Stripping of the Membranes / Membrane Sweep / Stretch and Sweep and your Birth Plan

By: Aunt Doula (10/30/2022)

Known most commonly as a "Membrane Sweep", "Stripping the Membranes" or a "Stretch and Sweep" the procedure itself is fairly straightforward, but its outcomes are not nearly as clear or positive as they are often presented. A "Cervical Massage" may be offered if the cervix is completely closed. In your birth plan, it is important to declare that you do or do not wish to have this procedure done. At the very least it should be mentioned alongside your decision for manual rupture of the amniotic sac which is covered in a separate post.

As stated succinctly by Billie Harrigan - "I am challenging the ROUTINE of membrane sweeping that is done by some care providers as part of their normal and usual prenatal “package”, without any hint that there is a reason to expedite the birth of the baby due to an emerging medical condition."

By calling it a membrane sweep, or a stretch and sweep it makes it sound like a much more gentle and light process, a name change that likely lent itself to less hesitation than a harsh procedure name like "Stripping the Membranes" - which is much more true to the actual reality of what is happening.

Stripping of membranes can be done in an office visit as early as 36 weeks, but ideally should not be performed until much closer to 39 weeks gestation, and it must be consented to and discussed with you, the patient. A routine stripping should not be performed when gestation is still preterm such as 36 weeks without clear reasoning provided by your physician. Be sure you are talking to your doctor before disrobing and allowing any cervical check or vaginal exam. Knowing exactly what your doctor intends to perform, and what you do or do not consent to such as a membrane stripping, gives you the control over what happens. Membrane stripping has been performed routinely without consent in an alarming number of cases regardless of location worldwide. It is considered obstetric violence and a violation of your human rights. If you say no, and they perform it anyway, it is assault. You are not to blame, and if you have experienced obstetric violence please don't hesitate to reach out to me for a resource list best suited to your situation. Know that you are not alone, and there is help to heal.

Remember that it is your right to refuse cervical checks, stripping of the membranes, among all other medical interventions, and it is your right to ask for the benefits, risks, and alternatives, including doing nothing.

The Process

At a roughly 38 week appointment you may be offered the membrane sweep. You will be told it's quick, easy, and can jumpstart labor - not hearing any draw backs? Red card, flag on the play - stop your doctor right there and remember your B.R.A.N.N pneumonic. After describing the procedure, there will be a BRANN sheet on the stripping of membranes.

Ideally, you will have discussed your membrane sweep and given consent for the procedure and your doctor has told you what to expect and will be walking you through each step of the procedure as it is performed. Below are the general steps you should encounter and you can use this to ask your doctor how close to this what they are going to do is. If you want to stop at any time prior to or during the procedure, you may - it is your right to withdraw consent for any procedure, even after it begins.

• You will get undressed from the waist down

• You will place your feet up in stirrups on the examination table like a pelvic exam

• The provider ideally will be using sterile gloves and there should be no instruments being inserted inside your vagina, only the providers fingers.

• The provider will insert their fingers into your vaginal canal and locate your cervix. If it is midline or anterior and open at least 1cm, they will insert 1-2 fingers into and through your cervix into the uterine cavity and then begin stripping the membrane connections of the chorion (outer membrane of the amniotic sac) from your uterine wall by curving their fingers and attempting to strip the connection of the amniotic aac from the wall in a circular motion multiple times.

• When the provider is satisfied they have stripped enough of the membrane, they will withdraw their fingers and you will be able to sit up. Again, remember that you can stop this procedure at any time. You are not obligated to suffer through - consent can be withdrawn at any time, even during the procedure.

It is considered normal for there to be bleeding associated with a stripping of the membrane, as it is a highly vascular area and the connections broken may have pulled on and ruptured small blood vessels. Generally the guidelines that always apply to bleeding during pregnancy apply here - if you are filling a regular maxi pad with blood in under an hour, go to an emergency room. Be sure to ask your doctor what kinds of changes should prompt you to seek emergency care.

Cramping may begin as soon as the stripping starts. Pelvic pain is common. Some women find the procedure to be "no big deal" so experiences are all across the spectrum, all experiences are valid. Discomfort lasts on a spectrum just like the pain level of the procedure, it could be over quickly, it could persist into the next day.

If you develop a fever, follow the general pregnancy guidelines for fever which is to call your provider and if they are unavailable and your fever is above 100.4°F or 38°C go to your local emergency room. Ask your provider before you leave if there are any other signs to watch for after the stripping of the membranes.

We will approach the discussion of the membrane sweep with the BRANN model example below. Benefits, risks, alternatives, now/never, nothing.

Benefits:

• 1)Might start labor in 48 hours. (A lot of factors have to be true for this to work tho.) It is effective at inducing labor in approximately 20% of strippings.

• 2) Feels like you're "doing something" to get labor going (ask yourself why you are in such a rush, and why your doctor may be in such a rush)

Risks

• 1) Could cause accidental artificial premature rupture of the amniotic sac in 9% of strippings (This could quickly turn into a medical emergency such as a cord prolapse. You would also immediately be admitted, monitored and likely induced into labor or require an emergency C-section)

• 2) Severe pain, cramping, bleeding and discomfort with inconsistent contractions that don't lead to labor.

• 3) Infection of the uterus, amnion, chorion or fetus especially if sterile technique is not followed. Insist upon sterile gloves and water based lubricant!

• 4) May require multiple strippings of the membranes to see any labor signs. The risk of rupturing the amniotic sac is present for every sweep, with slightly inreasing odds each time it is performed

• 5) Your cervix may be posterior (normal for pregnancy and before labor) so your provider may attempt to 'walk your cervix forward' and not prepare you or explain this being necessary to continue the sweep. If your cervix is posterior (pointing backwards) your provider will not be able to easily insert their finger(s) through your cervix so they will put pressure on the body on your cervix to bring it in-line with your vaginal canal. This can be more painful than the sweep itself! You do NOT have to continue with a painful sweep!

Alternatives

A cervical massage is an alternative to a full membrane sweep, and if you have consented to a membrane sweep you may be given a cervical massage instead if your cervix is firm and closed which would prevent entry into the uterus for the stripping. Again, as it sounds, a cervical massage is making something that could be quite painful sound like a gentle and ideal way to promote labor. It is not regarded as gentle by most who have experienced the vigorous grasp of their cervix that is then pinched and spun in circular movements. This is supposedly attempting to cause the stripping from external to the uterus by grasping the cervix and rotating it with force to disconnect the membranes internally - its efficacy is well below the already low 20% efficacy of an internal sweep.

Now/Never

A membrane stripping is hardly ever an immediate emergent procedure that you must choose to have "Now" at any time during your pregnancy or labor. If this whole deal sounds Terrible to you, that would fall under the "Never" category and is what you would place on your birth plan to reflect.

Nothing

If you did not have the membrane sweep, you will still have your baby! A recent study showed that membrane sweeps we're only effective 20% of the time they were used, and that number includes multiple strippings for the same participant to go into spontaneous labor. Which is to say, if you do nothing, you probably aren't losing out on much. If you want to try a sweep, go in with strong communication with your provider and tell them exactly what you want and that you will be exercising your right to withdraw consent at anytime.

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Studies that have been run worldwide have gotten many mixed results, and the important part to remember when looking up information on this procedure, most all of the studies are not randomized controlled trials, and there is low confidence in the quality of the studies due to many factors including provider bias as they know which patient is in which group, and issues with controlling study participants inclusion criteria.

The stripping of membranes is heralded as the golden goose of labor induction as close to home as you can get - but when studied, it doesn't really pass the muster. A 20% chance to start your labor, with a 9% chance to prematurely rupture the amniotic sac and require an emergency or immediate birth are important factors to keep in mind when you are being offered this "routine standard of care" procedure.

As with any choice in your birth plan, it needs to represent what you want and how you feel about a procedure. This procedure does get offered well before your labor, so ideally you will have your birth plan hammered out to take to your next provider visit before the sweep would be offered, and your choice will be clearly there whether you do or do not want to have a stripping of your membranes.