I thought this was an educational section about the use of ARM/ Amniotomy!!!
This correlates with what is regularly witnessed in practice being a fourth year student as well as textbook description from Myles and Stables.

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Are you responding to my posting about the tendency for ARM to lead to oxytocin augmentation (and other disadvantages of ARM)? I'm sorry if you feel my posts are out of place in an educational section, but I think it's all relevant. You might be interested to read the new NICE guidelines on induction due out this summer (available as draft consultation document for download from the NICE website) - the draft recommends against ARM as a primary method of induction, even in women with favourable cervix. It will be interesting to see whether that recommendation stays in the final version published, but I suspect it will for all the reasons already cited.

I thought this section was for glossary definitions... Not to debate and throw references and quotes around?

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The glossary definition of Amniotomy given here included the following:

Isn't it reasonable that, in an educational resource section, this approach to Amniotomy should be questioned?

Kentish Spitfire specifically asked for references, since we were in the educational resources section, therefore I provided them. I don't consider that to be "throwing them around", but merely giving people an opportunity to look at the evidence and make up their own minds about the use of ARM for induction in various situations.

Hi all,

Noo et al have a point about this being the glossary and the the place for a description and the currrently accepted definitions of commonly used midwifery terms. However, even if it is the wrong place, this is a valuable discussion about the one of the ways that the clinical intervention of Amniotomy is applied in practice.

Where I work, Amniotomy is on the flow chart of interventions involved in induction of labour. A proportion of women will go into labour from the use of vaginal prostaglandins, but for those who don't the role of prostin is to ripen the cervix to enable an ARM to be performed. Again, for some women the ARM will cause the onset of labour, but others will progress further along the path of intervention and require a syntocinon drip. It is sometimes the case, particularly with parous women, to find on the initial examination (once maternal and fetal wellbeing have been ascertained, the process and risks of induction explained, and consent to proceed has been gained) that it would be possible to perform an ARM without the use of vaginal prostaglandins. In the majority of cases the women will still be given the prostin gel, but on some occasions, where the cervix is extremely favourable, the presenting part is low and the baby in a good position, the woman is in agreement, and (sorry) workload allows, an ARM will be done as the first line of intervention. This is the reality of clinical practice, in line with the current guidelines, at the unit I work in.

The new draft guidelines on induction of labour state that ' Amniotomy should only be considered when the cervix is favourable if there are specific contraindications to the use of vaginal prostaglandins' (page 83 of the draft guideline, available from www.nice.org). This recommendation is said to be based upon the conclusion of one systematic review, by Bricker and Lucas (1985) which can be found on the cochrane website www.cochrane.org. The conclusion of this review states that 'Data are lacking about the value of Amniotomy alone for induction of labour. While there are now other modern methods available for induction of labour (pharmacological agents), there remain clinical scenarios where Amniotomy alone may be desirable and appropriate, and this method is worthy of further research.' I read this to be significantly different to the interpretation that NICE places upon it. Especially when you consider that NICE cites comparable fetal and maternal outcomes in the use of Amniotomy compared with the use of vaginal prostaglandins, and the cochrane review comments that Amniotomy may be preferred by women wanting a drug-free labour, and it is relatively cheap.

During my training, and reading I have done to consolidate my experiences in clinical practice I have found other instances where NICE recommendations are based on quite loose (and often arbitrary) interpretation of the evidence which they cite. An example of this would be in the establishment of accepted time invervals for auscultation of the fetal heart during the first stage of labour for low risk women - but that is outside of the scope of the discussion here. I guess a national body, whose guidelines are inherited from the RCOG, attempting to build a 'one size fits all ' model of care fails to take into account that women do not all conform to that model. Isn't that what intelligent, intuitive, woman centred midwives are for?

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That is a very thorough explanation Dory, I have found it very helpful to learn about the different methods of induction that can be used.

Thank you for taking the time to post that.

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Thank you to both Dory and Wannabe for their input. I found the information really useful.


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I quote NICE, not because I think they are the be all and end all, but simply because the attitude to Amniotomy is generally (in most units) so far the other way...if she is ARMable, then ARM her (and that's the scenario that the glossary described).

Obviously there are clinical scenarios in which, on the basis of clinical judgment, a doctor might propose Amniotomy in preference to prostin. In particular, any scenario in which you are concerned about the risk of hyperstimulation with prostin. Guidelines are, after all, guidelines not rules. The point about the Cochrane review of Amniotomy alone (I didn't think it was that old...I will have to check, if that's the only review NICE is working from it's suprising) is that there is limited evidence for this intervention. However, there is a ton of evidence to support the efficacy and relative safety of prostin in women with a favourable cervix (women who would be "ARMable") - but you'll find that evidence in the reviews of prostin.

However, when you use Amniotomy as described in the glossary (i.e. doing ARM because it is possible, rather than when it is positively desirable) you then start the clock and if the woman is not in established labour and making good progress, the synto goes up and she then has a tethered labour (synto drip, CTG monitor, loses "pool birth" privileges when the drip goes up, more pain so likely epidural with BP monitor, IV fluids, possibly a urinary catheter).

For a woman who is practically in labour anyway, Amniotomy may be all that's required. For her, Amniotomy may be the better option - but that rather begs the question...if she's on the point of going into labour anyway, why induce? (Assuming low-risk induction to prevent prolonged pregnancy). You could probably stimulate endogenous prostaglandin production effectively enough with a good sweep!

It's the more common scenario of women who will end up with ARM & oxytocin when they could have had prostin-only induction that I'm concerned about.

I think women need to understand that Amniotomy is every bit as much an intervention as prostin, and that they should be told what the rate is of IV oxytocin following ARM (obviously, that can only be for populations - I'm not saying we should get out the crystal ball for her individual case...). I have known of a case in which the woman didn't want drugs for induction (fair enough), but was however persuaded to consent to ARM for induction, did not go into labour, then declined synto despite pressure, went home (to await labour), on return to the hospital was pyrexial (maternal) and with Tachycardia (fetal).

On the basis of scenarios like that, I think the idea of Amniotomy as a drugless wonder needs to be questioned. Anyone who offers Amniotomy for induction needs, at the same time, to gain consent for synto use if Amniotomy doesn't do the job, and if synto declined in principle (i.e. wants to avoid drugs) then DON'T DO THE Amniotomy. A failed induction after Amniotomy alone, and drugs declined, is the worst case scenario. You've just performed the most high-risk RoM possible from point of view of introduction of infection (even higher risk that PROM) and then have no mechanism to expedite labour.

Midwives don't make decisions about which methods of induction are used in which cases without decision by an obstetrician (though can certainly make the case for one course of action or another if they so choose) so whether or not one is practising women-centred midwife is not really the point here. My own feeling is that synto is put up too readily in situations where prostin would have allowed a woman a more normal labour, and that ARM is usually the start of that. If guidelines give an opportunity for units to reconsider their practices, then that is a good thing.

Just checked, Bricker and Lucas review is 2000, and included study dates to 1995. One of the excluded studies is 2003, so obviously has been updated since then. The review is tiny, but that's because the number of studies of good quality on the efficacy and safety of Amniotomy as primary method of induction is tiny. Lack of research is usually an argument against an intervention, not for it!

Forgive me for my interuption in this matter but I dont think the 'is ARM nessesary' argument needs to be carried out in a glossary thread. Clearly the ins and outs and clinical debate over ARM is relevant but it wont change the definition of what ARM is - to my understanding this has been explained in basic detail in the first post. I shall be cleaning up this thread tomorrow after consulting Dory over the matter. The majority of posts in this thread will be moved to a new thread within the main forum and will henceforth become an ARM debate thread. The debate thread will be linked to from within the glossary for those who wish to discuss the subject further.

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