When Your Water Breaks: AROM Labor Management

/ The Happiest Doula, LLC/

“I think we should try breaking your water to help speed things up,” said the OB. This is a very common method of attempting to hasten a stalled or slow labor, or an induction of labor. It sounds promising, but does breaking the amniotic sac - a procedure known as “amniotomy” or AROM (artificial rupture of membranes) - always accomplish this? 

Are there any risks associated with this intervention? Because this procedure is quite commonplace in American hospitals, here’s the scoop on some of the science, benefits, and risks surrounding this procedure.
 

So what exactly is the “bag of water(s)” or the amniotic sac? 

It is a very thin, strong, membrane that contains fluid that surrounds your baby in the uterus. This creates a nice cushion for your baby to soften any jolts or impacts to the belly. It also helps maintain a constant temperature and allows for easier movement and growth of your baby.
 


Why break it? The belief behind amniotomy in early labor, to induce labor, or to kick-start stalled labor before 6cm, is that breaking the bag of water using a small amniohook removes the fluid cushion between the baby’s head and the cervix, allowing more pressure to be placed on the cervix, resulting in faster dilatation of cervix. Often - whether artificially or on its own - the water breaking will encourage a rise in your natural oxytocin level, thus bringing on more contractions. Sounds great, right? 

Maybe not. Opponents of AROM argue that the amniotic sac and fluid play an important role in protecting your baby against the stress of contractions. Imagine trying to squeeze/crack an egg inside a filled water balloon using pressure from your hands around the balloon. 

Every time you squeeze, the squeeze is translated to pressure across the surface of the egg and it can move down and around as needed. Same concept with baby and their umbilical cord. That fluid can also make it easier for your baby to maneuver, should any additional maneuvering be necessary. 

“Your intact amniotic sac can actually help with thinning and dilatation of the cervix.”

But what about the whole speeding up labor thing? 

Although amniotomy can help shorten labor by one hour according to the American Pregnancy Association if done at the appropriate time, your intact amniotic sac can actually help with thinning and dilatation of the cervix as well, thanks to the water in front of baby’s head creating even pressure across the cervix. So leaving everything alone and letting your body do it’s job can also shorten your labor versus starting interventions that may not necessarily be needed.
 

What’s this about risks? 

As with everything in life, there are also risks associated with artificially rupturing the membranes. These can include: 

  • A prolapsed cord. This is when baby’s umbilical cord slips past the head into the vagina, cutting off circulation to baby significantly, resulting in an emergent c-section.

  • Risk of infection is also a problem. For this reason, most providers won’t let you labor too far past 24 hours after your water breaks or is broken and will suggest a c-section if your water is broken and you are not ready to push the baby out.

  • Another possible risk can be with the baby’s heart rate. Without the cushion of the fluid, it can be harder to un-squish an umbilical cord or placenta that is thought to be causing a drop in baby’s heart rate.

  • Also worth noting; a common side-effect of AROM is a significant increase in the intensity of what you are feeling, and are more inclined to ask for pain management or epidural.

That last one is not a true “risk” factor (and I myself have been a fan of the epidural) but for those who wish to avoid medicinal pain management and intervention domino-effect, it can make sticking to that choice much more difficult.


So no AROM ever, right?? 

WRONG. There are exceptions to almost everything in labor, and this is no different. If your baby is showing signs of extended distress and the medical staff are unable to get an accurate reading on the external monitor, it may be necessary to apply an internal monitor to the baby’s head in order to monitor baby’s heart rate without signal loss to ensure the heart rate stays stable. This is a situation where modern medicine and interventions shine and truly help protect baby and mother.

“The evidence showed no shortening of the length of first stage of labor and a possible increase in caesarean section.”

For those who skip to the end of these long posts to get the short version...Providers often suggest AROM to “speed things up” or “bring on labor.” However, a recent Cochrane review of 15 studies involving 5583 women states that “the evidence showed no shortening of the length of first stage of labor and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labors or in labors which have become prolonged.” The World Health Organization also reviewed the findings and supports that recommendation. 

This is not to say it doesn’t ever help. It is simply best to understand your options, and always weigh risk versus benefit. No matter whether you choose to have your water broken or wish to avoid having it done, be sure you are making your choices because you understand and are comfortable with the decision at hand.
 

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