Artificial Rupture of Membranes...The Least Invasive Procedure With the Least Appreciable Benefit?

Artificially rupturing your membranes (AROM) seems like such a small inconsequential intervention when you compare it to interventions like pitocin augmentation or episiotomy or forceps.  And it's true, compared to those and others, breaking your bag of waters is not quite as rife with risk, but that is not to say that it is entirely without risk either.  If your goal is a natural intervention free birth and you've already established some clear idea of your stance regarding other interventions let me encourage you to think a bit more deeply about this one.  Here is some background from what I've read and experienced:

The most often cited reason for doing an AROM is progress.  When labor is slow or arrested many times breaking your waters is suggested as a safe way to speed things up.  One time I had a client who was laboring very well and making adequate progress and then the doctor came in 5 minutes before her shift was up and suggested breaking her waters since according to her, it had cut her own labor time nearly in half.  I couldn't believe such blatant misinformation!  In this case there was no medical indication, simply a desire to speed an already well progressing labor.  My client agreed (as who wouldn't when promised a speedy delivery?!)  The unfortunate result was that the contractions intensified, causing pain my client could not keep up with prompting her to request a narcotic for the pain, which then led to her being confined to the bed, which slowed her progress down considerably and as far as I could see only increased her frustration and discomfort.  A veritable snowball of interventions that began with in my opinion an unnecessary AROM.

Another example of AROM used to speed up labor is from my own first birth.  My first birth was long but not atypically so.  I was going on a good 18 hours of labor with steady progress but not yet complete dilation.  My mood was tense and tired.  When my midwife suggested that breaking my waters might speed up my labor, I latched onto that fact with all the hope and expectation of a dying woman being offered a cure.  My husband tried to remind me of what we had learned in our Bradley childbirth classes, but I was not convinced.  Anything that might mean an end to my pain was very very welcome.  In my case I was close enough to complete dilation that it did not cause any very severe increase in pain nor necessitate my requiring any other intervention. What did happen was that I ended up feeling as if I had failed somehow in my attempt to birth.  I felt like I needed the help of my midwives in order to give birth and that my body just wasn't able to get the job done.

With my third I again accepted an AROM although I can no longer remember why (which bothers me a bit...) but anyway I was laboring well although contractions were incredibly intense.  My son's heartbeat stayed steady throughout labor but after the AROM there were significant decelerations to the point that my midwives gave me oxygen and told me to get up on the bed (I had been on the birth stool).  A significant side-effect of AROM is that cord compression is more likely to occur causing fetal distress.  Without the bulgy bag of waters for protection the baby is less protected and more subjected to the rigors and stresses of labor.  Since my son could no longer tolerate the contractions and pushing as well, I had to be up on the bed and slow things down in order to proceed safely.  If I had left my bag of waters intact would labor have continued as steadily but with less distress for my son?  It's possible...

My third and final example is from a birth where the baby was actually born in the sack.  It was my client's first birth, and everything was progressing steadily and normally.  The doctors were very gentle and patient, encouraging my client and remaining calm and steady throughout.  An ideal situation!  Whenever my client complained of pain or wondered when labor was going to end, instead of offering to "do something" i.e. break her waters to speed things up, offer pain medication, the nurses and I instead offered words of encouragement and gently helped her breathe through her contractions.  The baby's heartbeat never faltered and when pushing time came, my client pushed slowly and steadily with each contraction.  We all expected the bag of waters to break explosively on any or all of us there assisting but it never did, and in the end the baby was born, beautifully and gently with the bag intact.

Expecting labor (especially a first labor) to be slow and steady and allowing for pushing to be slow and steady as well is key.  Avoiding stress for mother and baby is also key when aiming for a natural childbirth.  Looking back, I think what I needed most towards the end of my first labor was encouragement that I was doing well and that all was proceeding normally.  To me, my labor seemed abnormally slow and painful.  I wanted/expected the AROM to be my miracle pill, dropping my baby out of me quickly.  That didn't happen and afterwards I still remember feeling that there had been something wrong or abnormal about my labor and my experience of pain.

Birth is difficult but shouldn't be scary.  When a laboring woman expresses pain or fear the best thing her caregivers can do for her is give her a sense of her own power to birth.  How this is done varies woman to woman.  Some need words of encouragement and praise.  Others need to do something, so suggesting position changes can be really helpful.  Others like touch, so massage or counter-pressure can give them the boost they need to keep going.  Offering to break their waters or offering any other intervention even when needed should be done carefully and considerately since it carries with it the implicit observation that whatever the woman is doing it is not working.  And equally importantly, breaking the waters should not be touted as a safe effective way to speed up labor.  It can speed things up but it is not always safe or the most effective way to do so.  The potential risks should be adequately explained and it should be suggested only after other methods have been tried.

Maternal Mortality in the U.S. a True Health Care Crisis

Studies have shown that women-centered care improves outcomes.  Women-centered care should mean that the care is focused on the women and offers consistent quality health-care while being respectful of each woman's unique needs and background.  For me personally, women-centered care means that each woman gets to choose where she gives birth, who gets to be there, and that she receives respectful and quality care from her providers.

In the United States, we may claim that we offer "women-centered care," when in fact the care most consistently delivered is sub-par with less than stellar outcomes.  How can this be, you may wonder, when we are a developed country with the most up-to-date medical technology money can buy?  To demonstrate, I will simply point to the statistics gathered from the United Nations showing that between 1990 and 2008 the vast majority of countries reduced their maternal mortality rates for a global decrease of 34 % while maternal mortality nearly doubled in the United States (Maternal Mortality in the United States: A Human Rights Failure, Association of Reproductive Health Professionals Journal, 2011).  Of the many reasons for this statistic, I would like to focus on the one that I see most often in hospitals today: the overuse of medical technology.

Studies between 1996 and 2008 show that there has been a 56% increase in surgical births, with no evidence for improved outcomes.  In fact, there have been studies showing data that the increase in medical intervention actually increases maternal and infant morbidity.  This is not to say that there haven't been losses due to the lack of medical technology; there have been.  It's just that there are far fewer of those deaths than there are preventable deaths due to in part to the overuse of medical technology than otherwise.  For example, there are countries with less life-saving medical equipment that have lost fewer mothers and babies than we do in the United States.  And the reality is that the United States ranks 50th in the world in terms of maternal mortality.  So while we like to think that we are safe and protected in our hospitals surrounded by the best technology on the planet; we may in fact be placing ourselves in far greater danger than we realize.

I don't mean to sound all gloom and doom, but I do think that an increase in awareness is called for.  The statistics are scary, yes, so rather than argue, let's do something about it!  Some states have already put in place systems to increase reporting so that we can find out more about why these deaths are on the rise and what we can do about them.  There are even a few health care models utilizing fewer medical interventions and their outcomes have been consistently good.  We are making progress, but it is slow.  And here is where I will venture into the philosophical realm.  To quote a Native American saying used most often by environmentalists, "tread lightly upon the Earth, and live in balance and harmony."

In order to improve our obstetric care in the United States we have to start treading lightly.  Birth is not something that responds to a hammer fist of intervention.  Truly, birth works best when it is left alone.  In this instance an encouraging word and a gentle touch will do far more to effect good outcomes than a mighty weapon (forceps, episiotomy) and a take charge attitude.  I've seen too many doctors enter a delivery room and take over the whole scene.  I am here now, and since I am here, I must now do something to get this baby out!  Seriously?!

Again, just to qualify, I do not mean that birth always works best when left alone.  Of course, there are times when medical intervention is called for and necessary.  But when there is no true medical need and intervention is still applied, for whatever reason, that is what I am railing against.  That is where we run into trouble.  So when a doctor says it doesn't matter how the baby is born, you have my permission to say, "Actually it does and you are not following evidence-based practices if you believe otherwise."  Medical procedures should be left for when they are truly medically necessary.  Women should be assured that medical professionals have their best interests at heart.  They should be assured that nothing will be done that might endanger their lives or the lives of their babies.

The really backwards thinking that goes on is that by doing more medical interventions, we think we are preventing complications and death, but that is just not true based on the statistics.  So, to improve care, we need to start paying attention to the data.  It does not pay to induce labor unnecessarily.  It does not pay to do routine cesareans.  Most importantly, it does not pay and it can do severe harm.  It's time we started paying attention to other countries where outcomes are better and try to adopt more women-centered practices here in the United States.