Why is the bubble pierced before childbirth? A puncture of the amniotic fluid - does it hurt? How to induce contractions after a bladder puncture.

The culture of birth shapes practices and incorporates established rituals. The movement from hospital birth to natural birth with a midwife is now popular; this is happening as women and birth care professionals re-evaluate some of the practices and interventions that are typical of hospital births. Amniotomy is a long-standing practice that is considered permissible in order to reduce the length of labor. There are practically no publications on the effect of amniotomy on a child. This article explores the pros and cons of amniotomy, its role as a ritual for helpers in childbirth, and its possible psychological effects on the baby.

Puncture of membranes of the membranes or amniotomy is a common, not to say routine, practice in North American childbirth culture. Amniotomy is perceived as a useful technique to improve labor if it weakens (1). During pregnancy, amniotic fluid is the baby's natural habitat. In the aquatic environment, the child masters the first movements, learns to breathe and swallow; all this prepares him for extrauterine life. During labor, amniotic fluid serves as a "safety cushion" for the baby during contractions and while passing through the birth canal (2). The decision to pierce the bladder or, conversely, wait for the natural rupture of the membranes is an important part of the birth plan. But since amniotomy has long become a common practice and is perceived as such even in the circles of supporters of natural childbirth, this issue is often overlooked altogether.
When the doctor or midwife decides to have an amniotomy, the puncture is done with a special instrument, like a hook; the instrument is inserted into the birth canal, the membranes are picked up and pierced. As a result, it is assumed that the baby's head will press on the opening cervix, which will speed up the opening and the birth itself. Some studies (3-6) have found that amniotomy does not speed up labor too much, up to an hour or two. Another study (7) argues that amniotomy makes contractions more painful and interferes with the formation of maternal attachment immediately after birth, as many women feel that the natural course of the birth process has been grossly disrupted (8). However, in some women, especially multiparous women, amniotomy reduces pain during the second stage of labor (9). There is practically no contraindication to amniotomy in case of fetal distress (10). Amniotomy is routinely used to access the fetal head when distress is suspected to confirm or refute this assumption (11). A puncture of the fetal bladder helps doctors examine the waters for the presence of meconium or blood. Amniotomy also allows monitor probes to be attached directly to the baby's head when signs of distress are present. However, there is not enough scientific evidence on the advisability of a bladder puncture in the early stages of labor in order to study the amniotic fluid when fetal distress is suspected. Early amniotomy can exacerbate distress as it reduces the amount of fluid that can lead to partial compression of the umbilical cord, reducing the supply of oxygen to the baby, and as a result, often even the need for an emergency caesarean section.

Spontaneous rupture of the membranes
Spontaneous rupture of the fetal bladder before the onset of labor occurs in about 12% of cases (12). Premature discharge of water can create a critical situation, as there is a risk of umbilical cord prolapse. If the umbilical cord is pressed against the bones of the maternal pelvis, then there is a risk of fetal hypoxia. If childbirth proceeds without intervention, then two-thirds of women with healthy full-term pregnancies achieve good dilatation in the presence of an entire fetal bladder (13). In an online obstetric discussion, one midwife argues that out of 300 unstimulated deliveries without intervention, about 15% of women had a bladder intact until almost the end of the second stage of labor (14). One of the advantages of trusting nature and expecting spontaneous rupture of the membranes is that in this case, the child's entire body experiences only hydrostatic pressure and thus receives protection during contractions, and the head does not change its configuration so much when passing through the pelvic bones (15 ). In addition, intact membranes reduce the chance of intrauterine infection.
The presence of meconium in the waters does not necessarily mean an increased risk to the baby. A full-term healthy baby can expel meconium in utero and even swallow it (16). Routine bladder piercing “just in case” is unwise and unethical (17, 18). On the other hand, some studies show that sometimes the presence of meconium in waters lowers the pH and then the child's APGAR score. Dr. Marsden Wagner says: “ Early bladder puncture as a routine procedure is not scientifically substantiated" (nineteen). Amniotomy is a procedure that takes away from a woman some of the experience of childbirth and reinforces the subconscious belief that childbirth is an unnatural process (20).

Hormonal, chemical and physiological adaptation During childbirth, there is a biochemical and hormonal adaptation of the mother and child to each other. The baby's pH is influenced by the mother's pH and changes over the course of labor (21). PH measures the acidity of the environment (acidic, neutral or alkaline) and determines the body's ability to get rid of decay products. A neutral pH of 7 is optimal and the body works to maintain the pH at this level. Blood levels of catecholamines (adrenaline and norepinephrine) increase as the stress associated with normal labor increases and facilitates its progress (22). Optimal changes in hydrostatic pressure and pH (downward) have a beneficial effect on the child's cardiac activity and his cardiovascular system, prepare for adaptation to extrauterine life. However, excessive stress and excitement raise hormone concentrations above the functional limit, which causes a drop in pH and slows down labor. The second stage of labor is marked by changes in pressure, position and position of the baby, when he leaves the aquatic environment, unbends and experiences the effect of gravity.
The level of anxiety and stress a woman experiences during childbirth depends on the culture of birth in a given society. Women need accurate, unbiased and complete information to be active participants in their childbirth. Women who do not have such information are often passive and afraid (23). The medical model of childbirth relies more on machines than on the woman's body, and this model is more likely to have interventions and unnecessary procedures. Ultimately, women do not participate at all in decision making during childbirth, and all that remains for them is to worry about what happens to them and their children.

Functions of the amniotic fluid
There is a huge amount of research examining the chemical composition of amniotic fluid and its role in fetal maturation, as well as during childbirth. Although the hormonal, chemical and physiological mechanisms of adaptation of mothers and babies are largely understood, the composition of the amniotic fluid, its changes during the first and second stages of labor and how the baby uses the amniotic fluid during such an important period for its development as childbirth are all this is not yet fully understood (24). There is recent research on the carbohydrates, proteins, fats, electrolytes, enzymes, and hormones found in amniotic fluid, and how these all relate to baby's birth weight, onset of labor, and pregnancy progress (25).
Research suggests that early spontaneous rupture of the bladder may be related to the composition of the amniotic fluid. Another study points to an increase in the concentration of prostaglandins in the amniotic fluid, suggesting that this growth triggers labor; this postulate contradicts the generally accepted opinion that the concentration of prostaglandins increases as a result of the onset of labor (26). Other studies (27, 28) investigate the relationship between the presence of one of the parathyroid peptides (PTHrP) in the amniotic fluid and its effect on labor and the functioning of the membranes in late pregnancy (29). Another study (30) investigates the role of interleukin-2 in the mother-fetus immune system during early pregnancy and possibly during childbirth. Amniotic fluid, a baby's natural habitat, is taken for granted and manipulated without fully understanding its function in childbirth. Research points to the need for additional study of the chemical changes in amniotic fluid composition during labor and the effect of these changes on the child's experience of labor. Although everyone knows that amniotic fluid creates a protective layer for the baby during labor, bladder piercing continues to be a routine procedure. It is possible that there are still important, but not yet known to us, functions of the amniotic fluid, which help the child to adapt to the new life conditions after birth.

Rituals surrounding birth The process of birth is reflected in the culture of any society, and any culture uses various rituals to overcome the fear of the unknown. Childbirth can be unpredictable, carry elements of a spiritual mystery. With the help of rituals, it is possible to avoid dangers and come to a good ending. Medical interventions, explains childbirth anthropology researcher Robbie Davis-Floyd, give physicians a psychological sense of power over the forces of nature and help relieve fear (31). The ritual includes symbolic objects (for example, a hook to pierce the bladder), ideas (for example, “amniotomy speeds up labor, which is good for a woman”) and actions such as taking responsibility, explaining the meaning of the procedure. The imagery associated with amniotomy implies forces that "release water and bring life", while in the hands of the person taking the birth. Such rituals convey an unconscious message that the woman feels rather than consciously perceives. The effect is incredibly powerful. The hospital birth culture stands for technical symbols and procedures that try to transcend nature and individuals, as if telling us that a woman's body is imperfect and that, using tools, doctors can manipulate nature.
The obstetrician, mobilizing the strength of the woman in labor, allows the natural process to develop independently, he understands that the woman's body itself knows what to do (including the moment when it is time to get rid of the amniotic fluid). Such an obstetrician accepts the fact that amniotic fluid helps the cervix open by pushing outward in the bladder, working like a wedge, using hydrostatic pressure to gently and evenly open the cervix (32). This is the progress that mother and child are making together, not the hasty mechanical intensification of labor that amniotomy produces and which takes away the birth experience that is rightfully theirs for mother and child.

Types of influences and behavior
Childbirth is a biological frontier. Recent studies on prenatal causes of adult illness indicate that more changes occur during the prenatal and early postpartum periods than at any other age. Studying the interaction of the body with its environment during critical periods of development, the study concludes that the child makes compensatory efforts in utero, which increase his susceptibility to disease (33). The researchers also found that this type of reprogramming can be passed down from generation to generation. It is impossible not to ask the question: is not a sharp change in the conditions of a child's existence when a bladder is punctured the reason for an increase in the number of children with sensory integration difficulties, who then receive neurological diagnoses such as "attention deficit hyperactivity disorder" ). There is a hypothesis that the consequences of a puncture of the bladder in girls appear later, since the eggs in her body register this interference at the level of cellular memory, and when she grows up and becomes pregnant, this will change the properties of the membranes in her children. From a prenatal and perinatal point of view, it is known that how our heredity and our personality traits manifest themselves depends, among other things, on the events that accompanied conception, intrauterine life and birth (34). Unfortunately, the effect of amniotomy on early psychological development is not taken into account, while the ritual of puncturing the bladder to enhance labor is widespread. Amniotomy is routinely used to speed up labor and to diagnose fetal distress, while amniotomy itself promotes irregular heartbeats in the fetus (which is a sign of distress!) By decreasing the amount of water in the uterus, thus compressing the umbilical cord and access of placental blood and oxygen to the child. When the membranes are left untouched, the baby experiences much fewer heart rhythm disturbances during labor. Part of the irregular heartbeat is caused by the birth itself, and this is natural (35). It is likely that amniotomy is used to diagnose fetal distress much more often than is actually necessary. Amniotomy forces the child to urgently adapt to the fact that his body is subjected to strong mechanical compression, and the head passes through the bony ring of the maternal pelvis without any protection. A sharp drop in hydrostatic pressure and an unexpected squeezing of the head in the bone ring that a child experiences in connection with an amniotomy is perhaps too much stress on the child's body. When the bladder is punctured, it experiences symbolic, physiological and psychological loss (36). When the environment around the child — the protective and nourishing amniotic waters — suddenly pours out, the child instantly experiences a sense of irreparable loss. He passes through the birth canal on command, this is his first "loss of himself." " Stress matrix»Is a conceptual model that helps us better understand the shock and trauma that a baby experiences during childbirth (37). As the physiological shock increases, the changes may be overwhelming and excessive for the child. Shock is “a sudden disturbance of psychological balance” (38) and it certainly affects behavior. The body will recall the experience of childbirth at the motor, vestibular, emotional and social levels (39). Some physical signs that are noted in children who have experienced stress during birth are limb twitching, muscle hyper- or hypotonia, manifestations of rage, fear, or lack of response to the world around them (40). Their condition is often attributed to infantile colic, ignoring the trauma they suffered. While these signs must be noticed and accepted, working with them, if we do not want them to gain a foothold and affect the development of personality throughout life.
Young children are often diagnosed with attention deficit hyperactivity disorder (ADHD), when their nervous systems aggressively resist stimuli from their environment. Or the child may be unresponsive, non-contact - this is a reaction of "escape" from environmental stimuli. Such children are at risk of getting depression in the future, as teachers and parents often misjudge their condition. As they grow up in the modern high-tech world, these children often isolate themselves from society and immerse themselves in computer games, which, of course, negatively affects their behavior. Technology affects the social life of a child from the very beginning, it has such a strong impact that stressed children prefer to connect with the world through technology. In the worst case, the latent desire for human contacts with oneself and with others (and the rage of their impotence to establish these contacts) is fueled in such children by electronic games in which violence and murder are glorified. Accordingly, these contacts are carried out in the form of aggression directed at oneself or others.

Early developmental psychology
Amniotomy is rarely, if ever, mentioned as an intervention that could potentially be psychologically traumatic for the mother or child. Abrupt changes in intrauterine conditions are stressful for the baby, and the mother may perceive amniotomy as a rude intrusion into the process of childbirth. Without a doubt, a baby can be born in a state of shock, and no one will notice, this procedure has become so routine in our culture of childbirth. One of the principles of early developmental psychology, related to the development of human potential, refers us to the capabilities of the infant, which include intellectual, sensory and energetic adaptation. It seems clear that the decision to perform an amniotomy will have many consequences for the child. From the very beginning of its nascent life, the child is influenced by the thoughts and feelings of his mother, and during childbirth he is also influenced by the thoughts and feelings of those taking birth. The foundations for the growth and development of a baby are laid during pregnancy and childbirth. He reacts to the sensations and emotions of the mother and her environment, and this affects his development. The behavior and thoughts of others during childbirth can have a lasting impact on him. Amniotomy means that a stranger appears with an instrument that grossly violates the environment around the child and causes its abrupt changes, for which the child is completely unprepared. It is an invasive procedure that violates the child's innate need for belonging, safety, and care. Bladder piercing makes contractions more painful for both mother and baby, and can disrupt their telepathic connection. The drastic changes caused by the outpouring of water trigger the release of stress hormones that affect the sympathetic nervous system, and this process can be reproduced whenever a child finds himself in a stressful situation throughout his life.

Problem solving strategies
To overcome the widespread use of amniotomy, you need to open your mind to unfamiliar statements and break through stereotypes. We are moving forward as textbooks already indicate that amniotomy is useless in shortening labor (41, 42). It is also recognized that amniotomy "just in case" to assess the condition of the fetus does not justify itself. It is necessary to educate and educate people working with children on how to recognize the symptoms of shock in infants, children and parents in order to facilitate healing from its effects. It will take passionate people to carry this information about every toddler and every parent and personally to parents, and those who work with these children and parents, it will take many people to organize conferences and publish credible research. We need an environment that gives us a sense of security. She will be able to heal the trauma we received in the early stages of development. As workers in obstetrics, we must slow down the pace, reduce our activity in order to enable the child's body to turn on self-regulation and adaptive mechanisms (43). Slowing down the pace helps us connect. " here and now»And form full-fledged relationships. Being calm increases our empathy for babies and allows us to recognize their unique bodily manifestations of trauma.
We have a long journey ahead of us - we have to create and maintain a softer birth culture. This requires communicating to the community, pregnant women, childbirth trainers and policymakers the need for a change in the delivery system to empower women. We must recognize the value of the art of midwifery and support it everywhere, as it makes our society better.

Verna Oberg received her master's degree from the Institute's Department of Prenatal and Perinatal Psychology in Santa Barbara in 2010. She works as an early development consultant, monitors the developmental stages of newborns and young children, promotes parent-child attachment, and advocates that newborns and young children are full-fledged people with consciousness and feelings. Verna expresses her deep gratitude to Dr. Jean Rhodes for her help with this article.

Literature: 1. Goer, H. 1999. The Thinking Woman's Guide to a Better Birth. New York: The Berkeley Publishing Group. 2. Simkin, P. 2001. The Birth Partner, 2nd ed. Boston: The Harvard Common Press. 3. Davis-Floyd, R., and C.F. Sargent, eds. 1997. Childbirth and Authoritative Knowledge: Cross-cultural Perspectives. 3rd ed. Berkeley and San Francisco: University of California Press. 4. Enkin, M., et al. 2000. A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. New York: Oxford Press. 5. May, K.A., and L.P. Mahlmeister, eds. 1994. Maternal & Neonatal Nursing, 3rd ed. Pennsylvania: JB Lippincott Company. 6. Wagner, M. 2006. Born in the USA. Berkley, CA: University of California Press. 7. Robson, K. M., and R. Kumar. 1980. Delayed Onset of Maternal Affection. Br J Psychiatry 136: 347-53. 8. Mayes, M. 1996. Mayes Midwifery, 12th ed. Oxford: Baillière Tindall. 9. Brenda. 2001. Artificial rupture of membranes: breaking the waters. Message posted to UK Midwifery Archives at http://www.radmid.demon.co.uk/arm.htm. Accessed 2 Jun 2010. 10. See Reference 6. 11. See Reference 4. 12. Childbirth Graphics. 1993. Directional Learning. Wasco, Texas: A Division of WRS Group, Inc. 13. See Reference 6. 14. Rehana. 2001. Artificial rupture of membranes: breaking the waters. Message posted to UK Midwifery Archives at www.radmid.demon.co.uk/arm.htm. Accessed 2 Jun 2010. 15. See Reference 2. 16. See Reference 5. 17. Ibid. 18. See Reference 6. 19. See Reference 3. 20. Davis-Floyd, R. 1987. Hospital birth routines as rituals: Society's messages to American women. J Prenat Perinat Psychol Health 1 (4): 276-96. 21. See Reference 5. 22. Ibid. 23. McKay, S. 1991. Shared power: The essence of humanized childbirth. J Prenat Perinat Psychol Health 5 (4): 283-95. 24. See Reference 5. 25. Gotsch, F., et al. 2008. Evidence of the involvement of caspase-1 under physiologic and pathologic cellular stress during human pregnancy: a link between the inflammasome and parturition. J Matern Fetal Neonatal Med 21 (9), 605-16. 26. Lee, S. E., et al. 2008. Amniotic fluid prostaglandin concentrations increase before the onset of spontaneous labor at term. J Matern Fetal Neonatal Med 21 (2): 89-94. 27. Ferguson II, J. E., et al. 1992. Abundant expression of parathyroid hormone-related protein in human amnion and its association with labor. Proc Nati Acad Sci USA. 89: 8384-88. 28. Wlodek, et al. 1992. Abundant expression of parathyroid hormone-related protein in human amnion and its association with labor. Reprod Fertil Dev 7 (6): 1560-13. 29. Ibid. 30. Zicaria, A., et al. 1995. Interleukin-2 in human amniotic fluid during pregnancy and parturition: implications for prostaglandin E2 release by fetal membranes. J Reprod Immunol 29 (3): 197-208. 31. Davis-Floyd, R. 1990. Obstetrical rituals and cultural anomaly: Part I. J Prenat Perinal Psychol Health 4 (3): 193-211. 32. See Reference 12. 33. Nijland, M.J., S.P. Ford and P.W. Nathanielsz. 2008. Prenatal origins of adult disease. Curr Opin Obstet Gynecol 20 (2): 132-38. 34. Odent, M. 2008. New Criteria to Evaluate the Practices of Midwifery and Obstetrics. J Prenat Perinat Psychol Health 22 (3): 181-89. 35. Barrett, J. F. R., et al. 1992. Randomized trial of amniotomy versus the intention to leave membranes intact until second stage Br J Obstet Gynecol 94: 512-17. 36. Emerson, W.R. 1997. Birth Trauma: The Psychological Effects of Obstetrical Interventions. Petaluma, CA: Emerson Seminars. 37. Castellino, R. 2005. The Stress Matrix: Implications For Prenatal and Birth Therapy. Santa Barbara, CA: Castellino Prenatal and Birth Therapy Training. 38. Ibid. 39. Perry, B. 2009. On the brain: How we remember. CYC-Online (122) http://www.cyc.net.org/cyc-online/cyconline-apr2009-perry.html. Accessed 14 Apr 2009. 40. See Reference 37. 41. See Reference 3.42. See Reference 6. 43. Glenn, M. 2002. The use of body-centered psychotherapy in working with prenatal and perinatal imprints within a group. Paper presented at Third United States Association of Body Psychotherapy Congress and Emergence in Body Psychotherapy. http://www.sbgi.edu/cont_edu/glenn/glennceuя.html. Accessed 30 Sep 2009.

During pregnancy, women are faced with the fact that the terms have already passed, and childbirth does not begin. Then the decision is made to induce delivery. The bladder is pierced before childbirth to provoke contractions. This is not the only way to stimulate, but the most gentle.

Indications and timing

The procedure is performed if there are reasons that threaten the woman or the fetus. A woman in labor should understand that a qualified doctor will not prescribe manipulation without good reason, so you should immediately agree with his decision.

Why the bladder is pierced during childbirth:

there is a rhesus conflict;
late toxicosis is diagnosed;
if a woman suffers from hyponia;
a woman in labor is sick with diabetes mellitus;
with kidney disease in a pregnant woman

Puncturing the bladder before delivery is called an amniotomy. If the child is in danger or there was a leakage of amniotic fluid, and the contractions did not start, he suffers from a lack of oxygen. The indication for the procedure is also prolonged pregnancy.

Bladder piercing before childbirth is used as a method of increasing contractions with weak labor activity. The amniotic fluid contains prostaglandins, which stimulate labor. Only if the onset of full-fledged contractions with amniothymia has not been achieved, medicated stimulants are administered to the woman in labor.

When is the bubble pierced during childbirth? It all depends on the reason for the appointment of the procedure. If the reason is prolongation - at 41 weeks, a planned bladder puncture is used to start delivery. If the reason for the manipulation is weak labor, then the procedure is carried out during the onset of labor, regardless of the timing.

premature (one that is carried out before the onset of labor as a method of stimulation);
early (a puncture is made when the uterus is open by 7 cm);
late (performed on the delivery chair after lowering the child into the small pelvis, when attempts began, and the water did not leave).

A bladder puncture during pregnancy is also carried out in the absence of anterior waters (flat fetal sac). Then the shell wraps around the baby's head and delays the birth process. The reason for amniotomy is considered to be too low attachment of the placenta. Bleeding and detachment are likely, so it will be safer for the woman in labor to pierce the bladder.

However, this method of stimulating labor is not always used. Dr. E. Komarovsky believes that the period when a child is born should be extremely natural. Helping the female body should be the most extreme measure. He believes that the too frequent use of amniotomy is nothing more than the desire of doctors to speed up the delivery.

Contraindications and diagnostics

As with other medical procedures, the puncture cannot be performed due to the characteristics of the woman in labor. If a woman has heart disease, as well as with high blood pressure, childbirth is not carried out in the usual way.

It is forbidden to cause contractions in pregnant women with sutures on the uterus, especially if they have become too thin during the gestation period. The condition of the birth canal is assessed before prescribing an amniotomy for the expectant mother.

It is forbidden to puncture the fetal sac if:

the expectant mother has genital herpes;
the fetus has a transverse presentation;
low location of the placenta;
heavy umbilical cord entanglement of the child;
vaginal delivery is prohibited for medical reasons

It is advisable to undergo ultrasound diagnostics shortly before the procedure. So you can find out the state of the birth canals, and accurately determine the degree of opening of the uterus. Blood pressure is also measured and the intestines are cleansed, because childbirth after a puncture of the amniotic fluid can quickly and suddenly gain momentum.

It is necessary to weigh the pros and cons and only after that proceed to the manipulation. If the woman is nervous, the obstetrician should try to convince her that this is really necessary. After all, a woman in labor knows that, despite the safety of the operation, there is a possibility of complications.

Operation technique

In order to prepare as much as possible for possible obstetric manipulation, you should familiarize yourself with the procedure during pregnancy. Not necessarily an amniotomy will be applied, but it doesn't hurt to be informed about the issue.

How to pierce the bladder during childbirth:

a woman to sit on an examination chair;
the nurse treats the genitals with septic agents;
the woman in labor is taking pain medications;
the obstetrician spreads the walls of the vagina and inserts a special hook there;
the doctor grabs the fetal bladder with the device and pulls it towards himself until the moment of rupture;
contractions should appear for half an hour.

This procedure is rather unpleasant than painful. Pulls the hook towards the obstetrician, giving discomfort to the woman in labor. This is the only sensation that accompanies a woman in labor during a mini-surgery.

Why do the waters drain when you start giving birth? In the natural course of labor, the cause of the outflow of amniotic fluid is the rupture of the fetal bladder. If an amniotomy was performed, the water moved away as a result of it.

How is labor going with planned bladder piercing? The procedure is carried out with prolongation, intrauterine fetal death or gestosis. As a rule, after the integrity of the fetal sac has been violated, there is a gradual outpouring of amniotic fluid, and then contractions begin.

Over time, the strength of uterine spasms increases, and the neck, waters by the influence of prostaglandins, smoothes and opens more intensively. When the body has not prepared itself for delivery, contractions are much more painful than those that come without an amniotomy.

But not always a puncture of the bladder leads to contractions. It also happens that one opening of the fetal sac is not enough to start a full-fledged labor, then they use medication methods to stimulate labor.

Is it possible to give birth if the waters have not departed? No, because the child, along with the amniotic fluid, is in the fetal sac. And if it is not opened and the water has not departed, then the birth of the baby will not occur naturally. The only possible option without the outpouring of water is a cesarean section. Then the baby is removed directly from the placenta.

Complications

Amniotomy, of course, causes generic activity and helps the baby to be born, but there are also unpleasant consequences of a puncture of the amniotic fluid. Such pathologies occur extremely rarely, however, they do happen.

Complications of a puncture of the fetal sac:

bleeding (appears as a result of the obstetrician getting into a large vessel that passed along the membrane);
prolapse of the umbilical cord, body parts (arms, legs);
deterioration of the child's well-being due to a sharp change in the environment;
scratches in the newborn;
decrease in labor activity;
excessively rapid development of the generic process;
infection of the fetus.

The reason for such pathologies is the lack of professionalism of the obstetrician, that is, the incorrect performance of the operation. Therefore, a bladder puncture during childbirth should be trusted by an experienced obstetrician.

Complications provoke health problems for the baby. It is unacceptable to do such a manipulation at the request of doctors or women in labor. Childbirth with a puncture of the bladder should be reasoned and indicated for the health of the woman or fetus.

Amniotomy is a mini-operation, but you need to use it if there is evidence. The desire of a doctor or a woman in labor to induce labor is not a reason for manipulation. When prescribing a procedure, a woman should find an experienced obstetrician so that complications do not arise.

In utero, the baby is protected by a special shell - amnion, filled with amniotic fluid. They protect it from shock when moving, and the membrane prevents the ascending penetration of infection from the vagina.

In childbirth, the baby's head is pressed against the cervix and a fetal bladder is formed, which, like a hydraulic wedge, gradually stretches the cervix and forms the birth canal. Only then does it break on its own. But there are situations when a bladder puncture is performed before childbirth without contractions.

This procedure is not prescribed at the request of the woman or the whim of the doctor. The success of an amniotomy is possible under certain conditions:

the head of the fetus is presented;
full-term pregnancy at least 38 weeks with one fetus;
the estimated weight of the fetus is more than 3000 g;
signs of a mature cervix;
normal indicators of the size of the pelvis;
there are no contraindications for natural childbirth.

Amniotomy types

The moment of the puncture determines the type of procedure:

Prenatal - carried out before the onset of contractions, its goal is labor arousal.
Early - before the disclosure of the neck by 6-7 cm, it is able to speed up this process.
Timely - performed with effective contractions, neck opening 8-10 cm.
Late - in modern conditions it is rarely performed, it is performed at the time of the expulsion of the fetus. An amniotomy is needed to prevent bleeding in a woman in labor or hypoxia in a child.

How is labor going after a bladder puncture? The process of the birth of a child in this case does not differ from the natural one. In any case, the condition of the fetus is monitored using the CTG apparatus.

Indications for a puncture of the bladder during labor

A bladder puncture stimulates or is performed during planned labor.

Labor induction with amniotomy is indicated in the following cases:

gestosis, when there are indications for urgent delivery;
premature placental abruption;
fetal death in utero;
prolongation of pregnancy;
severe chronic diseases of the cardiovascular system, lungs, kidneys, in which delivery is indicated from 38 weeks;
rh-conflict between mother and child;
pathological preliminary period.

The latter condition is the onset of small contractions over several days that do not develop into normal labor. This causes fetal suffering from lack of oxygen and fatigue of the woman.

How long will labor start after the bladder is punctured? The onset of labor is expected no later than 12 hours later. However, doctors do not spend that much time waiting at this time. Prolonged stay of a child in a waterless environment increases the risk of infection. Therefore, 3 hours after the opening of the amnion, if contractions have not begun, stimulation with medication is used.

With already developed labor, the puncture is performed according to the following indications:

The cervix opened 6-8 cm, and the water did not leave. Their further preservation is impractical, the bubble no longer fulfills its function.
Weakness of labor. Bladder puncture in most cases leads to its activation. After the amniotomy, they wait 2 hours, if there is no improvement, then they resort to oxytocin stimulation.
Polyhydramnios overstretches the uterus and interferes with the development of normal contractions
With low water, a flat fetal bladder is observed. It covers the baby's head and does not function during labor.
A low-attached placenta may begin to flake off after contractions develop. Opening the amnion will allow the head of the fetus to snuggle tightly against the lower segment of the uterus and contain detachment.
In multiple pregnancies, the bladder of the second child is punctured 10-15 minutes after the appearance of the first.
High blood pressure decreases after opening the waters.

Bladder puncture technique in a woman in labor

30 minutes before the stimulation of labor by puncturing the bladder, the woman is injected with the antispasmodic Drotaverin.
Later, an examination is carried out on the obstetric chair, the doctor assesses the neck, the location of the head.
With a sliding movement of the fingers, a special branch is inserted into the vagina - a hook.
With its help, the shell clings during the contraction, and the gynecologist inserts a finger into the resulting hole. The tool is being removed.
Holding the head of the fetus through the abdomen with the other hand, the membranes are gently divorced and the anterior amniotic fluid is released.

They are collected in a tray, and their condition is visually assessed. Green waters with flakes of meconium indicate intrauterine fetal hypoxia. This condition deserves additional attention. The pediatric service is warned in advance about the possible condition of the child.

If a large volume of water is drained at once, it can lead to the loss of the umbilical cord loops or small parts of the fetus.

After the procedure, the CTG apparatus is connected to the mother in labor for 30 minutes to assess the child's condition.

Is it painful or not to puncture the bladder before giving birth? The membranes are not penetrated with nerve endings, so the procedure is absolutely painless.

At the same time, complications sometimes develop:

trauma to the umbilical cord vessel, if it was attached to the shell;
loss of umbilical cord loops or parts of the fetus (arms, legs);
deterioration of the fetus;
rapid labor activity;
secondary birth weakness;
infection of the child.

How long does labor last after a bladder puncture? The duration depends on their parity or quantity:

In primiparas, the normal duration of labor is 7-14 hours.
Multiparous ones take less time - from 5 to 12.

Contraindications to a puncture of the bladder in a pregnant woman

Despite the simplicity of the procedure and the small number of complications of the manipulation, there are serious contraindications for its implementation. Most of them coincide with contraindications for natural childbirth:

A herpetic rash on the perineum will lead to infection of the child.
Pelvic, leg, transverse or oblique presentation of the fetus, umbilical cord loops in the head region.
Complete placenta previa. In this case, childbirth is impossible - the placenta is attached over the internal pharynx and prevents the lower segment of the uterus from expanding.
Inconsistency of the scar on the body of the uterus after cesarean section or other surgical procedures.
Narrowing of the pelvis of 2-4 degrees, bone deformities, tumor processes in the small pelvis.
Fruit weight over 4500 g.
Severe scars causing deformation of the cervix or vagina.
Triplets, conjoined twins, breech presentation of the first child of twins.
High myopia.
Fetal growth retardation grade 3.
Acute fetal hypoxia.

In the absence of the listed contraindications, amniotomy is a safe procedure and does not affect the condition of the fetus.

Yulia Shevchenko, obstetrician-gynecologist, specially for the site

Useful video

Artificial opening of the fetal bladder, or amniotomy, often raises some concerns in women who are expecting a baby. Not every patient in the maternity ward understands the meaning of this procedure: why open the fetal bladder, if during childbirth the water will go away by itself? Let's try to reassure expectant mothers and answer this question.

According to the tasks and timing of the amniotomy, amniotomy is divided into three types. Premature amniotomy is used to induce labor. Early and delayed amniotomy may be necessary during labor.

Premature amniotomy

A so-called premature amniotomy is one way to end a pregnancy before spontaneous labor begins. The use of amniotomy for the purpose of labor induction means the immediate onset of labor: once the membranes are opened, there is no way back. During pregnancy, the obstetrician is forced to initiate labor activity most often ahead of schedule, at different stages of pregnancy, including in its last week before the onset of spontaneous labor on the part of the mother and the fetus - this is induced labor... Indications for amniotomy can be:

severe form of late pregnancy, when edema, high blood pressure, changes in urine tests cannot be corrected with medication, the condition of the mother and fetus remains unsatisfactory, despite treatment;
maternal diseases (cardiovascular disease, diabetes mellitus, liver disease, chronic lung disease, etc.);
post-term pregnancy;
acute increasing polyhydramnios with symptoms of cardiopulmonary insufficiency of a pregnant woman;
deterioration of the fetus for various reasons.

In other cases, premature amniotomy for the purpose of labor is performed on time without medical indications, when the fetus has reached full maturity, and there are no signs of spontaneous labor. Such preventive labor induction with amniotomy during normal pregnancy is called programmed childbirth.

One of the possible conditions for the use of amniotomy for the purpose of labor induction is the presence in a woman of optimally expressed signs of readiness for childbirth, In 70-80% of cases at full-term pregnancy, when the cervix is \u200b\u200b"mature" (it is short, soft, slightly open, located in the center of a small pelvis), childbirth can be caused by just one amniotomy without the use of drugs that stimulate uterine contractions (, prostaglandins).

Premature amniotomy in the absence or insufficient severity of signs of readiness for childbirth does not always lead to the development of adequate labor activity - as a rule, childbirth is protracted, requires drug delivery, there is a danger of an increase in the waterless gap, infection of the birth canal and fetus, asphyxia (cessation of oxygen access ) and birth trauma in the fetus.

Programmed childbirth, widespread in the 90s, is now practiced less frequently due not only to possible complications (anomaly of the insertion of the head, impaired uterine contractile activity, bleeding after childbirth), but primarily due to the tendency towards the natural course of pregnancy and childbirth.

Early amniotomy

During labor, you may need an early amniotomy - it is performed when the opening of the cervix is \u200b\u200bstill small. Let's list the indications for its use.

Cases when accelerating labor is necessary:
- with weakness of labor (there is a close relationship between a low level of uterine contractility and the slow progress of labor at any stage of the first and second periods), Early opening of the fetal bladder leads to increased production and release of prostaglandins - special physiologically active substances. Prostaglandins cause uterine contractions, and also contribute to increased uterine activity during labor;
- with a functionally defective fetal bladder ("flat" or "flaccid"). The usual volume of anterior waters located in front of the fetal head is up to 200 ml. If there is little anterior water, which happens with low water, the membranes are stretched over the head of the fetus ("flat fetal bladder"). A decrease in the volume of amniotic fluid in most cases is associated with the presence of malformations of the urinary system of the fetus, with prolonged aging, a decrease in the amount of amniotic fluid to 50-100 ml is also observed. Such a bladder ("flat" or "flaccid") does not fulfill its function as a "hydraulic wedge" in the opening of the cervix, which is also the reason for the slow progress of labor;
- with polyhydramnios due to a large amount of amniotic fluid, the uterus is overstretched, its contractions are weak, More often than in half of the cases, the causes of polyhydramnios remain unclear. Polyhydramnios is not only a disease of the amnion (membranes) - it can be associated with a disease of the mother (diabetes mellitus, inflammatory diseases of the genitourinary system), with the development of fetal diseases (hemolytic disease or the presence of various defects and chromosomal abnormalities). Possible infectious nature of polyhydramnios when the mother is sick with syphilis, influenza, etc. Early amniotomy with polyhydramnios results in a decrease in the volume of the uterus, as a result of which the contractions of the uterus become stronger.
Use of amniotomy for the therapeutic goal of the day of achievement:
- hemostatic (hemostatic) effect in bleedingassociated with partial presentation or low attachment of the placenta, that is, in cases where the placenta is attached close to the exit from the uterus. The placental tissue is not capable of stretching, the membranes during contractions entail the edge of the placenta. As a result, a portion of the placenta breaks off from the presenting wall of the uterus, which leads to a violation of the integrity of the vessels of the placental site and bleeding. After an amniotomy, the wall of the lower segment of the uterus, together with the membranes and the placenta, is displaced upward, the placenta no longer exfoliates, so bleeding stops. The presenting part of the fetus descending into the entrance of the pelvis presses the bleeding part of the placenta to the walls of the uterus and to the walls of the pelvis and thereby also helps to stop bleeding;
- hypotensive effect - lowering blood pressure during childbirth in women in labor with late toxicosis (preeclampsia), as well as in hypertension. In this case, the reduced volume of the uterus after amniotomy exerts less pressure on large vessels, blood pressure decreases.
The presence of indications on the part of the fetus, if, with additional methods of examination in childbirth, signs that threaten the life of the fetus are revealed:
- detection of green amniotic fluid (with an admixture of meconium) during amnioscopy, examining the amniotic fluid through the membranes with an optical device - this indicates that the fetus is lacking oxygen;
- violation of blood flow in the vessels umbilical cord according to Doppler data;
- pathological type of fetal cardiotocogram curvesthat does not require a cesarean section.

Delayed amniotomy

Sometimes, despite the complete opening of the uterine pharynx, the fetal bladder remains intact and the period of expulsion occurs when the anterior waters have not departed. The reasons for this pathology may be as follows:

excessive density of the membranes interferes with their timely opening under the pressure of intrauterine pressure;
excessive elasticity of the membranes leads to the fact that the fetal bladder becomes thinner and fills a significant part of the vagina, and sometimes comes out of the vagina;
with a "flat" bladder with a small or negligible amount of anterior waters, the shells are stretched over the head of the fetus and cannot be opened independently,

In these cases, the period of expulsion (the second, tighter period of labor) is delayed. A non-opening fetal bladder interferes with the insertion of the head into the pelvis and pulls the overlying sections of the membranes along with it, the placenta begins to exfoliate from its bed - bloody discharge appears. In rare cases, a child can be born in a fetal bladder with a detached placenta (people say about such cases: "born in a shirt"), as a rule, in a state of asphyxia. To prevent such complications, they resort to delayed amniotomy already in the second stage of labor. After the opening of the fetal bladder and the outpouring of water, labor activity intensifies, the forward movements of the fetus begin along the birth canal.

Amniotomy. Procedure progress

After processing the external genital organs, the doctor inserts the index and middle fingers into the uterine os of the cervix until it comes into contact with. at the end, the fetal membranes are opened, after which the obstetrician uses his fingers to dilute the fetal membranes to the sides. The manipulation is painless because there are no nerve endings in the membranes.

At the time of the amniotomy, the doctor evaluates the color of the waters: by this sign, one can judge the condition of the fetus. Normally, the waters are transparent, but if the waters are green, this indicates that the baby is experiencing a lack of oxygen, which, in turn, leads to relaxation of the obturator muscles of the intestine, and the original feces are mixed with amniotic fluid. Yellow amniotic fluid indicates a disease that develops in the fetus when the blood of the mother and the fetus is incompatible with Rh or blood group.

Fortunately, serious complications from amniotomy are rare. However, this manipulation may be accompanied by undesirable consequences: pain and discomfort, infection, worsening of the fetal heartbeat, prolapse of the umbilical cord or small parts of the fetus (arms or legs), as well as bleeding from the fetal vessels in the membranes, from the cervix or from the placenta attachment (partial) ...

The opening of the fetal bladder is used only if necessary, the manipulation is carried out with the consent of the woman. Since, as already mentioned, the fetal bladder plays a protective role, including protecting the fetus and the uterus from infection, then no more than a day should pass from the moment the amniotic fluid flows to the birth of the baby. Currently, the time limits have become even more stringent, and it is believed that a more sure protection against infection of the fetus and uterus is the duration of the waterless gap of no more than 12 hours.

Why is a fetal bladder needed?
The importance of amniotic fluid is great. They prevent the formation of adhesions between the membranes and the fetus; protect the umbilical cord and placenta (baby's place) from pressure from large parts of the fetus and uterine contractions during labor; make possible and easy fetal movements that are necessary for its proper development; protect the fetus from jolts and bruises from the outside; affect the position and distribution of the fetus - the relative position of the limbs, trunk; make fetal movements less noticeable for a pregnant woman; the integrity of the fetal bladder protects against infection, promotes the opening of the uterine pharynx during labor - during each contraction, the fetal bladder wedges into the cervical canal, facilitating the opening of the cervix. Normally, the opening of the fetal bladder occurs when the cervix is \u200b\u200bmore than 6 cm.

Lyudmila Petrova,
Obstetrician-gynecologist of the highest qualification
category, head of the maternity department
maternity hospital N 16, St. Petersburg
Article provided by the magazine "Pregnancy. From conception to childbirth" N 03 2007

Why amniotomy needed? Can you do without it? Will she harm mom or baby? We figure it out together with our expert - Yulia DRYOMOVA, obstetrician-gynecologist at the Avicenna Medical Center.

According to statistics, amniotomy or, simply put, a puncture of the fetal bladder is used in our country in about seven out of a hundred childbirth.

Sibmama data based on surveys of women who have recently given birth ( ) , are radically different from official statistics: last year, a puncture of the fetal bladder became the most common intervention in the process of childbirth: it was least often resorted to in maternity hospital No. 2 (38% of cases), most often in the maternity hospital of the 25th medical unit (68% of cases).

In 2015, 541 out of 1,426 women in labor who completed the amniotomy, according to a new survey, (among them there are those who have had a caesarean section, i.e. amniotomy is performed at least every third woman).

What happens to the fetal bladder during childbirth

The fetal bladder - the baby's first "home" - is a strong, thin and very elastic "pouch". It is filled (in medical language, they are called amniotic fluid): a warm (about 37 degrees) comfortable environment that reliably protects the baby from external influences: noise, pressure, ascending infections.

What happens to the fetal bladder when contractions begin? The muscles of the uterus begin to squeeze it with force. Amniotic fluid begins to move and part of the fluid (about 200 ml) moves downward, forming a kind of "water cushion", which, with each uterine contraction, presses on the cervix and helps it open. Normally, a rupture of the bladder occurs when the cervix is \u200b\u200balready wide enough - by 4-6 cm. The lower part of the bladder penetrates deeper into the internal os of the cervix, the pressure increases, the bladder breaks and the amniotic fluid that was from below is poured out.

From this moment on, the baby's head begins to press directly on the cervix, the opening accelerates, bringing the moment of the baby's birth closer. This is not only due to increased pressure, but also because the rupture of the bladder is accompanied by the release of biologically active substances - prostaglandins, which stimulate uterine contraction.

Why amniotomy is needed

“Why open the fetal bladder at all, if the waters go away on their own, and suddenly this stimulation disrupts the natural course of labor?” - many women in labor express such fears. But the fact is that when childbirth takes place naturally and without complications, the need for an amniotomy does not arise. Simply put, if you can do without a puncture of the fetal bladder, then the doctors are happy to do.

The procedure may be required when the condition of the child or mother requires urgent delivery, or when labor is weak. Also, a puncture is a way out in a number of cases when the natural sequence of the generic process is violated. The fetal membranes can be so strong that they do not break and a puncture is required, another common reason for amniotomy during childbirth is the so-called "flat bladder", when there is no fluid in its lower part and the fetal membranes cover the baby's head and interfere with its advancement and disclosure cervix.

However, it is not at all harmful to remember the indications for which this procedure is done, so that, if necessary, it is good to understand what is happening.

Expert commentary

Indications for amniotomy:

induction of labor during prolongation;

weakness of labor;

, ;

"Flat" fetal bladder (fetal membranes are stretched over the head of the fetus, interfering with its movement along the birth canal);

complete opening of the uterine pharynx, if the fetal bladder did not open on its own (dense membranes);

in case of multiple pregnancies, after the birth of the first fetus, an amniotomy of the second fetal bladder is performed;

suspicion of fetal hypoxia and premature placental abruption;

the condition of the pregnant woman, which does not allow further prolongation of the pregnancy;

carrying out an amniotomy is desirable before labor pain relief using the prolonged .

From the moment the integrity of the bladder is violated, there is no turning back - it counts for hours, because the anhydrous period cannot last indefinitely (usually doctors recommend limiting the time interval from the opening of the bladder to the onset of labor by 10-12 hours, but this issue is resolved in each case individually).