Piercing the bladder before childbirth, consequences, reviews. How to puncture a bladder before childbirth. Useful video: the need and possible consequences of amniotomy from the point of view of foreign specialists

In utero, the child is protected by a special membrane - the amnion, filled with amniotic fluid. They protect it from shock when moving, and the shell prevents the upward penetration of infection from the vagina.

During childbirth, the baby's head is pressed against the cervix and a fetal bladder is formed, which, like a hydraulic wedge, gradually stretches the cervix and forms the birth canal. Only after this does it break on its own. But there are situations when the bladder is punctured before childbirth without contractions.

This procedure is not prescribed at the request of the woman or the whim of the doctor. Successful amniotomy is possible if certain conditions are met:

the fetal head is presented;
full-term pregnancy of at least 38 weeks with one fetus;
estimated fetal weight more than 3000 g;
signs of a mature cervix;
normal pelvic size;
There are no contraindications for natural childbirth.

Types of amniotomy

The moment of the puncture determines the type of procedure:

Prenatal - is carried out before the onset of contractions, its purpose is to induce labor.
Early - before the cervix is dilated by 6-7 cm, it can speed up this process.
Timely - performed during effective contractions, the opening of the cervix is 8-10 cm.
Belated - in modern conditions it is rarely carried out, it is performed at the time of expulsion of the fetus. Amniotomy is needed to prevent bleeding in the woman in labor or hypoxia in the child.

How is childbirth after a bladder puncture? The process of the birth of a child in this case does not differ from the natural one. In any case, the condition of the fetus is monitored using a CTG machine.

Indications for bladder puncture during childbirth

Bladder puncture stimulates planned labor or is performed during it.

Labor induction using amniotomy is indicated in the following cases:

gestosis, when indications for urgent delivery appear;
premature placental abruption;
fetal death in utero;
post-term pregnancy;
severe chronic diseases of the cardiovascular system, lungs, kidneys, for which delivery is indicated from 38 weeks;
Rh conflict between mother and child;
pathological preliminary period.

The latter condition is the occurrence of small contractions over several days, which do not develop into normal labor. This causes intrauterine suffering of the fetus from lack of oxygen and fatigue of the woman.

How long will it take for labor to begin after the bladder is punctured? The onset of labor is expected no later than 12 hours later. Although nowadays doctors do not allow that much time for waiting. Prolonged stay of a child in a waterless environment increases the risk of infection. Therefore, 3 hours after opening the amnion, if contractions have not begun, stimulation with medications is used.

When labor has already developed, the puncture is performed according to the following indications:

The cervix dilated 6-8 cm, but the water did not break. Their further preservation is impractical; the bubble no longer fulfills its function.
Weakness of labor. Puncture of the bladder in most cases leads to its activation. After amniotomy, wait 2 hours; if there is no improvement, then resort to stimulation with oxytocin.
Polyhydramnios overstretches the uterus and prevents normal contractions from developing.
With oligohydramnios, a flat amniotic sac is observed. It covers the baby's head and does not function during childbirth.
A low-attached placenta may begin to separate as contractions develop. And opening the amnion will allow the fetal head to press tightly against the lower segment of the uterus and contain abruption.
In case of multiple pregnancy, the bladder of the second child is punctured 10-15 minutes after the appearance of the first.
High blood pressure decreases after autopsy.

Technique for puncturing a mother's bladder

30 minutes before inducing labor, the woman is given the antispasmodic Drotaverine by puncture of the bladder.
Later, an examination is carried out on the obstetric chair, the doctor evaluates the neck and the location of the head.
With a sliding movement of your fingers, a special jaw - a hook - is inserted into the vagina.
With its help, the membrane clings during contractions, and the gynecologist inserts a finger into the resulting hole. The tool is removed.
Holding the fetal head through the abdomen with the other hand, the membranes are carefully separated and the anterior amniotic fluid is released.

They are collected in a tray and their condition is visually assessed. Green water with meconium flakes indicates intrauterine fetal hypoxia. This condition deserves additional attention. The pediatric service is notified in advance of the child’s possible condition.

If a large volume of water is drained at once, this can lead to the loss of umbilical cord loops or small parts of the fetal body.

After the procedure, the mother in labor is connected to a CTG machine for 30 minutes to assess the baby’s condition.

Is it painful or not to puncture the bladder before giving birth? The membranes are not penetrated by nerve endings, so the procedure is absolutely painless.

However, complications sometimes develop:

traumatization of the umbilical cord vessel if it was attached to the membrane;
loss of umbilical cord loops or parts of the fetal body (arms, legs);
deterioration of the fetus;
rapid labor activity;
secondary birth weakness;
child infection.

How long does labor last after bladder puncture? The duration depends on their parity or quantity:

In primigravidas, the normal duration of labor is 7-14 hours.
Multiparous women require less time - from 5 to 12.

Contraindications for bladder puncture in a pregnant woman

Despite the simplicity of the procedure and the small number of complications of the manipulation, there are serious contraindications for its implementation. Most of them coincide with contraindications for natural childbirth:

Herpetic rashes on the perineum will lead to infection of the child.
Pelvic, leg, transverse or oblique presentation of the fetus, umbilical cord loops in the head area.
Complete placenta previa. Childbirth in this case is impossible - the placenta is attached above the internal os and prevents the lower segment of the uterus from unfolding.
Failure of the scar on the body of the uterus after cesarean section or other surgical interventions.
Narrowing of the pelvis 2-4 degrees, bone deformities, tumor processes in the pelvis.
The weight of the fetus is more than 4500 g.
Rough scars causing deformation of the cervix or vagina.
Triplets, conjoined twins, breech presentation of the first child of twins.
High myopia.
Delayed fetal development 3rd degree.
Acute fetal hypoxia.

In the absence of the listed contraindications, amniotomy is a safe procedure and does not affect the condition of the fetus.

Yulia Shevchenko, obstetrician-gynecologist, especially for the site

Useful video

Throughout pregnancy, the baby is surrounded by amniotic fluid, which reliably protects it from external irritants. With the onset of labor, with each contraction of the uterus, compression of the amniotic sac occurs, which in turn puts pressure on the internal os of the uterus, promoting its opening. Normally, with complete or almost complete dilation of the uterine pharynx, the amniotic sac ruptures, followed by the release of amniotic fluid. In some cases, there is a need to perform an amniotomy - surgical puncture of the amniotic sac.

What is a puncture of the amniotic sac?

Amniotomy is a procedure in which the doctor performs an instrumental opening of the amnion using a special surgical instrument that resembles a hook. After a vaginal examination, under manual control, the doctor carefully inserts the instrument into the cervical canal, makes a small hole in the amnion, and then stretches it with his fingers. The procedure does not require special preparation or anesthesia.

IMPORTANT! Amniotic fluid is conventionally divided into “anterior” and “posterior”. After amniotomy, only part of the “front” waters pour out, so the stories about difficult “dry” births that are replete with forums are nothing more than fiction.

Puncture of the amniotic sac: main indications

There must be good reasons for opening the amnion, because the procedure is performed in only 10-15% of all births. The need for amniotomy arises in the following situations:

If your pregnancy is over 41 weeks
In case of complicated pregnancy, for example, late gestosis, when it is necessary to speed up the progress of labor to alleviate the condition of the mother in labor
In case of development of a condition that threatens the fetus (partial placental abruption, low-lying placenta, umbilical cord entanglement, long anhydrous period)
Weakness of labor, as well as factors that may contribute to this (overstretched uterus with polyhydramnios, twins, physical fatigue of the woman in labor, cervical dilatation more than 7 cm, flat amniotic sac)
Presence of Rh conflict

IMPORTANT! Mandatory conditions for puncture of the amniotic sac are full-term pregnancy and the weight of the fetus in the cephalic presentation is more than 3000 grams. Despite the simplicity of the procedure at first glance, amniotomy is a kind of surgical intervention, and therefore is carried out only after obtaining the consent of the mother in writing.

Puncture of the amniotic sac without contractions

It happens that amniotomy is performed long before the onset of labor. As a rule, the main purpose of such manipulation is to stimulate labor. Opening the amnion in the absence of contractions is performed in the case of preliminary preparation of the birth canal with special preparations, as well as in the case of a pathological preliminary period in the mature birth canal.

Puncture of the amniotic sac during childbirth

Amniotomy during active labor is performed more often than others, as it is aimed at accelerating the labor process and increasing the efficiency of contractions. Opening of the amnion during labor is divided into: earlier, timely and late. An early puncture of the amniotic sac is done when the uterine pharynx is dilated to less than 7 cm, in case of weakening contractions. Timely amniotomy occurs when the amnion does not open spontaneously when the cervix is almost fully dilated. A belated puncture of the amniotic sac is carried out when the baby’s head is already lowered into the pelvic outlet cavity to facilitate birth.

Puncture of the amniotic sac: risks and consequences

Almost all pregnant women are interested in the safety of the amnion opening procedure. As a rule, if the manipulation is carried out correctly and all mandatory conditions are met, amniotomy does not carry any risk. It should be noted that the presence of polyhydramnios and other factors that contribute to hyperextension of the uterus during the opening of the amniotic sac can lead to arbitrary prolapse of the umbilical cord loops, which is an indication for emergency surgical delivery. To avoid the development of this complication, as well as to prevent bleeding during the manipulation, the main condition must be met - the fetal head is lowered into the pelvis.

If labor has not begun after early amniotomy, there is a risk of developing infectious complications with a long anhydrous period (more than 24 hours).

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

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

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

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

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

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

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

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

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

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

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

The culture of obstetrics goes back to those ancient times when humanity realized itself as a species. It was replenished with new rituals based on practical knowledge until it turned into a full-fledged scientific discipline. When women in labor enter a medical facility, they rely on the qualifications of the staff, but still often doubt the advisability of certain manipulations. Amniotomy - opening of the amniotic sac - always raises numerous questions and conflicting reviews.

Amniotic sac: what is it and why is it needed?

The baby in the mother’s tummy is protected from shocks, infection, temperature changes and unnecessary noise. This is possible thanks to the amniotic sac. It is a dense but elastic shell surrounding the child. Its formation occurs at 4–5 weeks of pregnancy simultaneously with the placenta.

The amniotic sac is filled with amniotic fluid, which acts as a protective “pillow” for the baby. In the 2nd and 3rd trimesters, the baby not only swims in the amniotic fluid, but also swallows it.

The baby in the amniotic sac is protected from injury and infection

During my 2nd pregnancy, my baby doll, a couple of months before giving birth, happily posed for an ultrasound, funnyly opening his mouth and swallowing amniotic fluid. It looked very cute and at that moment caused an influx of aching tenderness in my heart.

The amniotic fluid has a constant temperature, which ensures a comfortable existence for the baby. Doctors determine the child’s condition based on the type and composition of the fluid. By the 39th week of pregnancy, the clear waters begin to gradually become cloudy. This is considered the norm and should not cause any concern for expectant mothers. But a sharp darkening of the waters and the appearance of a greenish tint indicates the entry of original meconium into them, which leads to the development of intrauterine infection. Therefore, such changes in the color of the amniotic fluid become a reason for an emergency caesarean section.

Functions of the amniotic sac during childbirth

Nature has thought of everything for us, so natural, normal childbirth can occur without medical intervention. A woman’s body is a perfect mechanism that can do everything to help the baby see this world.

What happens to the bladder during contractions? The actively contracting uterus causes fluid to move and part of it flows to the cervix. This amount usually does not exceed 200 milliliters. A kind of water cushion is formed between the baby’s head and the cervix, protecting the fragile bones of the skull from possible birth injuries.

But this is not the only function of amniotic fluid. As contractions intensify, the cushion of water puts pressure on the cervix, which stimulates its dilation. This type of birth is considered the norm throughout the world. When dilated by 6 centimeters, the amniotic sac spontaneously ruptures, as the pressure exerted becomes too strong for the thin membrane.

After the water breaks, the baby's head enters the birth canal and the contractions intensify. Usually the baby is born 6–7 hours after the water breaks. Obstetricians also associate this with the increased production of prostaglandins - substances that stimulate labor.

It is interesting that the best minds in obstetrics and gynecology are still studying the composition of amniotic fluid and finding out its role in the development of the fetus. Amazingly, with every new discovery in this area, scientists are left with more questions than answers.

Amniotomy: why and when it is done

Puncture of the amniotic sac is a common practice known to obstetricians all over the world. The main purpose of the procedure is to stimulate labor. In some places this method is used more often, and in others only in emergency cases. If we talk about Russia, obstetricians perform amniotomy on 7% of women giving birth. All possible risks for the baby and mother are taken into account.

The membranes are stretched over the fetal head

The procedure is an operation performed only according to indications:

absence of labor during post-term pregnancy;
weak labor activity;
oligohydramnios and polyhydramnios;
tension of the membranes on the baby’s head;
dense shell structure;
multiple pregnancy;
complete dilation of the cervix while maintaining the integrity of the membrane;
hypoxia or suspicion of it;
complete or partial placental abruption;
threat to the life of a pregnant woman when the labor process is prolonged;
epidural anesthesia;
gestosis;
Rhesus conflict between mother and child.

Amniotomy has a number of contraindications. Obstetricians divide them into 2 groups:

are common;
preventing natural childbirth.

Common problems include the following:

presence of herpes;
incorrect position of the child;
overlap of the internal os with the placenta.

In obstetrics and gynecology, there are a number of diseases and symptoms in which a pregnant woman will be prohibited from giving birth naturally. They compile a list identical to the contraindications for bladder puncture from the second group:

keloid on the uterus after surgery performed 3 years before pregnancy or earlier;
anatomical abnormalities of the pelvic bones or their deformation;
inflammatory process in the area of the symphysis pubis;
the child’s weight is over four and a half kilograms;
plastic surgery performed on the cervix and vagina;
perineal ruptures (3rd degree);
twins when children are in the same amniotic sac;
malignant tumors;
eye diseases (especially myopia with pronounced changes in the fundus);
difficult past childbirth, ending in the death of the child or his disability;
pregnancy achieved through IVF;
kidney transplant.

The obstetrician leading the birth must notify the pregnant woman that he plans to rupture the membranes and explain the need for this manipulation.

Doctors notify a woman about the need to puncture the bladder

Operation classification

In obstetrics, the procedure is classified into 3 types. Each has its own indications, characteristics and negative consequences. Women cannot choose a certain type of procedure for themselves, because only the doctor monitoring the expectant mother determines when to puncture the amniotic sac and what tasks the amniotomy should perform.

Premature

Just 15 years ago, obstetricians actively practiced such an operation. It is performed when a woman is not in labor. Amniotomy plays a stimulating role, because after the release of water, contractions begin and the birth process ends after 10–12 hours.

Such births are called “induced” in obstetric practice. Their peculiarity is the absence of uterine contractions, which are activated only after the bladder is punctured. Doctors perform the procedure at different stages of pregnancy, but most often during postmaturity or in the last weeks.

There are 2 groups of indications for premature amniotomy. The first includes severe pathologies in the mother or fetus:

gestosis that cannot be controlled with medication;
serious health problems in a pregnant woman, aggravated by her situation (diabetes mellitus, cardiovascular diseases, liver and kidney failure);
postmaturity;
progressive polyhydramnios;
development of pathological processes in the fetus.

The main indication of the second group is fetal maturity. If the examination results confirm that the baby is ready to be born, but contractions do not begin, then the doctor recommends artificial rupture of the membranes. The birth process caused in this way is called “programmed”. A condition for amniotomy is considered to be sufficient maturity of the cervix:

length up to 1 centimeter;
softness and friability;
slight opening;
located in the center of the small pelvis.

If the listed signs of impending labor are observed, it is not recommended to stimulate the process with medication. Therefore, obstetricians puncture the amniotic sac.

It is important to understand that premature amniotomy does not always occur without consequences. Among the most common, doctors identify:

penetration of infection;
insufficient oxygen supply for the child;
asphyxia;
birth injuries;
delaying the process;
the need for IVs with oxytocin and prostaglandins arises.

Personally, I have not had to deal with premature amniotomy, and none of my friends have had it done either. Therefore, the conclusion suggests itself that this type of operation is performed in rare cases.

Early

The process of natural childbirth is unpredictable and rarely follows the rules. The team of obstetricians on duty, accepting a woman in labor, takes full responsibility for her and the unborn baby. Therefore, at the labor stage, the doctor may decide to perform an early amniotomy. It is performed with a slight opening and stimulates uterine contractions. This is required if you have the following problems:

primary weakness of labor (after surgery, prostaglandins are released, stimulating uterine contractions);
“flat” bladder (the necessary cushion of water cannot form during oligohydramnios, so the membrane stretches over the fetal head and does not rupture);
polyhydramnios (excessive amniotic fluid causes the uterus to stretch, preventing it from contracting effectively).

Early amniotomy also solves some therapeutic problems. Indications for it are:

bleeding as a result of a low location or placenta previa (the membranes, stretching, capture the placental tissue, thereby causing their detachment);
hypertension or late toxicosis (after the puncture, the volume of amniotic fluid will decrease, which automatically normalizes blood pressure).

Often, the reasons for the artificial opening of the bladder are pathologies identified in the child already during the birth process. This requires additional examinations. Obstetricians carry them out at the slightest suspicion of a threat to the baby’s life. Doctors call the main reasons for early amniotomy:

a change in the color of the amniotic fluid to green (this can be seen through the membrane using a special device);
disruption of blood flow through the vessels of the umbilical cord;
cardiotocogram indicators.

In the presence of the listed indications, the only way to complete childbirth without surgical intervention is artificial opening of the membranes.

Belated

Obstetrics textbooks indicate that spontaneous discharge of water occurs after dilation to eight fingers. This is considered normal for most births. But in rare cases, a pathology occurs that preserves the integrity of the bladder even when fully expanded. This provokes a number of complications:

prolongation of the pushing period;
placental abruption and bleeding;
asphyxia of the newborn.

Doctors name several reasons for this pathology:

high shell density;
increased elasticity of shells;
minimum volume of water cushion.

Obstetricians can only help mother and baby by rupturing the bladder. After the operation is completed, the baby quickly passes into the birth canal.

Advantages and disadvantages of amnitomy

In this matter, it is important to focus on the opinion and experience of obstetricians. Moms on forums often share memories of past births and the sensations of having the amniotic sac punctured. It is interesting that their words have a negative connotation despite a complete lack of knowledge in medicine.

I had an amnitomy twice. The operation was carried out with a dilation of 6 fingers, although, as it seemed to me, there were no special indications for this. In both cases, healthy boys were born, and the birth took place without complications. Therefore, I will not say anything bad about this procedure. But doctors are very reserved in describing its pros and cons.

Table: advantages and disadvantages of bladder puncture

Preparation for artificial opening of the bladder

Pregnant women often complain that they did not even understand when they had time to prepare for the operation. Amnitomy does not require additional tests or examinations. When the decision to puncture is made by obstetricians, the process of preparing for the procedure takes no more than 2 minutes:

the expectant mother comes to the examination room;
located on the gynecological chair;
The doctor treats the external genitalia with an antiseptic.

After these simple manipulations, you can begin amniotomy.

Operation description

For pregnant women, the mere mention of amniotomy raises serious concerns for the health of the baby, since most expectant mothers have little understanding of the procedure itself and its features.

Particularly impressionable women in labor are rendered faint by the instrument with which the operation is performed. At first glance, it really looks intimidating - a long narrow object with a curved hook at the end.

Amniotome - a tool for puncturing the bladder

Amnitome, as obstetricians call it, is made of plastic. It arrives at the department in sterile form and is disposed of after use. Decades ago, it was made from surgical steel and regularly sterilized.

The procedure itself lasts no more than 2 minutes. If amniotomy is performed already during childbirth, then the doctor waits for the height of the contraction and penetrates the uterine os with two fingers. They should come into contact with the membrane of the amniotic sac.

A doctor uses an amniotome to pick up the membranes

At this moment, the bladder is in a state of highest tension and, after being hooked by the amniotome, the membranes easily tear. The obstetrician moves them apart so that the water flows freely and he can assess the color of the liquid.

Highly clear or slightly cloudy waters will not cause concern, but yellowish or greenish tints will be a reason for an emergency caesarean section. Such colors indicate that the baby’s life is in danger and the course of natural childbirth needs to be changed.

I remember the first time I saw an amniote. It shocked me, and I even cringed internally, preparing myself for pain as the hook approached me. But I didn’t feel any pain or even the slightest discomfort. The fact is that there are no nerve endings in the membrane of the amniotic sac, so the puncture does not bring discomfort to women.

Possible complications after surgery

Doctors do not hide the fact that amniotomy can cause complications for a woman in labor. The percentage of such cases is small, but they are possible. Obstetricians associate the unpleasant consequences of artificial rupture of membranes with a violation of the integrity of blood vessels. It must be taken into account that for a child who suddenly finds himself in a different environment, this transition causes significant discomfort.

The list of possible complications includes:

bleeding (amnitoma can affect a large vessel on the membrane of the bladder);
loss of the baby's arms and legs, which complicates the birth process;
deterioration of the child’s general condition;
weakening of labor;
a sharp increase in labor activity;
penetration of infection.

Women do not need to be afraid of these complications. In obstetric practice they are rare. And in some cases, puncture of the amniotic sac is the only way to prevent the development of such complications.

Doctors closely monitor the duration of labor after amniotomy

Features of childbirth after amniotomy

Women who have undergone a puncture of the amniotic sac claim that contractions become stronger after the operation. Obstetricians confirm this fact, because this is the result they strive to achieve with the help of amniotomy. After the procedure, labor continues to be natural and ends in a matter of hours.

It is important to remember that a child cannot remain in a waterless space for more than 12 hours. Ideally, the time interval is limited to 10 hours. During this period, childbirth should be completed. If the pushing process is delayed, doctors will resort to a caesarean section.

Women share their views on amniotomy

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

What it is?

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

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

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

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

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

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

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

How is it carried out?

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

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

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

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

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

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

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

Indications

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

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

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

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

When is it not possible?

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

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

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

Possible difficulties and complications

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

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

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

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