 hours of labour) and I was starting to feel increasingly anxious every time I had what felt to me like a false-start. Every day I got more anxious, more adrenaline (thinking “is this is? is it starting” is it going to stop again? how can I make them keep going?) – not the best frame of mind for labour! I had tried acupuncture, daily walks (for weeks), sex (which was the last thing I wanted to do), clary sage, nipple stimulation. All of these brought on contractions, but they always petered out.
So I decided to go for an ARM. I was very nervous about it knowing all the interventions that coule follow, and I knew my midwife wasn’t keen, but I felt like I was going to go crazy if I kept going like that, and intuitively I just felt really ready! (or maybe just desperate!) She checked my cervix and said it was about 3cm dilated, very favourable etc. My waters were broken, contractions started feeling a bit more bitey almost straight away, and I had a really awesome labour – about 4 hours all up, with my daughter arriving after 2 spontaneous pushes. I felt in control, present, everything I wanted my labour to be.
I think next time I would still like to wait a bit longer, and I will be more prepared to be patient and trust my body if is happens this way again. I guess I was expecting things to go the way they had the first time, and it really threw me when they didn’t! I just wanted to share this story as an example of an ARM which didn’t end badly. 🙂
Thanks for all your amazing articles, I’m really enjoying trawling through your site. I’ve also applied to study mid next year and this is a great starting point to get me warmed up!
Thanks for sharing your experience Bri
It seems that you make an informed decision to have an ARM – and it worked out well for you. For me, the real concern is when women are coerced into this intervention without knowing the potential consequences. Good luck with your midwifery education! 🙂
Thank you so much for elaborating on this subject! I’ve wondered for YEARS about this….when i was 18, my firstborn(10 days early) was born after i was fully dilated with regular painful contractions(no drugs/completely natural) only AFTER the dr chose to finally “break my water”, which in looking back I feel like it was “my turn to deliver” and he needed to go ahead & get to the others in the labor rotation!
When my next son was born, 12 years later, I opted for the epidural(afraid of extra severe pain this time since I have a horribly herniated vertebrae in my lower back)…however 30 minutes after the epidural I was once again FULLY dilated. They made me wait over 3 hours until they felt I would feel enough to “push”(which didn’t bother me at the time). But AGAIN, when it was “my turn” to deliver(3 others in labor at same time), my water had not broken so I gave the okay to “break it” and then I pushed and he was born within 2 pushes(just like his big brother!).
I’m pregnant again and due with another precious boy on the way. I’ve heard that “babies born in caul” can run in families. This has happened in multiple generations of my family tree.
My question is, have you learned the same? I want to be prepared for the same thing this
time and just wanted to find out if I have a chance of finding out if my kids were just all meant to be born that way! I didn’t realize that your water didn’t HAVE to break before birth until I started doing some research into our family tree, saw something about a baby being born in a caul, and then researched from there. Go figure!!! Thanks again for this informative post!!
Thanks for sharing your birth experiences. And I can’t answer your question. I don’t think anyone has researched babies born in the caul – there probably isn’t enough happening in hospitals as they usually break them before birth. There may be a genetic component to how ‘strong’ the membrane sac is… or nutrition may be a factor too (and diet is often shared by families). You will have to come back and let us know if your baby is born in the caul this time 🙂
This was a great article and the discussion afterwards just as interesting. Thank you!
I just had a hospital birth in Sydney in November 2012. After reading similar articles and horror stories like those in the many replies above, I decided a natural, physiological child-birth was the goal to aim for if I wanted an uncomplicated labour and recovery. So I hired a Doula, did a lot of research, pushed to be booked into my closest midwife-led unit at my basic public hospital (not the larger one they wanted me at, allegedly due to being a 1st-time mum!), and set about preparing my mind and body to do what I knew it should be able to naturally, without pain relief or procedures that could lead to a cascade of trouble.
In the end, my baby girl’s birth went according to my highest hopes and expectations. We narrowly avoided potential disaster after 3 days of early/pre-labour (totally underrated!), when we went to the hospital too early- we hadn’t seen my Doula in person just yet, and thought I was more advanced than i was. I was only 1.5cm dilated, and an inexperienced midwife couldn’t find our baby’s heart beat (I COULD, there in the background of the doppler, even though she was unsure. I could also feel her kicking still). I refused to be placed on a trace since I could foresee us both being in distress after an hour of restricted movement. So we returned home against advice and continued on our journey unnaided…and unobstructed. Over the next almost 24hrs, my husband, Doula and family supported me at home, and when we went to the hospital the following night I was at a hard-earned 6cm.
After contracting for 4 more hours, the fantastic midwife who had been observing me did her 2nd internal exam and described my fore-waters were bulging down before the baby’s head. I agreed to let her push me out from 9.5 to 10cm- and then she told me to bear down at the next contraction to break my waters…and I did! My waters came free in 4 separate quantities in the next 2 hours of pushing, the final gush only as my baby’s torso emerged.
Reading the above article and the other stories here, I am so thankful my labour progressed the way it did, and particularly in awe of the marvelous job my girl’s waters did to protect her during her lengthy progression Earth-side. Her’s is an example though of how a hospital birth can involve little intervention, at least with the preparedness, dedication and commitment of the mother and her team. Next time I hope to do it at home. It is scary to imagine the very different path things may have taken if I hadn’t listened to my instincts and been wary of deferring to an inexperienced midwife with technology her only tool (crutch?) upon our 1st visit to the hospital.
As for there being a genetic component to the strength of the amniotic sack; my mother tells me that her waters broke late in my sister and my own births. My older sister’s membranes came away as she emerged, and I was born with a “lucky cap”, the rest of the caul also either coming away naturally or being peeled off by the Dr. We suspect my Mother herself was born with a lot more of her membranes intact- the last of 7 children, my Grandmother used to tell her there was a lot of commotion, then silence, and then a fast exodus of all the midwives from the room- leaving my Mother swaddled and asleep without a word. There is also more than one midwife in our ancestry, notable because caul-bearers were traditionally pre-destined to become midwives (amongst other things). I look forward to paying particular attention to my waters and the amniotic sack in my next pregnancy, labour and birth.
Congratulations! And thanks for sharing your experience. Early labour is very under-rated… not sure if you have read this: http://midwifethinking.com/2012/09/22/early-labour-and-mixed-messages/
It is a shame that midwifery assessments/interventions interfered with your birth a little ie. not finding the heart rate… and manually dilating your cervix – youch! And telling you to bear down and break your waters… hmmm. Luckily your body and baby did an great job of birthing and you had prepared yourself well with great support 🙂
Thank you for your reply and thoughts. I just read that post on early labour yesterday (I read more of your blog whilst I was pregnant, but finding myself back here after coming across the link to this old article, I enjoyed catching up). It echoes my fears and impressions exactly- I hope to get a chance to add my 2 cents worth to both discussions at some point!
Strangely enough, I don’t regret the assessments and interventions I had done. Strange because I had, in fact, decided that I did not want ANY internals many weeks before. My birth plan specified as much. But, I had spoken to my Doula more recently and decided that I would consider them if offered when the time came. I’d had a friend have a very complicated, traumatic experience that may have been less-so if she’d had certain interventions at the appropriate times, and I realized that some the restrictions was holding myself and my carers to may have become more ideological for me than pragmatic. As it was, I think the midwives suggested and performed fewer of them than they might have otherwise, and I’m still glad for the ones they did.
Perhaps it has a lot to do with the length of my “pre-labour” that I agreed to the assessments and interventions that I did. This part of my story is very relevant to your other post, but I had been experiencing early labour symptoms for two days on my own before my husband stayed home and things ramped up on the third day. I had slept very little the two nights previous, and by the end of the third day I was tired, vomiting and quite exhausted. Finding out that I was only 1.5cm dilated could not dishearten me because I knew that 1.5cm had been hard earned. I was determined not to let any measurement get me down, and had steeled myself against feeling judged at this point. In hindsight, it was helpful to know that I had a long way to go (if only compared to an arbitrary ideal).
When we went back to the hospital 24hrs later, I was still sleep deprived and had barely eaten in two days. I had vomited a lot, but had stayed as hydrated as possible. 4 more hours of contractions on top of that meant I was glad for the midwife’s assistance in dilating that last 1/2 a centimeter. It WAS some of the greatest pain of the entire labour, but I didn’t resent it at the time. I am grateful for every ounce of energy I had left for the 2 hours of pushing that followed, and I am pleased that I managed it with just the midwives and my Doula’s assistance, without a Doctor being called (when that was discussed I defended myself very loudly against it). Is it possible that by stretching me that last 1/2 cm, the midwife saved me from further intervention, by saving me energy? Should I be less grateful? After all, I am not sure that I had all the information on the risks of this.
Also, since it’s more along the lines of this topic, would you mind explaining your misgivings about me being asked to bear down and break my waters? It didn’t feel wrong at the time, but then again I had little to compare it to. I’d prefer to be informed of the risks of such an action for next time!
Many thanks in advance.
Rachel.
You are not strange to have found comfort in assessments. Lots of women want the reassurance of knowing what is happening inside. Most of the vaginal examinations I do (which is not many) are done at the request of the woman – ie. not for my benefit 🙂
In terms of the interventions I guess I am coming from the perspective of a homebirth midwife. Whenever you intervene with a physiological process you risk creating a complication… Not something you want to do when away from resources/medical help. Manually dilating a cervix could result in: tearing the cervix = excessive bleeding and repair in theatre; forcing the baby’s head through the cervix and into the vagina before the baby is well positioned/rotated for birth = malpositioned baby requiring medical assistance… or the shoulders getting stuck on the cervix which had not finished dilating (I witnessed this once).
As for encouraging a woman to bear down to break her waters… why? They will break without instruction and there may be a good reason the haven’t yet.
Of course in a hospital setting you can take these risks because there is back up to deal with any complications you cause… and most of time, as in your case it will work out fine. However, the woman must give consent first based on full disclosure of the risks.
I hope that answers your questions… I am not criticising your birth experience. You did an amazing job. Just from my perspective I cringed a little about what was done to you… but I’m a little sensitive about such things 🙂
Thanks again for your awesome response. Don’t worry, I didn’t feel at all as though you were judging my birth experience. I have done enough of that of my own, anyway, and already decided that next time I would like a home birth. I would have done so this time if I’d felt comfortable with my current living space and had the resources to do so.
I had reached a similar conclusion (why?) about how I broke my waters. I guess that’s how I ended up reading this article. I was interested in how late mine broke, but quickly realizing that many of the examples I have to compare my experience to involved AROM anyway- itself interesting because I’d completely forgotten about mine’s existence by the time they were called into focus!
I only hope that I can find a homebirth midwife like you when next time comes! Thanks again.
Thanks for yet another excellent post. The summary of the risks is brilliant. Will definitely be sharing with my clients.
It’s worth reiterating the point that the available evidence does not support ‘breaking the waters’ to speed up labour. Many Midwives still believe this is good way to hasten a slow labour, and often the woman doesn’t get to make an informed choice because the risks are not openly discussed.
This reminds me of the whole argument that women shouldn’t get into a birth pool before 4cm dilation otherwise it’ll slow dilation. The evidence for this is so poor it’s barely notable, but we’ve still got our local NHS trusts trying to keep labouring women out of the water for as long as possible. Would love to see a post on this in the future!
X
Thanks Caroline
One of the problems is that this is a culturally normal practice and midwives have experience of doing an ARM and birth happening quickly afterwards… forgetting all the times when this is not the case. For women who have previously had a baby it does seem to speed things up – anecdotally. But I think we need to question the notion that a ‘quick labour’ is better.
As for waterbirth. Michel Odent provides a good physiological explanation about why contractions can slow when a woman is in water… but she can always get back out again… and slow might be what she needs at that time. I don’t think it is a reason to stop a woman getting into the pool when she wants to. Anyhow, I have waterbirth on my list of subjects. I just have a thesis to write first and then a big conference. Normal posting should commence in March. 🙂
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Rachel, I recently saw a photo of a baby born in the caul completely. Whole baby in intact membranes full of fluid, outside the body, but the picture was cut off just at one end….. How can the whole baby be born without ROM seeing as the membranes are attached to the placenta and the placenta would still be inside. I am SO confused by this.
I think I know the photo you mean (with a nuchal cord?)… I think it was a caesarean operation. They must have removed the baby without cutting the bag of membranes. If you look to the left of the picture you can see the woman’s skin (painted with betadine) and the sac ‘disappears’ into her abdomen ie. is still attached to the placenta inside.
Ah, that explains it. And now that i look closer it does look like its in theatre. This was the photo: http://www.therealsupermumblog.com/2013/01/veiled-birth-image/
Much shorter distance though the abdominal wall than the birth canal to the top of the uterus! (?)
Yes, that’s the photo I’ve seen but a wider shot with operative area visible. This one has been cropped to exclude the mother’s skin. Usually they cut through the membranes at c-section – no idea why they didn’t. But yes, not the same stretch required compared to when the sac is pushed through the vagina. 🙂
Greatly informative! Thanks for posting! Just two errors detracting. Please edit. Thanks 🙂 “After 40 weeks gestation around 20% of baby’s will pass meconium… ” I think you mean “babies”. Also somewhere “describes” should be “described”. Just trying to be helpful.
Thanks! I’ve edited… 🙂
I didn’t know about Caul or veiled births until my little one arrived en caul last year. I had an amazing birth, controlled with breathing techniques I learned at Daisy classes for 3 months and I swear that is why she was born this way. It was amazing and the midwives literally examined me once and let me get on with what I felt my body needed to do. I assumed my waters would break or would be broken but with my second due in August I will want to avoid intervention as much as possible. She was not born as a water birth and I also think giving birth without intervention helped me recover too. I can’t imagine giving birth laid up on a bed, Active birth is definately the way to do it 🙂
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I would really like to pin this on pinterest. Any chance you can add a pinterest button?
tis done 🙂
Thank You! Pinterest kept telling me it couldn’t find an image before.
Please correct your misinformation in your “anatomy and physiology” section. With that being so grossly incorrect, it’s difficult to trust anything else you have posted.
The amniotic sac does not secrete anything. Let alone “most” of the amniotic fluid.
Amniotic fluid is composed of fetal urine when the kidneys begin functioning.
The baby swallows the fluid, and urinates it out again- that is how it is circulated. It does not go into the placenta.
The amniotic fluid also aids in development of the lungs. The fetus breathes amniotic fluid to expand and develop mature lung tissue. Once lung development is mature (past 34ish weeks), there is no further function for the amniotic fluid in the respiratory system.
Thank you for bringing my attention to this… I have edited the post where needed. I had already included the lung development function of amniotic fluid. What are your thoughts on the routine use of ARM in labour?
actually, the amniotoic sac does secrete something; the mebranes are composed of two layers, the amnion, which is closer to the fetus and the chorion which lies outside the amnion, and closer to the cervix. The chorion (outer layer) produces prostaglandin dehydrogenase (PDHG) which breaks down prostaglandin PGE2, which is produced by the amnion (inner most layer) during pregnancy. The importance, prostaglandin promotes softening and shortening of the cervix, which we don’t want to happen too early, so the chorion secretes prostaglandin dehydrogenase to counteract the prostaglandin PGE2 until the pregnancy reaches term and then less PDHG is produced and PGE2 can ripen the cervix.
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Please what if a baby died at 7months and no water came out during labour till the baby was born?
So, so sorry for this baby, but there is nothing unnatural with no water coming out til the baby was born, as you say. If we do not intentionally rupture the membranes they will often not break or leak fluid during labor, but will break at the time the baby is being born, or just before. During the second stage of labor, which is when the woman feels the urge to start pushing. This is natural.
I’m sorry you lost your baby. Irene is correct. Often there is no water seen until the baby is born.
My first was supposed to be in birthing center. They broke my water, found meconium then said I couldn’t use birthing room. I had to go to Labor & Delivery. Then they gave me shot “to take the edge off” even though birthing plan clearly said “Do NOT offer drugs”. Had my 2nd at home with midwife. Wish I had more kids, but didn’t happen for me. They would’ve been at home. It was the most beautiful, educational and natural experience of my life. I cannot imagine anything to that magnitude.I wish everyone could feel that experience.Thank you for reminding me after so many years. They just turned 18 & 21.
Very informative… thank you!
when my first son was born in trenton ont canada there was only one doctor for miles around and not a single mid-wife. he was a month over due, and i had gestational diabetes so i gained almost 150lbs, ( went up to 256 from 106). the birth was very difficult and long, as he was the largest baby born in the area for over 70 years. max had been followed by the new england medical journal during his first 10 years of life, not sure after that. he was almost 3 feet tall, had 2 teeth no soft spot and held up his own head from the day he was born. (he is now a young man of 22, at almost 7 feet tall and 420 lbs. he has aspergers autism, not sure if it was from the forceps birth or not, as it took 3 nurses and a doctor to pull him from me, he was suffering from lack of oxygen, and it took them a long time to get him to breath, more than 7 minutes.) i received too many stitches, over 200 inside and out. when the doctor cut me, to relieve the pressure, the pain went away, but they cut me in every direction ,like a huge cross, down both legs too. my question is after i had given birth and went home a week later, so 2 weeks after delivery i had the sack and part of the umbilical cord stuck half way in and out of me. i called the doctors office and he told me to sit on the toilet and yank it out. which i did and have had serious health problems ever since. within days of doing this when i went in for my exam, i vomited all over the doctor the second he put that pap smear duck bill thingy in me, i was rushed to hospital resulting in a full hysterectomy and many lapiroscopies over the years. was this normal? not one doctor will give me a straight answer…
No this is not normal. I am sorry you have had to experience this. I think you would benefit from talking/debriefing with an independent person who is not protecting themselves or anyone else… it sounds like they left placental tissue (sac and cord) inside you and you then developed a severe uterine infection. I hope you get some proper answers from someone.
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In light of the data coming out over the oast few years on the magnificent importance of maternal vaginal flora on baby’s microbiome, GI health, and overall health, how do babies born in the caul fare? Similar to those born via cesaren, without exposure to mom’s vaginal flora? I wonder if this has been looked at clinically. Thanks for a great post!
Yes – that is a great point. I discuss this in my presentation ‘birth from the baby’s perspective’ and plan to update this post to include this issue. The issue has not been looked at clinically as far as I know. But, your theory makes sense in terms of physiology… unless the baby is born into water and obtains maternal vaginal flora from the pool water.
Hi Rachel,
Absolutely love your work. Your website is usually my first go to when starting research on many topics. I am just enquiring to whether you might be able to share your reference list for this particular article. I am a third year student of the B.Mid course through SCU and have a practice improvement plan as a group assignment- we have chosen to address the problems associated with the liberal use of ARM.
Hi Anita
Most of the information is in any good physiology text book (eg. Coad and Dunstall – anatomy and physiology for midwives is the one I generally use). I have included links in-text to research where appropriate and where I step outside of the general physiology textbooks eg. the cochrane review on ARM, effects of amniotomy, etc. If there is anything in particular you are looking for a reference for – let me know. The physiology and the cochrane review together create a good basis for arguing against the liberal use of ARM 🙂
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Thanx for this info on the infamous ‘waters’. I recently helped a woman birth her baby in a caul…i was so excited i forgot to ring buzzer for 2nd midwife!! Its been years since i have seen this as in hosp birth interference prevents this. I will print this and share with both obstetric/midwifery colleagues!!!
In Poland doctors and midwives use to say “It is better to do episiotomy than to tear”. Do you have any amazing article about this topic/argument? Will be grateful:)
No that is not true and most obstetric guidelines no longer advise this. An episiotomy increases the chance of a larger tear occurring and it does not heal as well as a tear. You can find more information about perineums in this post: http://midwifethinking.com/2010/08/07/perineal-protectors/ with a link to guidelines. It could be considered assault, battery and negligence to injure a woman’s perineum with an episiotomy.
Another excellent post! I wish every OB would read this…wishful thinking?!
Hiya, great article as always. As a midwife I always reflect on my practice and yesterday I was quite emotional when after 2 hours of the woman demanding that I break her waters, not just stand there (which I wasn’t) but get her baby out, I concededed to do this but only informing her of my reluctance, the risks of doing so and making sure I was to do it with her permission. I agreed and performed an ARM, the first in 8 years and my fears were realised, she didn’t progress as she wished, developed a thick anterior lip, which she pushed against and started to bleed. I knew it was her choice and even though I vehehemently believe in the physiological process and tried to delay the procedure, I couldn’t refuse her wishes. Fortunately, she did end up with a vaginal birth another 2 hours later but I felt so responsible thinking that she came so close to having a caesarean. It certainly reinforced my belief against ARM and hope I can find another way to empower some women to trust their bodies.
You did your job as a midwife… provided information about the risks of a procedure and supported the woman’s decision – despite disagreeing with it. The decision was her’s to make, and the responsibility for the outcome is also her’s. It is difficult, but as midwives we have to remember that it is the woman’s journey 🙂
Thank you for sharing such a clear and concise review of the membranes and their important purpose/role! From being trained as a CNM in the USA I can tell you that breaking the waters before pitocin/syntocin is not routine. When I first started working in Australia I was quite shocked and alarmed how routine and often ARM occurs in Australia. This could be a rumor but I was told by another midwife that the doctor that had written about amniotic embolism as being a potential risk to having membranes intact when starting a pitocin/syntocin drip had made it up because the research journal said they needed more risks put into the article. Anyone else heard this before? Wonder if their is any research to support or refute this claim. Another interesting thing that you brought up was the colonization of normal flora by being born vaginally. How does a water birth effect this? I would assume that colonization may be less or diluted due to the immediate washing of the skin…this is why it is theorized or maybe their is research to support GBS colonization is less in water births.
Thanks again for your insightful posts.
The fluid embolism story is from Michel Odent and was about waterbirth. He wrote an article about waterbirth and was told he had to include risks… he ended up making up a theoretical risk of fluid embolism and it has stuck. There has never been a fluid embolism caused by waterbirth to this day.
I am aware that in the US ARM is not necessarily part of the induction process… if you read some of the previous comments there has been some debate around this issue.
Michel Odent also argues that waterbirth can reduce the risk of GBS colonisation… not sure if there is research to back this up as I have not investigated (yet). I would imagine that water would dilute flora, but maybe only a little is needed to start the colonisation process. There would be flora in the pool water if the mother had been in there for any length of time.
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bhe io non ho avuto un parto naturale ho avuto il cesareo perchè con la mia ginecologa abbiamo deciso di farmi partorire con il cesareo perchè io non mi facevo toccare lì sentivo fastidio e dolore e allora ho scelto di partorire con il cesareo è il mio primo figlio e l’ultimo
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Thank you for your post. My son is two years old now, and I still feel angry sometimes that my dr broke my bag of waters during delivery. She never discussed it with me, never asked for consent, just advised me she was doing it. I was handling things up until then, things were hard, but I was managing. Then the pain was really bad and I had to get an epidural, and then eventually a c-section. Not what I had in mind at all. It really pisses me off.
Natalie – would you be willing to write a letter to the dr or hospital involved? There are lots of angry women out there and the people making them angry often have no idea about the long term effects of their practice… it might just prompt some reflection.
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I’ve been wondering about this lately! Specifically, the PAIN aspect. I’m 31 weeks pregnant with my 4th child…. My first was a c-section and the next two were VBAC’s…. With the 2 VBACS I went to term and stayed at home as long as possible during early labor (so happened that it was all throughout the night each time) and then went in to the hospital when I felt I needed to the next morning. Both times I was admitted at about 3 cm dilation. Now here’s the thing…with both vbacs I was mentally prepared and ready for a natural drug free birth. Knew what I was doing. First vbac I was told to walk around the hospital to get my labor going and dilate more… I went outside, walked for 30 minutes when I felt my waters break in a big gush. I went back inside and they got a room ready for me but within 30 minutes from my water breaking I yelled out that I felt the need to push, and of course everyone ran in, and my daughter was born very quickly just minutes later. It was so painful that I begged for an epidural. I felt I was out of my mind with pain and could not cope. I thanked God later it went so quickly, but the pain haunted me for a long time afterward. With the 2nd vbac I was so exhausted from no sleep the 2 days prior, and went in a little early due to being GBS postive, knowing I was going to have to get those 2 doses of antibiotics… anyway I went in and measured about 3cm upon admittance… then things just kind of stalled out. I tried bouncing on the ball, walking was out since I was on the IV but truth be told I was so exhausted and just wanting to lay in the bed…. contractions would not organize when I laid down, only when I was up… My dr came in and offered to send me home but at 41 weeks and with no sleep and already being on an IV I said, no way, I am having this baby today. He offered to break my water and I gladly accepted. I loved my DR and he was very hands off and supportive of my vbac and no interventions request, but he did what I asked him to do. I was 4cm at that point. What followed was such agonizing pain… I immediately felt a HUGE contraction (and I had been stalled out by that time, having only minor ones)… I felt such a huge difference, it was immediately SO painful… I was so tired… it got so much worse and I remember praying out loud to God to help me. I felt out of my own body and felt I was dying. I was screaming at the top of my lungs with pain. There was no moving around in the bed, I felt frozen on my back because of the intense pain. My 2nd daughter was born so quickly, again just 30 minutes after the membranes were ruptured. So, now as I prepare for my 4th child and 3rd vbac, I am really anxious about this! Could my waters breaking early and then being broken early have caused me extra pain? From what I’m reading it sounds like YES! I am fascinated by this, and know that I will not be letting anyone break my water this time! What are your thoughts on my 2nd vbac story, and the perceived extra pain?
I guess the only way to know is to have a labour without your waters breaking. It might be that you would experience this intense pain close to birth but breaking your waters got you close to birth quick. Or it might be that it was the waters breaking that = intense pain. Not sure 🙂
This is a very insightful post and it makes me thankful for the choices i made when i had my DS; i was very young, 17, when he was born and i’d never done any specific reading on anything to do with childbirth but when i got to the hospital something primitive took over and i went into some kind of zone that made me unbelievably indignant; and i’m the kind of person who’ll agree to anything. I was very unfortunate to have a bully of a midwife deliver my son; the midwives before the change-over were amazing, then i got the night time battle-axe; reminiscent of an old fashioned matron. She came in, examined me (without asking) and told me i was 8cm and she WAS breaking my waters. She was not, and she did not, my waters went naturally as i started pushing (all over her)
She then insisted i was having an episiotomy; i declined this too – at 17 (well, i guess at any age) the thought of someone cutting your genitals especially whilst your unborn child’s head is right there – no way; she called me stupid. She seemed so smug after delivery that i’d tore and even said “i told you if you didn’t let me cut you you’d tear” there were more disgusting incidents after this but they are irrelevant to my reply.
I honestly believe 100% that in a straightforward, “low risk” labour the midwives need to back off, there is no need for the amount of VE’s women have (i speak from experience, both personal and through hearing about my friends deliveries also) Women were designed to birth babies, it’s what we have done for thousands of years and until the mid-late 20th century they were predominantly home births and often unassisted, instinct kicks in and when you’ve gotta push there’s no stopping it, so why, if everything is straight forward and mum is happy, do they insist on so many interventions? – constant VE’s, ARM, trying to convince you to have pain relief to shut you up (i refused all pain relief, not even a paracetamol and it was an empowering feeling), monitoring, putting time limits on x,y and z, insistence on a caesarian for a breech baby and so so many interventions – forceps, ventouse, caesarian?
Sadly, i truly believe (especially in the UK) it’s the preference of the midwife/consultant/hospital as to whether or not you have ARM, and because there is so much belief behind the speeding up labour theory that it almost becomes the norm; and it’s a well known fact that there is a huge shortage of midwives in our hospitals and it’s almost like a production line, they get you in, get you delivered then move you on. This is not the way it should be, every woman should be entitled (where possible) to the birth she wants but equally, every baby (again, safety allowing) should be allowed to come into the world in his or her own good time, as i mentioned earlier, we are anatomically designed to reproduce, so why the need to attempt to “fix” something that is not broken? Admittedly, these babies will not remember being born as they grow old, but that does not make it any less traumatic.
I am a UK based midwife and was lucky to see a baby born in the caul at Caesarean section a few months ago. The aim was to make the birth as stress-free for baby as possible.
It was a pleasure to see, and I am proud to have worked with this skilled obstetrician.
Well its been a year since my post and I wanted to keep you updated (first post on 2 Dec 2012). First off my son Logan is doing exceptionally well, he is still being breastfed although he has decided he doesn’t want his mid-day milk anymore, he has 12 teeth and is in 75th percentile for his height, weight, head size. He was 1 on November 28th. He can walk unaided since 10 month and copies every word he hears which is hilarious especially when I’m telling my partner to shut up. With regards to the birth, I wrote a letter to the hospital detailing my experience and to my surprise they put me in touch with a solicitor for medical negligence. I was unsure why they reffered me but I thought I’d follow through. Turns out that my hospital papers were doctored and they knew they had faulted. Times, medicines and interventions had need scribbled out and re-written . To cut a long story short I was awarded £13,000. I thought long and hard about what to do with it, I decided that even though the experience was bad, I survived and so did Logan-Jack so I greedily kept £3000 and donated the rest where it matters…to the Neonatal unit. I have a smile on my face every time I see an expecting mother now, thinking I have done something trully amazing… twice.
That is such great news Chloe! Thanks for updating us 🙂
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Hi Rachel
Just wondering if you have any comments on this study: http://journals.lww.com/obgynsurvey/Abstract/2013/03000/The_Efficacy_of_Early_Amniotomy_in_Nulliparous.3.aspx
It seems to me a bit odd, early amniotomy speeding up labour without side effects of some sort, in light of studies like this which suggest during induction it can take a long time to get into active labour: http://www.obgmanagement.com/index.php?id=20667&tx_ttnews%5Btt_news%5D=177246. However, I’m just a layperson. I’d be interested in your perspective.
Hi Anna
The two studies are measuring different scenarios but both focussing on induction. The first study is looking at whether an ARM is more effective earlier or later. I’m not really surprised with the findings. In the hospital I have working in UK and Aus the induction process involves early ARM. On the occasions that this was not done, or when a woman was augmented for ruptured membranes – syntocinon + intact amniotic sac = ineffective contractions. In fact you could ‘diagnose’ intact membranes by the contraction pattern. And induction itself has side effects… the timing of the ARM is probably not going to make a difference to overall outcomes because it is the syntocinon in particular that creates the complications… both groups had that.
The second study… again not surprised. If you are controlling a labour by inducing it you will get a slow initiation ie. the process of getting the cervix soft and responsive and then breaking waters (can take a day or more). Once syntocinon is going it should be as quick or quicker than an un-induced labour. They did not take this into account in the findings:
“Harper and colleagues did not stratify their findings by favorability of the cervix at the time of induction. Women who required cervical ripening had a slower labor than did women in spontaneous labor until they reached 6 cm, at which point labor patterns converged. Of interest, women who had a favorable cervix at the time of induction had a faster labor than did women in spontaneous labor, largely as a result of shorter times to reach 6 cm.”
Remember that these studies are not investigating ARM during spontaneous physiological birth.
I should probably add I had ARM at 1 cm during induction (and don’t quite understand from my records why further cervical ripening wasn’t suggested) upon which things went majorly downhill leading to c-section decision within about 3.5 hours. Just trying to understand my experience a little bit better (I’m a physiologist so can’t help overanalysing!)
The assessment of the cervix should take into account a number of factors – not just dilatation. You could have a very soft and ready 1cm cervix and a very hard and unready 3cm cervix. If the induction went ‘down hill’ so quickly I’d be interested in why… was it a response to syntocinon ie. fetal distress? With that timeframe it is unlikely that further ripening would have made a difference… if you had ended up with a c-section for ‘failure to progress’ ie. your cervix did not respond to syntocinon then maybe more ripening would have helped it be ready…
And it is OK to overanalyse 🙂
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Hello MidwifeThinking,
I had the great pleasure of being accoucher to a birth in the caul today :-), not a water birth, the baby was placed onto the mother in the caul, the membranes then broke as I manouvered to free the cord from the babies neck (it was loosely round once, obviously still inside the membranes). baby cried spontaneously and proceeded to ‘full’ skin to skin.
We had a delayed cord clamping, with the mother and birth support persons all feeling the pulsating cord :-). Once the third stage was completed I talked to the mother and family about how ‘special’ the birth had been, to also explain why the mother was so wet, and warn there may be some ‘bits’ sac in the bed. Sure enough, when the mother got up to shower, she found a large piece of what now looked like soft/rubbery skin …. this ladies third birth was indeed very special for her, and provide for me, a hospital midwife the kind of energising experience we need from time to time.
Thank you for having the website available for me to check back with on topics and scenarios that occur.
Thanks for sharing Susan 🙂
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First of all, I love your blog! Thank you for the information. Especially this post. I may be able to shed some light on your question about microbiotia in a “land” caul birth. I had both my daughters at an amazing free standing birthing center.
My first, my water did not break until I was pushing, yet people always want to know why my midwives didn’t break it. Because it didn’t need to be broken!
My second daughter was born in the caul, not a water birth. I was on my hands and knees and deliveries her with waters intact. Naturally I was delighted as I had always found in caul births to be fascinating.
I soon noticed that my daughter threw up a lot after nursing. Not your normal baby spit up, but constant throwing up. Never seemed to brother her though. I went on elimination diets (what a pain) thinking she was allergic to something in my breastmilk. Nothing helped. We had to continually shampoo our carpet from milk stains.
Finally, my mother (who had 12 babies) mentioned that she might have missed essential bacteria in my birthing canal, a problem reported among c-section babies.
With this in mind, I began to grind up probiotocs and coat my nipple with the powder so she would take it while nursing.
Problem solved! She is almost a year now, healthy and happy and on the rare occasion she seems to have tummy problems, I give her probiotics and she is fine.
Thanks for the information, hope my experience helps other moms with this problem.
Thanks for sharing your experiences 🙂
First of all, I love your blog and I read your thesis – it was really interesting, it made me understand a lot more why the hospital does what it does. Thank you for sharing it.
I just recently had my third baby in at a birth center in QLD. My hind waters ruptured spontaneously (although didn’t know it was only hind waters til I was actually in labour), but bub wasn’t born until 55 hours later. We delayed induction as long as we could and baby fortunately came before the planned induction.
I had labour stop and start a number of times during that 55 hours with painful contractions for a few hours at a time that would eventually stop. In one such episode we called the midwife and she said to come up to the birth center. Contractions were still all over the place at this stage and not particularly painful (and the induction was planned for the morning). I had hopped in the shower to relax a bit and the baby’s heart rate had dipped to 116 – we had refused continuous monitoring and the midwife asked us to get out of the shower so she could have a better listen to baby and to examine me. She examined me and I was 4cm and forewaters were still intact. She asked to break my waters – which I agreed to – hell i would have agreed to anything at the point I was so tired (physically and emotionally) and angry with my body for “failing” me. The membranes were tough and it took her a number of goes to break them. After they were broken she noted that baby was posterior too. I thought I was in for the long haul, however just 50 minutes later baby was born. They were the most painful and out of control 50 minutes of my life. I felt like I was being run over by a train constantly. She checked me again during the labour because I was getting pushy – Cervix was 6cm, baby was -1 and still posterior – but she was born 19 minutes later. It was so intense and out of control, a far cry from the beautiful waterbirth I’d experienced with my second and was hoping for again.
I know it’s hard to say because you weren’t there. But after the event I was just so surprised that the midwife would even offer to break them. Usually BC midwives are so “hands off” – and in fact everything else was hands off. I had a physiological 3rd stage and my husband caught the baby with the MW just watching on. So everything else was great. Do you have any idea why she would ask to break them – was it to keep the labour going to avoid induction, maybe concerns about the heart rate?? I know you don’t “know” – I’d just be interested in your guesses.
I keep swaying between if she hadn’t have broken them, maybe labour would have stopped and then we would have been induced in the morning, but maybe by her breaking them it made the labour too fast?
Based on those set of facts, was there due cause (in your opinion) to break the forewaters, given the hind waters had already broken. Do you think that breaking the waters led to that fast labour or do you think that the days of pre-labour just paved the way for a quick delivery?
Will you get a chance to debrief with the midwife and ask her? Sometimes breaking the waters does speed things up for a woman who has had previous labours – so maybe she wanted to speed things up due to concerns about the baby’s heart rate? The forewaters have a different function to the hindwaters… and in a syntocinon induced labour forewaters can result in uncoordinated and ineffective contractions which is why during the induction process they are broken before syntocinon starts (in the UK and Aus). I realise that you were not having an induced labour. So, I’m not sure why your midwife suggested breaking your waters… I think you should ask her 🙂
Thanks for responding. 🙂 I did get a debrief, but at the time I hadn’t had a chance to really process what had happened and so didn’t think to ask. I’ll ask and see if she responds.
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My OB broke my waters with an instrument that has left a decent hole in my baby’s head. He is now 4.5 mths and the hair as not grown back and the hole appears to be getting bigger as his head grows. I have looked everywhere and cannot find another example of this… Has anyone out there experienced this?
I am sorry this happened to your baby. Unfortunately I have seen damage to babies heads following artificial rupture of membranes. Have you had your baby medically reviewed?
Love the article! Looking for info on how to help a stuck membrane out after birth? Its just hanging there and sometimes goes back up and then cramping occurs. THANKS for the info!
You may have retained ‘products’ ie. membranes in your uterus. They need to come out as there is a risk of bleeding and/or infection whilst they stay inside. Have you informed your care-provider?
Thank you for the information. A dear friend is pregnant with her second and she is scared to death as her doctor told her she would die if she had another child because after the delivery of the first, her sac came out in pieces. They gave her a shot to help expel it. As far as i know, she had no further troubles with her womb after delivery. I would like to reassure her that nothing of the sort (her dying) will happen but i don’t actually know whether her previous condition puts her at risk or not. I think it is very irresponsible for a medical ‘professional’ to tell a young woman something like this.
It sounds like she had ‘retained membranes’ – which can result in bleeding… but it is a bit dramatic to suggest could die from this. The situation is easily managed (as it was with her first birth). Retained membranes can happen when the placenta is pulled out by a practitioner. Physiological birth of the placenta is unlikely to result in tearing of the sac. Your friend may be interested in this post: http://midwifethinking.com/2012/05/05/an-actively-managed-placental-birth-might-be-the-best-option-for-most-women/ When the body expels the placenta, it expels the whole ‘package’. However, if someone pulls they can tear bits off.
Hi my friend just gás a babou boy, her water didn’t break but she had part of it out her vagina like a big white ballon sticking out. What does that mean??
During labour this is common. When the cervix opens the sac and waters bulge down through the cervix and vagina. It helps to open the cervix and stretch the vagina ready for baby to move down and out. It does look strange… like a balloon 🙂
My daughter had a baby girl in Cork University Hospital , Co. Cork, Ireland on Monday the 25th of June she weighted in at 6 Ib 13 oz. She was born completely inside the sac. She was told this was very rare. However there was no fuss made about it at the time. How rare is it? She is the third child but is so quite she is like a little angel her name is Jessa Grace.
It is generally rare as the waters are usually broken by the care provider during labour or they bulge out of the vagina just before the baby. However, it is fairly common without these interventions… particularly during waterbirth – possibly something to do with water pressure vs air pressure. If I had to estimate I reckon about 10% of water births and less than 5% of land births – but that is just based on my own observations 🙂
I am 26 and want to try to have a baby very soon. I am terrified of amniotic fluid embolisim and preeclampsia. I was never afraid of pregnancy not until i started really to think about it and do research and came across alot of horror stories and good ones too but my mind focuses on bad ones. I do not know why i do this but im freaking myself out.
I guess because no guarentee you can stop AFE from happening and almost guatenteed dead when does happen 🙁 so praying doesn’t happen to me. Is it true that while laboring your uterus vessels opens up so everyone gets amniotic fluid in their body just depends how your body responds to it?
Also i want to have a water birth when time comes will that prevent tearing?
Hi Ashleigh
It sounds like you have a lot of concerns about pregnancy and birth. There are no guarantees with birth. Most of the time all goes well. I think you would benefit from continuity of care with a midwife (or doula) who can help you work through your fears. Pre-eclampsia is not uncommon but can be managed. AFE is very rare. Waterbirth reduces your chance of tearing.
Ashleigh, so weird you are writing this. My name is Ashley also! I am 6 months pregnant and terrified of amniotic embolism and I mean terrified. This is my second pregnancy and did not feel like this at all with my first. I cry and think about it 24/7 that its gonna happen to me. I don’t know how to get over my fear, it makes it hard to be excited, don’t get me wrong I am so grateful for being pregnant and having a healthy first son, I just can’t get over the fact that I could potenionally only have 3 months left. Am I crazy???
It is normal to fear childbirth to some extent. But what you describe is not normal and you really should seek some support. You are not crazy but you do need some help so that you can put the risks of birth into perspective. I’m not sure where you are, or what is available to you – but please reach out.
This is wonderful to read, I had my first child 7 weeks ago. My intuition sounds like it might have saved me from quite a bit… Went into the hospital dilated to 5cm & 100% effaced at 2am. The L&D nurse handed me a paper about epidurals & asked me to read it & sign the 2nd page. I read it & told her I wouldn’t sign it. It read “The above had been explained to me by an anesthesiologist & I consent to receive epidural anesthetic.” Looked at her & said “1 you aren’t an anesthesiologist and 2 I’m not currently consenting.” Guess she thought she was dealing with a normal first timer & she could railroad me…. Then she went & got setup for an IV with pitocin. I said WAIT A MINUTE! I asked for only a Hep Lock IV port to be put in, she balked & said the OB would have to approve that. I asked her to get it approved because I wanted to be able to walk around/shower etc during my labor. The house OB was happy to approve the hep lock IV port & encouraged me to walk around as much as I was comfortable with. I had gone to the hospital at 2am & my OB checked me at 5:30am was dilated to 6cm & he wanted to break my water as it hadn’t yet. I asked him about pros & cons of the procedure & only got that it could speed up my labor & make my contractions more regular (every time I laid on the bed for monitoring etc, my contractions became unbearably painful & stopped being at regular intervals, while walking or standing they were just not while lying down!) He really didn’t give me much info so I was hesitant with having it done & said no. (I’d only been at the hospital for 3 1/2 hours, give me some time! lol) So I labored in the shower for a bit & then went back to walking, things got pretty intense about 9am & I was begging the nurse to find out where my dr was as things felt different! had intense pain in my lower back with every contraction, she said it was back labor & they’d call my dr. She brought me a birthing ball to help ease my back labor. At 10am I was demanding to know what was taking so long with my dr lol (was using some colorful terms) they offered to have the house OB check me as my dr was on his way in. NO PROBLEM!!!! lol OB was checking for dilation & said something is bulging as my water broke! was fully dilated & baby was at +3 she was coming!!!! my OB arrived as I was starting to push, had my little girl out in only a few pushes at 10:42 am. For all the fear people have about natural labor, I can honestly say only 2 hours were tough out of days of prodromal labor & being at the hospital in labor not even 8 hours! Just take it one contraction at a time & remind yourself the contraction is bringing you closer to having your baby in your arms 🙂 If we decide to have another there is no doubt in my mind that I would plan for as little interventions as possible again.
My labor was going smoothly and beautifully with no interventions as I wanted. Until the doctor kept forcing and pushing the water breaking to me. I believe he even lied to me that I was not progressing and dilating but by the way that I felt I was progressing, I coupdnt believe it.
When he broke my water, that was the most horrible experience in my life, I should never have succumbed to him forcing me against my objections, it was terrible. Thank God I didnt have a cord prolape or any such comllication, but its scary that this could have happened to me. I tried to fight this system hard but when you are having contractions and scared by what they tell you (just so the labor goes fast for them), it makes me so sad and angry.
Thank goodness all was well, but I would not recommend this amniotomy to mothers. Thank you for this article.
I hear so often from women that “they HAD to break my waters in order for my baby to be born.” Is there ever a true case where membranes MUST be artificially ruptured in order for baby to be born? I understand there are many interventions that require ARM, but I’m asking about normal physiology of labor. ARM gets the credit/blame for so many things!
No – unless the amniotic sac is stronger than the baby and the powerful uterine muscle (which I have never seen) – it will break at some point during the birth process. There are some cases where an ARM can speed up the birth, particularly for subsequent babies. But I can’t think of any circumstances in which the membranes MUST artificially ruptured in order for the baby to be born. Women are often told this though… and it becomes their birth story, feeding the cultural myth.
Rachel can you point me in the direction of research on why many professionals beleive you HAVE to perform an ARM with Synto and why some places don’t do it.
Thanks 🙂
Unfortunately not. I have been unable to find any. From my experience synto is more effective with an ARM. In fact, you can see when the membranes remain intact just by watching the CTG – contractions are all over the place and there is little progress on examination. I have never cared for a woman having synth without an ARM – intentionally that is. I have seen many ineffective inductions because the membranes were in tact and once they were broken contractions became more regular. It seems to be the US that will use synto without ARM. I have worked in the UK and Australia and never seen this. It is important to remember that contractions induced by synto are different to endogenous contractions. This is not physiological birth 🙂
I knew the exact date I got pregnant due it being an isolated occurrence. My son came exactly 40 weeks after. I stayed at home and only went to hospital when the pain was too much (after 12 hours) he was born an hour after in the sac and only gas and air needed and placenta followed straight after without and drug needed. It was the easiest birth I have had (out of 4) and the most relaxed. Even the pregnancy was easy. The only sign of being pregnant was when he started moving I had no morning sickness, I still had periods no heartburn or anything.
I had my child at Sisters hospitol on main street in Buffalo, ny.
BIG mistake!!
I was not given a choice nor was i informed, at all, for many procedures when i had my child. I was frequently lied to.
All of which caused me to labor much longer than i should have. They did NOT follow my birthing plan at all. And lied about not having to follow my birthing plan (by the way … I was required to update my birthing plan every week for the last 2 months of my pregnancy.)
After the birth i found all the supplies that were promised in the birthing plan were in the closet after all!!
Things were going quite well UNTILL… They broke my sac without telling me.
I did not want this nor was i informed it was going to happen. She had just walked in the door and reached in and cut without even introducing herself.
When i objected she snarked at me and said it was required to speed up labor. When i told her that i could feel that he was slidding out nicely already and was now getting stuck she called me a “stupid first time mother so how would you know”!! Then walked out
This was also in my birthing plan not to rupture the amniotic sac.
This caused many complications the during birthing process that I will not get into at this point.
After he was born another person kept tugging on the umbilical cord to remove the placenta and when i objected i was told “what do you know you aren’t medical personnel. Besides this is your first child”
Obviously they had not checked my file… I am quite familiar with the birthing process. I grew up on a farm. And not to mention i do have some medical background. I’ve also had several miscarriages and a couple late term that were essentially vaginal still births.
I even had a staff member tell me that the pelvic bones get in the way and she pressed me down onto my back insead of allowing me to use gravity to help and to seperate my pelvis.
They insisted that i could Not breast feed.
They insisted that i could not hold him immediately because he had to have heat to keep warm. (I could have done this by holding him myself and breast feeding)
My childs father was allowed to hold him immediately after he cut the cord but i was not.
My plan states to Not cut the cord immediately but to wait.
They refused to allow my mother into the room during the birth.
During the several days they forced me to stay they kept taking him away and giving him bottles of formula witout my concent and then blaming me when he cam back and had difficulty latching on to my nipple. Also threatening to get cps involved if i did not bottle feed him with formula. Even though he did begin to latch on propperly and i was using a breast pump to give him a bottle when he would not latch on. (eventually he did get used to both the bottle and the nipple.)
They all bullied me during the entire time i was there. I will never have another child in the hospitol again. I will do it at home.
I am so sorry that you were abused and disrespected by so called ‘care’ providers. I urge you to write a complaint letter to the facility and report the care providers. Warn other women planning to birth there. You could even take legal action for assault and battery because procedures were performed without consent: https://midwifethinking.com/2016/06/15/information-giving-and-the-law/
Thank you for such great information 🙂
I wonder if you can help? I believe I’ve just had a ‘hind water leak’. I’m just over 39 weeks and due in 5 days. But no contractions yet. I’ve experienced lightening already and I’ve had a bloody show about 24 hours before the waters leak. How long would you recommend I wait before seeking help to induce Labour? Or should I just wait patiently and no concern at this stage? Obviously I’m relying a quick response. I hope you can help. Thanks, Fon
I can’t give individual health advice. You need to discuss your situation and options with your care provider. And, you need to make your decisions – this is your body, baby and birth 🙂
You can find information about pre-labour rupture of membranes on this post https://midwifethinking.com/2017/01/11/pre-labour-rupture-of-membranes-impatience-and-risk/
Good luck with your birth 🙂
Thank you 🙂
Thank you for all the effort and time you have put into this. Having such a great resource of information available is so comforting. I wish that all doctors and midwives see this and follow your example.
I’m heading back into your website now to educate myself more 🙂
Hi I had a full term en caul vaginal birth. My question is do you think that the contractions are more intense for mother as the sack adds additional weight and size to the baby during delivery?
I doubt it. The weight of around 500-700mls is not great. The sac squashes = no additional size coming through the pelvis/vagina. And the sac stretches open tissues more gently than a baby’s head.
Thanks for another great update. I hope FB does not temporarily cut me off yet again when I use the link because of their ridiculous restrictions on pictures of women’s body parts?