Proof that AROM is risky

[Litcrit]

I've just had a meeting with a midwife at the hospital where I'm strongly considering delivering.

I'm happy about most of their protocols and can tolerate the rest with relative ease.

What I'm uncomfortable with is routine amniotomy. They perform it at 3-4cm if the baby is descended and correctly positioned at that point, making sure nothing gets trapped between the baby's head and the cervix (they don't do them for breech births, multiples, etc.), and the midwife told me there were thus no risks to the baby.

I mentioned the possibility of the baby's heart rate dropping and the amniotic sac cushioning the baby from contractions, and she said that wasn't true and there was relatively little fluid in there anyway.

During my first birth, dd's heart rate plummeted immediately following AROM and I just don't want it, period.

I will be able to decline any intervention, including amniotomy, or so the midwife said, without too many explanations, but I want to take a copy of some solid research on the topic, preferably from a serious medical journal, proving the risks of amniotomy and benefits of keeping the amniotic sac intact.

If you can direct me towards anything, I'd be very greatful

[MegBoz]

Originally Posted by Litcrit

I mentioned the possibility of the baby's heart rate dropping and the amniotic sac cushioning the baby from contractions, and she said that wasn't true and there was relatively little fluid in there anyway.

Sorry, can't help but both and at that. So funny how some HCPs bully women into induction due to low AFI ("not enough fluid"), others will perform amniotomy so they don't get drenched with the fluids when the baby is born, and yours is saying there's not much fluid in there anyway. It just seems sometimes HCPs say whatever is most convenient for them, even if contradictory!

Personally, my hospital-based CNMs required twice weekly NST + AFI for women who passed 41W gestation. So, apparently the amount of fluid in there is some sorta indicator of fetal well-being. So hearing, "There's not much in there anyway" seems very odd to me!

In any case, as far as research is concerned, I recommend the book "The Thinking Woman's Guide to a Better Birth" by Henci Goer. She has an entire chapter on AROM! & everything she writes is backed up by LOTS of science - all references in the back of the book.

Aside from the lack of fluid cushioning the baby, there's the other risk of infection!!!!!! I'm pretty sure tons of studies show that the longer waters are broken, the higher the risk of infection. Did that come up?

If an in-tact bag is so trivial, how come so many hospitals require birth within 24 hours of ROM (so, if baby isn't born vaginally, they push CS)?

Finally, lots of women say it hurts more to labor with broken membranes. But I don't know if that's purely anctedotal or if anyone has studied it.

Besides all this, the only benefit to AROM is speeding up 1st stage labor and then, studies show it only speeds it up by a whopping 20 min! So even if the risks are nil, the benefits are negligible anyway!

Did she mention any other benefits to it? Obviously it's required to place an internal monitor, but that would be about it.

[MittensKittens]

Here is the thinking woman's guide on google books

Don't forget that AROM also increases the risk of cord prolapse, and the baby getting stuck in less than ideal positions, if done in early labor. Can't remember where I got that from! However, it is totally logical.

Perhaps check out Rixa Freeze's blog too.

[MittensKittens]

Originally Posted by MegBoz

Besides all this, the only benefit to AROM is speeding up 1st stage labor and then, studies show it only speeds it up by a whopping 20 min! So even if the risks are nil, the benefits are negligible anyway!

Where is that study available?

[Amatullah0]

I blame AROM at 9cm for my DS's Amniotic fluid aspiration at birth, and subsequent NICU stay

[Right of Passage]

This might be helpful?

[emnic77]

Um, I would turn around and ask her to provide proof that routine AROM is in any way, shape, or form beneficial to mother or baby.
Or simply ask her if AROM puts you on a timetable. If your water is broken, how many hours do you then have to deliver? Anything that puts you on an artificial timetable is reason enough to decline right there (I would tell her).

[MittensKittens]

Also, how about not turning up at the hospital until later in labor? If they do AROM at that point, it will be less risky. On top of that, they won't have much chance to force pitocin on you.

[Litcrit]

Originally Posted by MegBoz

Aside from the lack of fluid cushioning the baby, there's the other risk of infection!!!!!! I'm pretty sure tons of studies show that the longer waters are broken, the higher the risk of infection. Did that come up?

If an in-tact bag is so trivial, how come so many hospitals require birth within 24 hours of ROM (so, if baby isn't born vaginally, they push CS)?

Did she mention any other benefits to it? Obviously it's required to place an internal monitor, but that would be about it.

This hospital has a policy of not starting induction for 48 hours after spontaneous full ROM with no labor, so I can't use that as an argument. My first labor lasted 6 hours total, so I can't honestly claim I'm fearing an infection because of the length of time with broken waters.

They don't do internal monitors. They don't do continual monitoring at all.

The benefit she mentioned was something I honestly didn't understand, but it was somehow supposed to be better for the baby

Originally Posted by MittensKittens

Here is the thinking woman's guide on google books

Don't forget that AROM also increases the risk of cord prolapse, and the baby getting stuck in less than ideal positions, if done in early labor. Can't remember where I got that from! However, it is totally logical.

Perhaps check out Rixa Freeze's blog too.

Thanks!

Well, she said they only do it if the baby is already in an ideal position and the head is fully descended, preventing prolapse, so I can't argue that.

[Litcrit]

Originally Posted by Right of Passage

This might be helpful?

Yes, sounds great! I'll def use it!

Anyone got anything on the amniotic sac cushioning the baby from contractions and AROM causing heart decels?

Originally Posted by emnic77

Um, I would turn around and ask her to provide proof that routine AROM is in any way, shape, or form beneficial to mother or baby.
Or simply ask her if AROM puts you on a timetable. If your water is broken, how many hours do you then have to deliver? Anything that puts you on an artificial timetable is reason enough to decline right there (I would tell her).

I asked, but didn't understand. I'll ask again.

There's no timetable really. When a woman shows up with her water broken and no contractions, they wait 48 hours, and then start induction if labor still hasn't started. They give antibiotics after some time to prevent infections instead.

Originally Posted by MittensKittens

Also, how about not turning up at the hospital until later in labor? If they do AROM at that point, it will be less risky. On top of that, they won't have much chance to force pitocin on you.

Problem is, I don't know what 'later in labor' is - in my first labor, I had strong ctx 3 mins apart from the start and went to the hospital immediately and didn't feel I was there too soon. Now the hospital is 45 mins away and this is my second

Oh, they don't do pit! Well, she said it does very rarely happen that they consider it useful (labor suddenly stops for a long time after it has progressed to the point of no return and the baby is in distress or something), but she was adamant they do NOT use it routinely. She sounded angry that others do.

[Litcrit]

Originally Posted by MittensKittens

Here is the thinking woman's guide on google books

Ugh! The preview doesn't show pages 50-127. AROM is discussed on pages 103-107.

[CherryBomb]

I'm not against AROM, but 3-4cm seems pretty early.

[RedOakMomma]

I think it's nuts/rude that they wouldn't just honor your wishes to avoid that intervention. Why is the burden of proof on YOU? Why shouldn't they just let labor progress naturally?

I would wonder, in the back of my head, what other kinds of disrespect or doubt they would throw at my birth plan or birth wishes. Is it about your wants, or just their routines?

(And FWIW, I'm a huge fan of natural births in hospitals, and have done both of mine there.)

[Belle]

Originally Posted by Litcrit

There's no timetable really. When a woman shows up with her water broken and no contractions, they wait 48 hours, and then start induction if labor still hasn't started. They give antibiotics after some time to prevent infections instead.

Spontaneous ROM is different than AROM. They may have different protocols for AROM. With SROM the care providers can refrain from doing vaginal exams and sticking up anything that can introduce infection. With AROM they are using an amnihook to break the bag and the process of breaking the waters can introduce infection itself.

[sioleabha]

I found this excerpt from The Thinking Woman's Guide to a Better Birth here: http://onyx-ii.com/birthsong/page.cfm?amniotomy

Benefits And Risks Of Routine Amniotomy

Benefits: Routine early amniotomy shortens labor by an hour or two. It appears to reduce the incidence of 5-minute Apgar scores below 7 but has no other effects on the infant’s condition at birth. It may reduce the use of oxytocin and the number of women who report the most intense degree of labor pain. However, the use of oxytocin, which makes labor more painful, and pain medication, especially epidurals, makes it difficult to determine the relationship between amniotomy and labor pain.

Risks: Amniotomy increases the incidence of abnormal fetal heart rate patterns. Studies may underestimate this risk because women not having early amniotomy are more likely to receive oxytocin, which also increases the odds of abnormal fetal heart rate patterns. Routine early amniotomy risksistently increases the cesarean rate. When data from seven trials in which women were randomly assigned to early amniotomy or not were analyzed (meta-analysis), women in the early amniotomy group were 20% more likely to have a cesarean. An additional two studies not included in the meta-analysis also reported more cesareans in the early amniotomy group. The percentage found in the meta-analysis may be low because cargivers in several trials were not able to stop doing amniotomies in the “riskserve membranes” group. Specifically, half or more of women in the “riskserve membranes” group in the two biggest trials had amniotomies, albeit somewhat later in labor. If amniotomy does, in fact, lead to c-section, this would tend to minimize the differences in cesarean rates between the two groups. Early amniotomy may also increase the risk of infection.

Benefits And Risks Of Amniotomy For Indication

Benefits: Rupturing membranes may help labor progress, allow closer monitoring when there is concern about the baby, and permit caregivers to determine whether the baby has passed meconium into the amniotic fluid.

Risks: Studies suggest that early amniotomy may not benefit slowly progressing labors and that late amniotomy may have unpredictable effects. Valerie El Halta, a prominent home birth midwife, suggests one reason why: if the baby is posterior, that is, facing the mother’s belly instead of her back, labor often progresses slowly until the baby turns into the anterior position. With membrane rupture, the head may surge downward into the pelvis and get stuck. As for permitting closer monitoring for suspected fetal distress, releasing the amniotic fluid adds to the baby’s stress by exposing the umbilical cord to compression during contractions. In addition, one potential cause of fetal distress is that the umbilical cord has slipped between the head and the cervix. Rupturing membranes could then cause prolapse, converting a concerning situation into an emergency.

excerpt from Henci Goer's The Thinking Woman's Guide to a Better Birth

Also, you said:

Originally Posted by Litcrit

When a woman shows up with her water broken and no contractions, they wait 48 hours, and then start induction if labor still hasn't started. They give antibiotics after some time to prevent infections instead.

Realize that what they are telling you here is not, "You don't have to worry about infection because we've got that covered," but "We'll turn one intervention into two by giving you antibiotics that you wouldn't need if we hadn't artificially ruptured your membranes."

Also, I found this study suggesting that AROM does not shorten labor:
http://www.mrw.interscience.wiley.co.../abstract.html

[Litcrit]

Originally Posted by RedOakMomma

I think it's nuts/rude that they wouldn't just honor your wishes to avoid that intervention. Why is the burden of proof on YOU? Why shouldn't they just let labor progress naturally?

I would wonder, in the back of my head, what other kinds of disrespect or doubt they would throw at my birth plan or birth wishes. Is it about your wants, or just their routines?

(And FWIW, I'm a huge fan of natural births in hospitals, and have done both of mine there.)

Oh, long story. I live in Serbia. Only state hospitals are allowed to do births. Patients are not meant to be customers, but... um... more like pupils in state schools? There IS a law that says patients can refuse any procedure, but somehow in births that never happens in the vast majority of hospitals. They're not afraid of being sued, because doctors are godlike authority figures here and the courts don't work and they know even if someone threatened to sue it would mean the person would spend lots of money on a 10-year long court process that would eventually lead nowhere.

This is by far the best hospital I can birth in and the MW actually said I could decline anything. I fully intend to decline AROM, I just like the idea of having a black-on-white serious-medical-journal article with research data and references showing why I'm right to decline it. No one declines interventions here, and if I'm going to set a precedent, I need to do it right. I can't just say 'No, thank you.' Not in this country, not with this mentality.

Originally Posted by sioleabha

I found this excerpt from The Thinking Woman's Guide to a Better Birth here: http://onyx-ii.com/birthsong/page.cfm?amniotomy

Thank you! Why doesn't she give proof, data, references?

Realize that what they are telling you here is not, "You don't have to worry about infection because we've got that covered," but "We'll turn one intervention into two by giving you antibiotics that you wouldn't need if we hadn't artificially ruptured your membranes."

Also, I found this study suggesting that AROM does not shorten labor:
http://www.mrw.interscience.wiley.co.../abstract.html

Thank you!