Puncture of the bubble for tribulation

When a baby is ready to be born, things don’t always go according to plan. Doctors may need to intervene occasionally to help things along. The artificial rupture of membranes (AROM), or puncturing the amniotic sac, is a common procedure used during labor. This method can assist in inducing contractions or accelerating a labor that has stalled.

Even though it may sound a little scary, puncturing the amniotic sac is a common and secure medical procedure when carried out by qualified medical personnel. Parents can feel more at ease and ready for the big day if they understand why it might be required and how it’s done.

We will discuss the rationale for this procedure, what to anticipate if it is recommended during labor, and how it may impact the birthing process in this article.

A medical procedure called a "puncture of the bubble," or amniotomy, is performed during labor to rupture the amniotic sac and accelerate or induce childbirth. It is usually performed to facilitate the baby’s easier passage down the birth canal when labor is sluggish or requires assistance. Even though the procedure is usually safe, there are some risks associated with it, like increased pain or infection, so it’s crucial for parents to understand why it’s advised and how it fits into the overall birth plan.

What is it?

During the entire pregnancy, the baby is inside the amniotic sac. Its outer layer is more durable, it is a reliable protection against viruses, bacteria, fungi. In case of damage to the mucous plug in the cervical canal, it can protect the child from their harmful effects. The inner shell 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 fetal bladder opens during natural childbirth. Normally, this occurs at the very height of active labor contractions, when the opening of the cervix is ​​from 3 to 7 centimeters. The mechanism of opening is quite simple – the uterus contracts, with each contraction the pressure inside its cavity increases. It is this, as well as special enzymes that the cervix produces at the time of expansion, and affects the fetal membranes. The bladder becomes thinner and bursts, the waters break.

If the integrity of the bladder is broken before contractions, then this is considered premature rupture of the waters and a complication of labor. If the opening is sufficient, pushing begins, and 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 mechanically puncture it at any time. In medicine, puncturing the amniotic sac is called "amniotomy". Artificial disruption of the integrity of the fetal membranes allows the release of an impressive amount of biologically active enzymes contained in the waters, which acts as a labor inducer. The cervix begins to open more actively, contractions become stronger and more intense, which allows to reduce the time of labor by about a third.

Amniotomy also makes it possible to resolve a variety of other obstetric issues. Therefore, placenta previa can stop bleeding after it, and in addition, this intervention significantly lowers blood pressure in women who are hypertensive during labor. Either prior to or during labor, the bladder is punctured. The amniotic sac is not touched prior to a cesarean section; instead, an incision is made during the procedure. Given that the procedure is only performed when there are indications, the woman is not granted the freedom of choice. However, the law requires physicians to obtain consent before performing an amniotomy.

It is strongly advised against abusing the bladder because opening it causes a direct intervention in the natural order, through a process that is both natural and autonomous.

How it is done?

The fetal membranes can be opened in a few different ways. It is manually piercable, cut, or ripped. Everything is dependent upon the cervix’s degree of dilation. It will be better to puncture it if there are only two fingers that are open. Amniotomy is not painful because the fetal membranes lack nerve endings and pain receptors. Everything is completed swiftly. The woman receives an intramuscular or tablet antispasmodic 30 to 35 minutes prior to the manipulation. An experienced obstetrician can sometimes perform manipulations that do not require medical supervision. The woman spreads her thighs apart as she lies down in a gynecological chair.

The doctor inserts the fingers of one hand in a sterile glove into the vagina, and the woman"s sensations will not differ in any way from a regular gynecological examination. With the other hand, the health worker inserts a long, thin instrument with a hook at the end – a branch – into the genital tract. With it, he hooks the fetal membrane with an open cervix and gently pulls it towards himself. Then the instrument is removed, and with his fingers the obstetrician widens the puncture, making sure that the waters flow smoothly, gradually, since their rapid outpouring can lead to the 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 the amniotomy. CTG sensors are installed on the woman in labor"s stomach 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 we talk about premature amniotomy. To strengthen contractions in the first stage of labor, early amniotomy is performed, and to activate uterine contractions during almost complete dilation of the cervix, free amniotomy is performed.

Given that these births are risky because the mother may bleed during the delivery, it is thought to be more reasonable to do a puncture as soon as the baby enters the birth canal if the baby has chosen to be born "in a shirt" (in the bladder).

Indications

For women who must induce labor as soon as possible, amniotomy is advised. Therefore, in cases of gestosis, a bladder puncture will induce labor if natural labor does not start after 41–42 weeks of pregnancy. When a woman is ill-prepared for childbirth, her contractions usually start two to six hours after a bladder puncture, especially if the prenatal period is unusual and prolonged. The baby will be born in 12 to 14 hours due to the accelerated birth process.

• the cervix is ​​7-8 centimeters dilated and the amniotic sac is intact, it is considered inappropriate to preserve it;
• weak labor (contractions suddenly weaken or stop);
• polyhydramnios;
• flat bladder before labor (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).

Deliberately opening the bladder without a reason is not customary. Evaluating the degree to which the female body is prepared for childbirth is also crucial. Early amniotomy can have disastrous effects if the cervix is immature. These effects include weak labor, fetal hypoxia, a severe anhydrous period, and, in the end, the need for an emergency cesarean section to save the mother and child’s lives.

When it is impossible?

Even in cases where an amniotomy is clearly indicated, they will not puncture the bladder for the following reasons:

• the cervix is ​​not ready, there is no smoothing, softening, its maturity assessment is less than 6 points on the Bishop scale;
• the woman has an exacerbation of genital herpes;
• the baby in the mother"s womb is positioned incorrectly – it is presented feet first, bottom first, or transversely;
• placenta previa, in which the exit from the uterus is closed or partially blocked by the "baby"s place";
• 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 the child to be born on her own;
• monochorionic twins (children in one amniotic sac);
• pregnancy after IVF (a cesarean section is recommended);
• a state of acute oxygen deficiency of the fetus and other signs of trouble according to the results of CTG.

If a woman has indications for an operative delivery (a cesarean section) and natural childbirth may be dangerous for her, an obstetrician or doctor will never open the gestational sac.

Possible difficulties and complications

Sometimes there are no contractions during the post-amyniotomy period. Then, two to three hours later, they start stimulating with drugs; they give "Oxytocin" and other drugs that intensify the contractions in the uterus. In case they prove ineffective or the contractions fail to stop within three hours, an emergency cesarean section is carried out.

An external intervention is a mechanical puncture or rupture of the fetal membrane, as was previously discussed. Consequently, there can be a wide range of outcomes. The most typical ones are:

• rapid labor;
• development of weakness of labor forces;
• bleeding due to damage to a large blood vessel located on the surface of the bladder;
• prolapse of the umbilical cord loops or parts of the fetus"s body along with the outflowing waters;
• sudden deterioration in the child"s condition (acute hypoxia);
• risk of infection of the baby if the instruments or hands of the obstetrician were not sufficiently processed.

You can prevent most complications if the procedure is performed correctly and in accordance with all the requirements. However, it is difficult to predict in advance how the uterus will behave, whether it will contract, and whether the necessary contractions will begin at the appropriate pace.

An amniotomy, or puncturing of the amniotic sac, is a procedure that can facilitate or expedite labor. Despite being a common practice, it should only be carried out when absolutely necessary and under a healthcare professional’s supervision. Expectant mothers may feel more at ease with the procedure if they know when and why it’s done.

It’s critical to keep in mind that each birth is distinct and that what suits one individual may not be the best choice for another. Do not be afraid to ask your doctor or midwife any questions or concerns you may have about the procedure. Being informed and aware of your options can significantly impact how labor goes for you.

The ultimate objective is a delivery that is safe for the mother and the child. Even though an amniotomy is just one of many instruments used in labor, knowing what it might be used for can help you plan for the best possible birth experience.

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