Artificial Rupture of Membranes / Breaking the Waters and your Birth Plan

By: Aunt Doula (10/31/2022)

During the majority of spontaneous labors and any induced labors, the amniotic sac is often intact when the pregnant person arrives at their delivery facility. The likelihood of the amniotic sac breaking as the first sign of labor (as often portrayed in films and television) sits below 10%. Rupture of the amniotic sac is more casually referred to as the breaking of waters.

The amniotic sac is actually the inner layer of membrane that is surrounded by the chorion. So inside your uterus the baby is fully surrounded by two layers of membranes, both of which typically rupture before the baby enters the vaginal canal to be born. For ease of terminology that most people recognize, I will be referring to the amniotic sac alone, but for educational reasons I want all to understand the full anatomy of the uterine environment.

In rare cases, a baby can be born inside of their membrane sacs, known as an En Caul birth. An En Caul birth is no more dangerous or advantageous than a birth with a broken membrane sac, it is just much more rare. For the off chance that a person who reads this experiences an En Caul birth, you can know that your baby will be quickly released from the membrane sacs and there are no known adverse side effects from an En Caul birth. The baby is still connected to the umbilical cord and receiving oxygenated blood for the short period they remain in the sac until it is removed and the waters will fall away so the baby can take their first breath of air.

During the last weeks of pregnancy, ideally the baby begins to settle into a head-down position to ready for birth. The amniotic sac presses directly against the uterine wall, and the chorion has fibrous connections to the uterine wall. During a stripping of the membranes, it is these fibrous connections that are targeted to be stripped by the providers finger. There is very little room left by the end of the 3rd trimester for the placenta, amniotic fluid and the baby. The uterus has expanded extensively from it's pre-pregnancy size of an adult fist, and the membrane sacs are quite tough and taut. Most of the sac strength is balanced just so to be able to protect the baby in cases of bumps and jostles, but also be able to rupture at the time of birth so not all births end up En Caul.

The Process

If your provider discusses an "AROM" Artificial Rupture of Membranes - and you consent, the procedure is fairly straightforward. The baby must be head down, with their head pressing firmly on the cervical opening. Ideally the cervix will have softened, thinned and dilated to some extent to allow the tool to pass through the cervix and allow the waters to exit through the vaginal canal.

• The provider will ideally put on sterile gloves and will open a sterile package with a long handled tool that looks a bit like a crochet hook.
• The provider will insert the tool through your vagina and your cervix just past the internal edge of the cervix.
• The provider will slide the hook across the taut sac covering the baby's head (it would not hurt the baby if it pressed against them) and catch the sac with the corner to rupture the sac. Once the rupture is confirmed and the majority of fluid has emptied the doctor will remove the tool and their hand after ensuring there has been no cord prolapse.

The Benefits and the Drawbacks

There have been many studies on the efficacy and use of artificially rupturing the membranes during a spontaneous or induced labor. Across all of these studies, there have been few universal benefits found, meaning that while there are some cases that performing AROM seemed to have assisted in augmenting or "speeding up" labor, it does not prove out in well controlled studies. There has been no consensus across meta-analysis of many studies to indicate that AROM has any definite benefit to speeding up labor. As of 2019, ACOG no longer recommends the artificial rupturing of membranes as a routine practice of intervention.

The drawbacks from AROM are however well understood and defined. By artificially rupturing the membranes, the risks include:

• Iatrogenic umbilical cord prolapse (Iatrogenic is a doctor caused complication)

• Uterine or Chorion Infection

• Increased stress to the fetus due to losing the cushion of the sac that helps them tolerate the rigors of active labor contractions

• Increased pain for the delivering person due also to the lost cushion that was keeping the fetal head from directly pressing essentially bone-to-bone with the delivering persons pelvis and sacrum.

• Puts the pregnant person on a count-down to delivery, depending on facility it could be 12 or 24 hours, and if the baby is not born in that window a C-section becomes mandatory and nearly impossible to avoid.

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The artificial rupturing of membranes is another "routine" procedure that is often performed without permission or informed consent. Having the AROM on your birth plan sets the tone that at the very least you want to discuss the BRANN of the procedure before it is decided if the AROM is going to happen. There is not any typical situation of an AROM being performed as an "emergency" so you can take all the time you'd like to think it over.

Some providers maintain that rupturing the amniotic sac will speed up labor because the amniotic fluid has prostaglandins that should "get things going" however if your body has refused to respond to both types and multiple administration methods of synthetic prostaglandins, it is highly unlikely that the levels in the amniotic fluid will effect enough change to push you into labor when the synthetics have not. Remember, the amniotic sac rupturing is not a required event for birth to occur - the En Caul birth is proof of that fact. Remember as well that once your amniotic sac is ruptured you will be on the facilities clock to deliver vaginally by a certain time or have a C-section.

Up until your water breaks, and assuming you have no health conditions that precludes you delaying your induction, it is your right to discuss taking a break from the induction with your labor team! Some facilities will allow you to return home, some will let you stop the current methods of induction for 12-24 hours for you to eat, sleep, recharge and give your body a little more time to maybe accept the induction process.

It is your right to refuse to have your membranes ruptured - it is your right to go over the BRANN and take your time to decide. It is a step that once taken cannot be taken back - and that is the most important aspect of knowing what comes with having this procedure done.