The Cochrane Collabouration released a new review last week looking at amniotomy
and whether or not it offers any benefit to women and their babies.
The researchers reviewed 14 studies that included 4,893 women who had their
membranes broken routinely on admission to hospital where labour had started
spontaneously, and also women who had started labour spontaneously but labour
progressed had slowed down.
Length of labour
The length of labour was not statistically different between the experimental
group (with amniotomy) and the control group (no amniotomy). The first stage of
labour was 20 minutes shorter on average in the experimental group. The authors
highlight that there is no evidence that a shorter labour is beneficial, either
in terms of maternal and infant health, or in terms of maternal satisfaction.
caesarean section
There was a slight increase in the numbers of caesarean sections in the
experimental group, although this was not statistically significant. The authors
point out that many of the studies that were reviewed did not state whether or
not women in the study had continual foetal monitoring. Since this routine
intervention is known to increase the caesarean rate without any medical benefit,
they were unable to adjust for this factor. If women in the control group
received continual foetal monitoring it may have increased the incidence of
caesarean section.
Infant wellbeing
There was a slight increase in the number of babies born with an Apgar score of
less than 7 at five minutes in the control group compared to the experimental
group. However, there was no statistical difference in the number of babies
admitted to special care units, with abnormal heart rate traces, or meconium
aspiration, acidosis or infant death. Although there were slightly more babies
in the control group with low Apgar scores, it did not appear to have any effect
on their health.
Use of oxytocin
The review found that there was no difference between the two groups in the use
of oxytocin (e.g. pitocin or syntocinon). However, some of the studies excluded
women who were given oxytocin so this may have affected the results. ased on t
his review, there is no way of knowing whether or not amniotomy increases the
use of oxytocin.
Other interventions
There was no difference between the two groups in terms of use of pain relief,
forceps delivery or postnatal hemorrhage.
Discussion
There are a number of questions raised by this review. The authors noted that in
8 of the 14 trials, 30% of women who were in the control group (no amniotomy)
actually received amniotomy at some point in their labour. This has significant
implications for affecting the results. If the women in the control group
actually did receive amniotomy they are no longer an effective control!
The authors of the Cochrane review concluded:
"On the basis of the findings of this review, we do not recommend that
amniotomy be introduced routinely as part of standard labour management and
care."
There does not appear to be any evidence for supporting the use of routine
amniotomy. It offers no advantages to either the mother or baby, and may
increase the caesarean rate.
How does this affect your clients?
If you are working with women who have chosen active management caregivers,
there is a high risk of them having amniotomy performed routinely. Part of the
protocol of active management is the breaking of the waters when the woman is
admitted to hospital, or when her labour does not progress at the expected rate.
Recognising that a caregiver is likely to carry out this procedure provides omen
with the opportunity to determine whether or not they have chosen a caregiver
that meets their needs.
As a doula or antenatal teacher you can discuss this intervention with women,
helping them to formulate questions that explore this intervention and others.
It also provides them with the opportunity to discuss whether they want
themselves and their babies exposed to routine practices, or prefer a model of
personalised care that takes into account their own needs and preferences.
It can be difficult to cover these issues in antenatal classes - there are so
many interventions that to discuss each of them individually can lead to a focus
on intervention rather than normal birth. This is the perfect topic to write up
in a client handout, discussing the procedure itself, together with the benefits
and risks, based on the evidence. Rather than focusing on each individual
intervention, it can be more beneficial to discuss questions that help clients
to determine their caregivers philosophy and then techniques for how they can
explore their options, including the option of choosing a caregiver who is more
in line with their needs.
