Four Clinical Applications of Artificial Rupture of Membranes, Indications + Procedures + Precautions Explained!
01
Physiological Functions of the Amniotic Membrane
At term, the amniotic membrane is a tough and flexible layer, and this innermost avascular membrane secretes and absorbs amniotic fluid, playing an extremely important role in human pregnancy. The amniotic membrane provides almost all the tensile strength of the fetal membranes, and the amniotic epithelium can synthesize vasoactive peptides, prostaglandins, etc., which enter the chorion surface to promote cervical maturation and uterine contractions.
02
Clinical Applications of Artificial Rupture of Membranes (ARM)
1. Inducing Contractions – Labor Induction
When the cervical condition is immature, Bishop score ≤ 6, simple ARM not only has a low success rate for labor induction but also cannot predict the timing of labor onset. Additionally, the prolonged time from membrane rupture to delivery may lead to infection; therefore, it is not recommended to use ARM alone to promote cervical maturation. ARM is usually added after pharmacological or mechanical methods for cervical maturation. When the cervical condition is mature, Bishop score ≥ 7, ARM can be combined with oxytocin for labor induction.
Indications for ARM Induction:
(1) Conditions for vaginal trial of labor induction (IOL) are met.
(2) Bishop score ≥ 7.
Relative Contraindications:
(1) Fetal head not engaged in the pelvis.
(2) Fetal head not in close contact with the cervix.
ARM is more often used after pharmacological or mechanical induction of regular contractions, such as Bishop score ≤ 6, placement of a balloon catheter for induction, removal of the balloon after 12 hours, and immediate intravenous oxytocin after ARM; if the balloon is ineffective or the effect is not obvious, and ARM cannot be performed, sequential use of dinoprostone for cervical maturation or re-insertion of the cervical balloon after 24 hours can be considered. Currently, some scholars in China believe that after ARM, observation for 30-60 minutes is necessary, and if contractions do not strengthen, a small dose of oxytocin can be used again.
2. Shortening Labor Duration – Augmentation of Labor
Routine ARM during labor is not recommended: The 2020 Clinical Practice Guidelines for Normal Labor established by the Obstetrics Group of the Chinese Medical Association and the Perinatal Medicine Group clearly state that routine ARM during labor is not recommended.
ARM is not recommended during the latent phase, but is recommended during the active phase: At term, the chorion in direct contact with the cervix reduces the release of prostaglandin-degrading enzyme (PDHG), allowing prostaglandins in the amniotic membrane to contact the cervix, promoting cervical maturation and shortening labor.
If early ARM is performed, these prostaglandins’ effects on the cervix will disappear, and the intrauterine environment will be prematurely exposed to the outside, increasing the risk of chorioamnionitis. Therefore, ARM during the latent phase is not recommended.
ARM is generally performed when the cervical dilation is ≥ 5 cm during the active phase. If there is a lack of coordinated contractions after ARM, oxytocin can be used to promote labor progress. The combination of ARM and intravenous oxytocin can shorten the time from induction to delivery. If the membranes are still intact after full dilation, affecting fetal descent, ARM can be performed during contraction intervals to facilitate fetal descent and manual rotation of the fetal head.
3. Adjusting Fetal Position (ARM + Manual Rotation of Fetal Head)
For pregnant women with abnormal fetal positions, entering the second stage of labor or when the cervix is nearly fully dilated, when the biparietal diameter of the fetal head reaches the level of the ischial spines or lower, manual rotation of the fetal position after ARM is the primary measure for correcting fetal position.
4. ARM for Vaginal Delivery of Twins
ARM is not recommended during the first stage of labor. In our clinical practice, an interval of 5-10 minutes between the delivery of the two fetuses is suitable.
After the first fetus is delivered, promptly stabilize the second fetus in a longitudinal position. If the feet are presenting, the second fetus can be grasped by the ankle through the relaxed cervical opening, pulling it to the vaginal opening. During contraction intervals, ARM can be performed for breech delivery or breech traction; if the second fetus is head down, an assistant can gently push down on the uterine fundus, and after the fetal head engages, ARM can be performed during contraction intervals to deliver the fetus.
After the first fetus is delivered, oxytocin should be administered intravenously as appropriate according to the contraction status.
03
Precautions for ARM Operation
and Emergency Management of Cord Prolapse
The timing for membrane rupture should be selected between two contractions, ensuring the “Three Preventions”: prevent rapid outflow of amniotic fluid leading to cord prolapse; prevent sudden drop in intrauterine pressure leading to placental abruption, etc.; simultaneous artificial membrane stripping is not advisable to prevent amniotic fluid from entering the bloodstream during contractions, which may cause amniotic fluid embolism. The major complication of ARM is cord prolapse.
Risk factors include: ARM when the fetal presenting part is not engaged, rupture of membranes during external cephalic version, amniotic fluid infusion, placement of fetal scalp electrodes or intrauterine pressure catheters, or use of balloon catheters for cervical maturation, etc.
Most cord prolapse occurs within minutes after membrane rupture. One study found that 57% occurred within 5 minutes, and 67% occurred within 1 hour after membrane rupture. If fetal bradycardia or variable decelerations occur within minutes after ARM, especially if abnormal fetal heart monitoring occurs immediately after membrane rupture, vigilance for cord prolapse should be heightened. If cord prolapse is diagnosed, vaginal delivery cannot be performed in the short term, and immediate cesarean section should be performed. If the amniotic fluid is bloody after ARM, with or without abnormal fetal heart rate, high suspicion for placental abruption should be maintained.
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