|
|
Time to think again? In 1976 a group of student midwives met together to form a support group, they were the founders of a group which was to have a significant effect on the future of midwifery and maternity care. They needed a name that fitted the initials ARM because these were the initials of the most common intervention in labour - artificial rupture of membranes. These midwives, who challenged and questioned every `routine' carried out on individual and idiosyncratic women, called themselves the Association of Radical Midwives - affectionately known as ARM. Go into the labour ward in the country and on the board will be the initials ARM written alongside many of the women's names there - artificial rupture of the membranes or breaking the waters remains the most common intervention that women in the UK are likely to experience, an intervention so common and perceived as so `normal' that statistics of its occurrence are frequently not kept. While we are looking at almost everything done to women in labour and pregnancy, perhaps it is time to look at the effects of this intervention and at actually what the implications are of what we are doing when we perform this most common of interventions. All interventions in labour have a multiple effect - they have an effect on the length and quality of labour, they often have an effect on the woman's mobility, they often have an effect on the amount of pain she perceives that she is experiencing - this can lead to a change in her need for analgesia. Interventions in labour have an effect on the attendants to the woman in that having crossed the barrier between `not doing' and `doing' something, then the inclination could well be to `do something more'.Interventions can affect women's level of fear and if a woman becomes very afraid could this have a direct effect in the fetus? Could this have an effect on the physiology of the uterus? Might it have an effect on whether the uterus contracts efficiently or not'? Last year (1989) the National Childbirth Trust published the results of a survey of 3,000 women who answered questionnaires on the effects of artificial rupture of the membranes. They answered questions on what the effects were, when it was done and how it was done. This survey (not a scientifically controlled study, but anecdotal) showed that artificial rupture of membranes invariably increases the pain of labour. It also showed that when membranes rupture spontaneously they appear either to rupture at the beginning of labour or before labour actually starts, or at the very end of the labour when women appear to be able to cope with the increase in pain. When artificial rupture of membranes is carried out it is usually done at between three and four centimeters dilation. Women answering the survey found that they could cope with labour and its pain until their membranes were ruptured artificially, and when they were ruptured the increase in severity and sharpness of the pain was so severe that they needed analgesia following the procedure. The NCT survey found that those women who were having their babies at home were much less likely to have their membranes artificially ruptured than women delivering in a Maternity Unit - and it was irrelevant whether the woman was having a domino delivery or a regular hospital delivery. Those midwives attending women in home births appear to use little analgesia - most women having their baby at home, if they use any analgesia at all, will use entonox as their form of pain relief, for the rest they moan, sit in the bath, gyrate their pelvis and get through somehow. The women who give birth at home in 1990 may be a self selected group of strong minded women, anxious to avoid analgesia, but maybe the reason that most of them manage to get through labour without analgesia is because their membranes stay intact?The reasons for performing amniotomy are usually stated as being in order to speed up the labour, in order to see the colour of the amniotic fluid, in order to attach a fetal scalp electrode and in order to introduce an intra-uterine pressure catheter. As far as shortening labour, Stewart, Kennedy and Calder (1982) showed that women whose membranes had indeed been ruptured did labour for a shorter period (4.9 hours compared with 7.0 hours when the amniotomy was carried out at between two and five centimeters dilation), but that the fetal acidosis reached worrying proportions when the membranes had been ruptured, the study was a small one -68 women, and further study needs to be carried out with women being randomized either into `for artificial rupture of membranes' or `to leave membranes intact until the baby is born in the caul' groups. Until that happens let us consider the benefits to the woman and the fetus of speeding up labour. It may be that women would opt for quick labours if they genuinely had the choice but this assumption may not be true at all. Many women appear to find fast labours extremely painful, rather shocking and extremely difficult to cope with - all the effects reported by the women in the NCT survey about the effects of ARM.It may be beneficial to the fetus to be born more quickly , but we really have no idea whether it is or not. If one thinks of other physiological functions besides labour which we share with other mammals - eating food, defecating, having sexual intercourse - with none of them is our aspiration `to speed them up', in fact there is no other human activity when our desired aim is to hurry a normal process. When a woman's pain in labour is increased, she may need an epidural, the effects of epidurals are often benign and beneficial in their excellence of pain relief, but studies have described lengthening of labour, increased need for intravenous infusions of syntocinon and an increase in instrumental delivery. This may be a perfectly acceptable trade-off for the pain relief afforded to the woman, but if the need for it was only occasioned by our use of artificial rupture of the membranes, are we right to subject a woman to an increased risk of having an episiotomy and greater bruising of the perineal area due to an instrumental delivery? Even more, are we justified in taking away the woman's ability to `cope with' her labour? Women point it out as being important factor to them in labour, they are inordinately proud of themselves when they feel that have `co-opted and disproportionately upset when they have to resort to analgesics when they had not planned to. The long term effects of this may not be relevant, but Oakley showed in her study `Transition of Motherhood' that women who felt they had `coped' in labour started mothering with a more positive attitude to their abilities than women who felt the 'victims' of the birth process. Other `soft' data which needs to be looked at further was the study by Kumar and Robson which described delayed onset of maternal affection for the baby following artificial rupture of the membranes - `a woman had a 90 per cent chance of feeling some immediate affection for her baby if she did not have her membranes artificially broken'. A woman having her membranes ruptured artificially had a 74 per cent chance of experiencing indifference towards her baby. The result was unexpected and may have been chance, but if we are intervening in the bonding between mother and infant by carrying out a procedure which is hard to justify and may be being done because `we've always done it', we really must start thinking about what we are doing.The desire to view the amniotic fluid may or may not be justified, viewing the amniotic fluid at four centimeters may be useful but probably not if the fetal heart shows no indications for anxiety. The fetal head entering the pelvis may well occlude later passage of amniotic fluid and the sight of meconium stained liquor. On the other hand the meconium may have been passed as a response to the increased pressure on the fetal head occasioned by the artificial rupture of membranes. Dunn, (1978), describes the beneficial effect of intact membranes when the presence of amniotic fluid ensures an even pressure on the fetus during uterine contractions, those isometric uterine contractions prevent impairment of utero-placental circulation due to retraction of the placental site. He also goes on to express anxiety at the increasing rates of congenital infections in his Unit, and he questioned whether these were a result of increasing amniotomy and increasing instrumental delivery following epidural anaesthesia (Sixth European Congress of Perinatal Medicine, Vienna 1978). In many ways it appears that by rupturing membranes as a routine procedure we are rushing in where angels fear to tread, the effects of ARM are legion and obviously we do not know them all. Donald in 1966 said `No labour is so pleasing and satisfactory tc mother and child as when intact membrane are maintained right up to full dilatation .. with very few exceptions, intact membrane: mean an intact mother and an intact baby' Might he have been right? ReferencesNational Childbirth Trust. (1989) Rupture of the Membranes in Labour, a survey. Stewart, P., Kennedy, J.H., Calder, A.A. (1982). `Spontaneous labour: when should the membranes be ruptured?' British Journal of Obstetrics and Gynaecology, January, Vol. 89., pp.39-43. Oakley, A. (1979). From here to maternity, becoming a mother. Penguin Books. Oakley, A. (1980). `Women confined, towards a sociology of childbirth'. Oxford: Martin Robertson. Robson, K.M., Kumar, R. (1980). `Delayed onset of maternal affection after childbirth'. British Journal of Midwifery, 136, pp. 247353. Dunn, PM. (1978). 'Problems associated with fetal monitoring during labour'. Sixth European Congress of Perinatal Medicine, Vienna, 1978. Donald, l. (1966). Practical Obstetric Problems. Autumn 1990. |
|