Artificial Rupture of Membranes Debate and Discussion

Dory · #1 (**permalink**) 15-Apr-2008, 17:31

This thread is for debate and discussion of ARM (Artificial Rupture of Membranes)

wannabe · #2 (**permalink**) 26-Apr-2008, 10:02

"if a woman is booked for prostin induction but has a favourable cervix on the Bishops score (usually a multip i.e has already given birth) then instead of prostin induction you may here the term "she is ARMable" thus meaning they will take her to delivery suite to perform this."

Is this consistent with evidence on whether prostin can be used in women with favourable cervix? (see current NICE guidelines on induction of labour, and consultation draft of NICE guidelines due out in June).

Does the term ARMable imply that ARM is necessary, or merely possible?

What are the implications for labour of induction by ARM (& oxytocin) versus prostin?

Should women have a choice of induction method where there are two possible alternatives?

Kentish Spitfire · #3 (**permalink**) 03-May-2008, 21:53

Originally Posted by wannabe

"if a woman is booked for prostin induction but has a favourable cervix on the Bishops score (usually a multip i.e has already given birth) then instead of prostin induction you may here the term "she is ARMable" thus meaning they will take her to delivery suite to perform this."

Does the term ARMable imply that ARM is necessary, or merely possible?

The protocol at one hospital states:
Once an ARM is appropriate it should be performed as soon as workload allows!

Josie · #4 (**permalink**) 03-May-2008, 21:54

You serious KS?...

Josie · #5 (**permalink**) 03-May-2008, 22:18

Originally Posted by wannabe

"if a woman is booked for prostin induction but has a favourable cervix on the Bishops score (usually a multip i.e has already given birth) then instead of prostin induction you may here the term "she is ARMable" thus meaning they will take her to delivery suite to perform this."

Is this consistent with evidence on whether prostin can be used in women with favourable cervix? (see current NICE guidelines on induction of labour, and consultation draft of NICE guidelines due out in June).

Does the term ARMable imply that ARM is necessary, or merely possible?

What are the implications for labour of induction by ARM (& oxytocin) versus prostin?

Should women have a choice of induction method where there are two possible alternatives?

Good points, as usual wannabe

... ARMable is a term loosley thrown around in my Trust, it always seems to me to mean that an ARM is possible not neccessarily required or even indicated. Augmentation to save time perhaps... hand in hand with use of syntometrine...

Your point about prostin vs ARM & oxytocin reminded me about a discussion with other students re Dr vs Midwife 'prostin ve's' as they have been called.... our midwives are very careful, gentle and inform the women exactly what they are doing as they locate the posterior fornix and insert the prostin gel. Whereas Drs (Im not generalising but in the cases we were talking about in our Trusts) some Drs seem a bit bish bash bosh job done. Is it that they have more experience with augmenting labour via prostin insertion or sloppy practice? how can they be sure the gel is in the posterior fornix so quickly? or are they shots in the dark? anyone else witnessed this?

Kentish Spitfire · #6 (**permalink**) 03-May-2008, 22:26

Originally Posted by Kentish Spitfire

The protocol at one hospital states:
Once an ARM is appropriate it should be performed as soon as workload allows!

Thanks Josie, I should clarify that this is only for induction of labour, and not for all women.
KS x

wannabe · #7 (**permalink**) 03-May-2008, 22:29

IME, ARMable is quickly followed by being ARMed (i.e. why bother assessing whether a woman is ARMable unless you want to do it?) and yes, I don't think necessarily required or indicated.

Is there any evidence that Drs insertions of prostin are less effective in inducing labour, despite being a bit "bish bash bosh"? I suspect that the exact location of prostin makes little difference, as long as it is basically in the right area. (e.g. intracervical gel - in regimes that used it - probably ended up all over the place and mostly not in the os - yet did work). Suspect that being "less gentle" also stimulates endogenous prostaglandins - similar to attempted membrane sweep on woman with unfavourable cervix.

wannabe · #8 (**permalink**) 03-May-2008, 22:38

Originally Posted by Kentish Spitfire

Thanks Josie, I should clarify that this is only for induction of labour, and not for all women.
KS x

But why use ARM instead of prostin/before prostin has had time to work for these women?

Disadvantages of ARM:

High chance that oxytocin will follow (if progress not adequate within 2 hours, which it rarely is if done as soon as woman is ARMable, rather than when VERY favourable). If oxytocin then drip & CTG tethering (reduced mobility), more pain -> epidural likely, if epidural then further tethering with IV fluids (to avoid hypotension) and BP cuff, even if 'mobile epidural' used.

Risk of infection, and time limits introduced to prevent this.

Risk of cord prolapse if pp not engaged.

If slow progress due to position rather than strength of uterine contractions, then ARM may exacerbate the problem rather than solve it.

Kentish Spitfire · #9 (**permalink**) 03-May-2008, 22:46

As this debate is within an educational section, it would be good if you would provide the references for your information, so that we can benefit from reading them.
KS x

Originally Posted by wannabe

Disadvantages of ARM:

High chance that oxytocin will follow (if progress not adequate within 2 hours, which it rarely is if done as soon as woman is ARMable, rather than when VERY favourable). If oxytocin then drip & CTG tethering (reduced mobility), more pain -> epidural likely, if epidural then further tethering with IV fluids (to avoid hypotension) and BP cuff, even if 'mobile epidural' used.

Risk of infection, and time limits introduced to prevent this.

Risk of cord prolapse if pp not engaged.

If slow progress due to position rather than strength of uterine contractions, then ARM may exacerbate the problem rather than solve it.

wannabe · #10 (**permalink**) 04-May-2008, 02:45

Originally Posted by wannabe

High chance that oxytocin will follow (if progress not adequate within 2 hours, which it rarely is if done as soon as woman is ARMable, rather than when VERY favourable). If oxytocin then drip & CTG tethering (reduced mobility), more pain -> epidural likely, if epidural then further tethering with IV fluids (to avoid hypotension) and BP cuff, even if 'mobile epidural' used.

Limited research, but see Cochrane review http://mrw.interscience.wiley.com/co...862/frame.html

in particular: "One trial compared Amniotomy alone with a single dose of vaginal prostaglandins for women with a favourable cervix, and found a significant increase in the need for oxytocin augmentation in the Amniotomy alone group (44% versus 15%; relative risk 2.85, 95% confidence interval 1.82 to 4.46). This should be viewed with caution as this was the result of a single-centre trial [however, it is the only trial data available]. Furthermore, secondary intervention occurred four hours after Amniotomy, and this time interval may not have been appropriate."

Many units, reassess < 4 hours after Amniotomy, so if 4 hourinterval is not appropriate (leading to increase in need for oxytocin augmentation), a shorter time interval would logically lead to even more oxytocin augmentation.

Risk of infection, and time limits introduced to prevent this.

Risk of cord prolapse if pp not engaged.

Both these are quoted as risks in the opening post, and "common knowledge" - I'm sure in Mayes, Myles or any number of other standard textbooks. Plus risks associated with Vasa Praevia ( Placenta Praevia has presumably been ruled out before you commence any form of induction).

If slow progress due to position rather than strength of uterine contractions, then ARM may exacerbate the problem rather than solve it.

This is not really relevant to ARM induction, but only to ARM augmentation. It's based on ideas from Jean Sutton, theoretical rather than research based - but yes, not strictly revelevant to ARM induction.

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Artificial Rupture of Membranes Debate and Discussion

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