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Sweeping Membranes for Starting Labor

Practice Variation in Cesarean Rates: Not Due to Maternal Complications
This brief but well-referenced post analyzes cesarean rates relative to differences in maternal diagnoses or pregnancy complexity. On average, the likelihood of cesarean delivery for an individual woman varied between 19 and 48 percent across hospitals.”

Birth attendants often claim that their high cesarean rate is due to their clientele - that they provide care for a lot of high-risk clients.  This analysis shows that:

    Among lower risk women, likelihood of cesarean delivery varied between 8 and 32 percent across hospitals.
    Among higher risk women, likelihood of cesarean delivery varied between 56 and 92 percent across hospitals.
    Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics.

This shows that practice variation in cesarean rates is real, substantive, and not just a reflection of the mother’s risk level.

Tips for Choosing a Care Provider - great overview! from Henci Goer

No Need to Sweep

Whether or not women underwent membrane sweeping, overall rates of induction, postmaturity, and prelabor membrane rupture were similar. 

Clinical question - Is stripping/sweeping of the membranes at term effective at promoting the onset of labor?

A randomized controlled trial of membrane stripping at term to promote labor.
Wiriyasirivaj B, Vutyavanich T, Ruangsri RA
Obstet Gynecol 1996 May;87(5 Pt 1):767-770

Membrane stripping to promote labor - A Review from the Journal of Family Practice Web site
Reference Reviewed by Valerie King, MD


Avoid membrane stripping in GBS positive mothers: Studies using ultrasound contrast media show "facilitated transport" of vaginal fluid into the lower uterine segment during cervical manipulation.  We have reported three perinatal deaths after membrane stripping in GBS positive mothers at term.  GBS vaginitis is well reported.*  [From a handout about The Jesse Cause]  [*Maniatis A, J Med Micro 1996.44.199-202]


Women usually want me to sweep membranes.  I ask them.  Yes it's uncomfortable, but it can be appropriate.  I call it massaging, not stripping.


My anecdotal stuff about stretch and sweeps is that it seldom works, and when it "works" to get someone into labour, it is long and drawn out. I do use castor oil for inductions.


Formation of the forebag of waters helps to start labor. Squatting may help to form the forebag.


Well, I figure you do a "good one" if you're going to do one at all. Must be good indications and mom must have been given informed consent. Never do it preterm, with a feverish mom, or if any suspicion of low lying placenta or previa....

That said: When mom is ready and relaxed (as much as possible), start as if a usual internal exam. It helps a lot if the mom can be in a position to give you a greater reach -- lying on firm surface with bottom elevated on low pillow helps. Using sterile gloves, and sterile technique, (gently) put one and then two fingers into the cervix. You will attempt to "follow the cervix around", loosening the membranes from their attachments. As you slowly do this, gently stretching the cervix, you should feel it opening and relaxing. (Often you can only get one finger in at first, after a minute, the cervix will open another few centimeters). Moving gently and slowly, you should gradually be able to move your finger(s) more deeply to the sides, separating the bag of waters from the lower uterus... take your time, be very gentle, move slowly -- five minutes is not too long -- stop and wait (or back off) if it's too uncomfortable for the mom. Move your fingers outward, to the sides, not upward toward the BOW. STOP if you feel firm adhesions, or a gravely surface (this might be placenta).


Often folks will say that sweeping the membranes doesn't work -- but (often) they just don't get in there deeply enough or spend enough time to make a difference. If you take your time at this, you might find the woman only 2 or 3 centimeters dilated at the beginning, and 4 or 5 with good forewaters formed by the end. I can often get two knuckles deep, most of the way around. If you get this far, it's an excellent bet that labor will start within 24 hours -- and probably sooner than that! the mom may begin cramping immediately, often this continues into active labor within a few hours.


You are loosening the plug, and will probably carry it with you as you withdraw your hand. It's a good sign that you stripped the membranes well. Let the mom know she may find more bloody show through the day. If labor doesn't begin within 24 hours, the plug should reform.


Stripping the membranes this way is quite an intervention -- next step is breaking the waters -- neither should be undertaken lightly. IF labor "must" begin, I'll usually choose this method over less certain ones -- herbs, enemas, castor oil -- or in conjunction with them. PS: for a better picture, I'll often explain it this way to my clients: To envision stripping the membranes, imagine a filled water balloon (BOW) inside another balloon (uterus); you want to loosen any "sticking" between the two balloons by putting your fingers through the opening of the outer balloon (the cervix) and sliding your fingers between the two layers.


Stripping membranes involves sticking your finger into the cervix and separating the cervix and lower uterine segment from the membranes. It generates local production of prostaglandins and frequently brings on labor in someone who is close anyway. It almost certainly increases the risk of chorioamnionitis and premature rupture of membranes. Its use is controversial in the obstetrical literature, and in my opinion, for what that's worth, it is dangerous and unnecessary. Labor starts when it is time, leave well enough alone.


I take my time, am gentle, and slow, but I really go in, if i can. If I get blood (or mucus plug) the success rate goes way up. I usually have them sit on their fists, for a better "reach". Sometimes you really have to walk a posterior cervix down, so that you can get in. I have also found that if the baby is not ready to come, mom off on dates, etc, then it doesn't work, and if the cervix isn't ripe i usually don't even try.


It's like "dialing the telephone".


For a better picture, I'll often explain it this way to my clients: To envision stripping the membranes, imagine a filled water balloon (BOW) inside another balloon (uterus); you want to loosen any "sticking" between the two balloons by putting your fingers through the opening of the outer balloon (the cervix) and sliding your fingers between the two layers -- just a little ways though...


I would only do this for strong indications -- not just because mom was tired of being pregnant or a few days past due...Stripping the membranes this way is an intervention -- and shouldn't be undertaken lightly. IF we feel labor should begin, I'll usually choose this method over less certain ones -- herbs, enemas, castor oil -- or in conjunction with them if labor MUST begin.

( We call this the "one, two punch" -- mom drinks castor oil, then we strip membranes, then she sips medicinal tea while we wait for the castor oil to work, then we might do a medicinal enema after the castor oil has taken effect. We use the same recipe for tea and enema -- pint of water, two droppers of "labor tincture" and one each of blue and black cohosh in strong red raspberry tea with a spoonful of honey -- tastes good by mouth; can't speak for the other end of course[Grin].)

We would only consider this in extreme necessity - membranes ruptured for 24 hours or so; or some other NEED to get labor started. It is nearly fool proof -- hasn't failed yet anyway -- and seems pretty risk free - and is far more comfortable than a pitocin induction. Labor will usually be going well within three hours; and usually no further stimulus is needed, the pattern seems quite normal once it begins. (more normal than pitocin anyway). But we don't do this lightly- and PLEASE don't try home inductions without EXCELLENT reasons! An induction by any method is one of the highest risks for eventual cesarean section -- please be careful!

Pro -- often starts labor within 24 hours - labor pattern seems normal - avoids pitocin and AROM (and associated discomforts and risks) -- A good gamble (if it doesn't work, little is lost)

Cons -- we are interfering with the normal timing of labor (and generally the natural time for labor to begin results in the best labor)

-- I guess there is a potential risk of infection; as in ALL cervical exams and manipulations (Never heard of one though)

- Perhaps one could rupture membranes if they were fragile and ready to break (never heard of this either)

- Might dislodge a low placenta (though unlikely if head is engaged; and we are careful!)

- Could get a false start going -- perhaps dislodge plug, start a few contractions and everything would quit; resulting in disappointed and tired mom?

PS -- some say that stripping works (when it works) because we start an infection in the cervix. To counter that argument, I would point out that contractions often begin while we are doing the stripping -- and it takes a lot longer than a few minutes or couple hours to get an infection going!

NOTE : the herbal tea/enema mixture is traditional use -- don't know of any research on it; folks have just been using it for a long time.

I have had little success with low dose herbs, or herbs to ripen cervix, or herbs used alone to start labor -- -- If I'd like to get labor going, I go for the purely mechanical -- stimulating the cervix by stripping membranes; and/or stimulating the bowel. If we REALLY want to get labor going we combine the mechanical and the herbal; if we feel the baby has the time to play around.... But If there is a medical reason to get this baby out right NOW -- we go to the hospital!


Hi! I love the topic of stripping membranes!!

First of all I wish it had a better name, like "separating" the membranes, because "stripping" sounds so painful.

I am a direct entry, homebirth, relatively non-interventive midwife. I think that stripping membranes is a fabulous was to get a labor started, when a lady is overdue, or needs to get her labor going for some other reason.

A finger, or two, are placed inside the cervix, and swept around as far as the fingers will reach. What happens is that the amniotic sac is separated from the cervical wall, thus releasing prostaglandins into the blood stream. If it is to work, it usually works within three days. If we see a little blood after the exam, that is a good sign that it will work. You can sometimes feel the membranes separating. It feels shiny, or squeaky. When I can feel that, it is more likely to work. I have a very high success rate, but then I almost never do it unless mom is overdue.

I would do it at 42 weeks, or if I had a client with lessening amniotic fluid and non-reactive baby. Any signs of postmaturity or a labor-support client who is up against any kind of chemical induction. I would strip membranes for someone who's only other choice was to get a biophysical profile, and NST, and hospital induction. Better and cheaper to get the baby born, in most cases.

Con- very small chance of breaking water. It is sometimes very painful. I do it slowly, with informed consent, calmly, explain every step. The slower it is done, the less the pain. It doesn't have to be painful.

Pro- better in my opinion, than any other means of induction, with virtually no side effects. Castor oil gives terrible diarrhea, which may last throughout labor. Breast pump is often very effective, but gives a brand new mom very sore breasts, and can get baby off to a bad start Herbs often don't work. Most of the other stuff doesn't really work. Drugs -- well, do I need to say anything about the side effects of drugs? Stripping can be done at home, is safe. The worst thing that can happen is that it doesn't work. The consequences of postmaturity are so much more serious than membranes stripping, that i never understand what the reluctance is about. I would not strip an unripe cervix, mostly because I don't think it would work, and because it would be very painful. I have heard horror stories about doctors who stripped without consent. I think that is unethical. It was done to me with my first baby without my consent. (It did work.)

Once it has been determined by caregiver and client that baby needs to be born, then I would vote for membrane stripping, first. It is the most effective means, with the least amount of side-effects. it doesn't start any time clocks, or cause any harm (in my opinion.) If it's being done for doctor or midwife's convenience, or because mom is impatient, well, that is a different subject altogether.


If amniotomy is safe (ie cx dilated and effaced, well applied to vertex, low station), and mom agrees, I think amniotomy induction is the appropriate thing to do. It's a risk/benefit analysis - I see very little risk to the procedure and lots of benefits.
I agree. IN SELECTED CASES as you mention (far from hosp. well dilated, bulging bag, history of rapid labors etc etc). I would sure like to make certain she is at term, and the head is WAY down there and would like to have some signs of uterine irritability first -- the more the better.

It's been done around here under those very tightly defined circumstances. Usually stripping membranes is done early AM or day before and some add an herbal tincture for a couple hours first. One really hopes it works and we get a good labor pattern going and don't end up with no labor (or lousy labor) and PROM. and if any question of dates i wouldn't think of it.

I think the major risk (if safety criteria are met) is of a lousy labor pattern and eventual need for pitocin in hospital. Unlikely with a multip and careful selection, but can happen. Sometimes that uterus is just plain balky!


[from ob-gyn-l]


Membrane stripping stimulates local prostaglandin production within (some or all of) decidua, myometrium, membranes. Oxytocin is a pituitary product and generally circulating levels of oxytocin are static until third stage. Labour is (partially) due to a change in oxytocin receptor counts and sensitivity. Prostaglandin leads to an increase in oxytocin receptor populations.


DeLee (Principles and Practice of Obstetrics) writes:  "Occasionally in a primipara, the head will be deeply engaged, but the cervix is far back in the hollow of the sacrum and very thin, the membranes are tightly stretched over the head and there are no forewaters . By pulling the cervix gently to the middle of the pelvis, separating the membranes around the lower uterine segment for 2 inches, and pushing up the head a little to allow some liquor amnii to run down and make a pouch, the mechanism of labor is started right and the pains improve at once."



This Web page is referenced from other pages containing related information about Non-Pharmaceutical Induction.

 




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