What happens after a puncture of the amniotic sac. Indications for puncture of the amniotic sac

Many women who are preparing to become mothers have heard that the puncture of the fetal bladder is a very effective measure for labor induction and acceleration of the birth process. What is such a procedure, to whom and when it is carried out, we will tell in this article.

What it is?

During the entire pregnancy, the baby is inside the fetal bladder. Its outer layer is more durable, it is a reliable protection against viruses, bacteria, fungi. In case of violation of the mucous plug in the cervical canal, it will be able to protect the child from their harmful effects. The inner membrane of the fetal sac is represented by the amnion, which is involved in the production of amniotic fluid - the very amniotic fluid that surrounds the child during the entire period of intrauterine development. They also perform protective and shock-absorbing functions.

The fetal bladder opens during natural childbirth. Normally, this happens in the midst of active labor pains, when the opening of the cervix is from 3 to 7 centimeters. The opening mechanism is quite simple - the uterus contracts, with each contraction the pressure inside its cavity increases. It is this, as well as special enzymes that the cervix produces at the time of expansion, that affect the fetal membranes. The bubble thins and bursts, the waters recede.

If the integrity of the bladder is broken before contractions, then this is considered a premature discharge of water and a complication of childbirth. If the opening is sufficient, attempts begin, and the fetal bladder does not even think of bursting, this may be due to its abnormal strength. This will not be considered a complication, because doctors can mechanically pierce it at any time.

In medicine, the puncture of the fetal bladder is called "amniotomy". Artificial violation of the integrity of the fetal membranes allows you to release an impressive amount of biologically active enzymes contained in the waters, which has a labor-stimulating effect. The cervix begins to open more actively, the contractions become stronger and more intense, which reduces the time of birth by about a third.

In addition, amniotomy can solve a number of other obstetric problems. So, after it, bleeding can stop with placenta previa, and this measure also significantly reduces blood pressure in women in labor with hypertension.

The bubble is pierced before childbirth or in childbirth. Before a caesarean section, the fetal bladder is not touched, its incision is made already during the operation. The woman is not given the right to choose, since the procedure is carried out only if there is evidence. But according to the law, doctors must ask for consent to an amniotomy.

The opening of the bubble is a direct intervention in the affairs of nature, in a natural and independent process, and therefore it is strongly not recommended to abuse it.

How is it carried out?

There are several ways to open the membranes. It can be pierced, incised or torn by hand. It all depends on the degree of dilatation of the cervix. If it is open by only 2 fingers, then a puncture would be preferable.

In the fetal membranes, there are no nerve endings, pain receptors, and therefore an amniotomy is not painful. Everything is done quickly.

30-35 minutes before the manipulation, the woman is given in tablets or injected intramuscularly with an antispasmodic. For manipulation, which does not have to be carried out by a doctor, sometimes an experienced obstetrician is enough. A woman lies on a gynecological chair with her hips apart.

The doctor inserts the fingers of one hand in a sterile glove into the vagina, and the woman's sensations will be no different from a regular gynecological examination. With the second hand, the health worker introduces a long thin instrument with a hook at the end - a branch into the genital tract. With her, he hooks the fetal membrane with the cervix ajar and gently pulls it towards him.

Then the instrument is removed, and the obstetrician expands the puncture with his fingers, controlling that the water drains smoothly, gradually, since their rapid outflow can lead to washing out and falling out of the body parts of the baby or the umbilical cord into the genital tract. About half an hour after the amniotomy, it is recommended to lie down. CTG sensors are installed on the abdomen of the woman in labor to monitor the condition of the baby in the womb.

The decision to perform an amniotomy can be made at any time during childbirth. If the procedure is necessary for labor to begin, then they talk about premature amniotomy. To enhance contractions in the first stage of labor, an early amniotomy is performed, and to activate uterine contractions during the almost complete opening of the cervix, a free amniotomy is performed.

If the baby decided to be born “in a shirt” (in a bubble), then it is considered more reasonable to carry out a puncture already at the time the baby passes through the birth canal, since such childbirth is dangerous with possible bleeding in a woman.

Indications

Amniotomy is recommended for women who need to induce labor as soon as possible. So, with preeclampsia, post-term pregnancy (after 41-42 weeks), if independent labor does not begin, a bladder puncture will stimulate them. With poor preparation for childbirth, when the preliminary period is abnormal and prolonged, after a puncture of the bladder, contractions in most cases begin in 2-6 hours. Childbirth is accelerated, and after 12-14 hours you can count on the birth of a baby.

In childbirth that has already begun, the indications may be as follows:

the opening of the cervix is 7-8 centimeters, and the fetal bladder is intact, it is considered impractical to save it;
weakness of tribal forces (contractions suddenly weakened or stopped);
polyhydramnios;
flat bladder before childbirth (oligohydramnios);
multiple pregnancy (at the same time, if a woman is carrying twins, the fetal bladder of the second child will be opened after the birth of the first in 10-20 minutes).

It is not customary to open the bladder on purpose without evidence. It is also important to assess the degree of readiness of the female body for childbirth. If the cervix is immature, then the consequences of an early amniotomy can be deplorable - weakness of labor, fetal hypoxia, a difficult anhydrous period, and as a result, an emergency caesarean section in the name of saving the lives of the child and his mother.

When not?

They will not pierce the bladder even if there are strong and valid indications for amniotomy for the following reasons:

the cervix is not ready, there is no smoothing, softening, the assessment of its maturity is less than 6 points on the Bishop scale;
a woman has an exacerbation of genital herpes;
the child in the mother's womb is located incorrectly - it is presented with legs, booty or lies across;
placenta previa, in which the exit from the uterus is closed or partially blocked by a "children's place";
loops of the umbilical cord adjoin the exit from the uterus;
the presence of scars on the uterus in the amount of more than two;
a narrow pelvis that does not allow you to give birth to a child on your own;
monochorionic twins (children in one fetal bladder);
pregnancy after IVF (caesarean section is recommended);
the state of acute oxygen deficiency of the fetus and other signs of trouble according to the results of CTG.

An obstetrician or doctor will never open the fetal sac if the woman has indications for operative delivery - caesarean section, and natural childbirth can be dangerous for her.

Possible difficulties and complications

In some cases, the period of time following the amniotomy proceeds without contractions. Then, after 2-3 hours, they begin to stimulate with medications - they inject "Oxytocin" and other drugs that enhance uterine contractions. If they are not effective either, or contractions do not normalize within 3 hours, a caesarean section is performed according to emergency indications.

As already mentioned, mechanical puncture or rupture of the fetal membrane is an outside intervention. Therefore, the consequences can be very diverse. The most common:

rapid childbirth;
development of weakness of tribal forces;
bleeding in case of damage to a large blood vessel located on the surface of the bladder;
prolapse along with flowing water loops of the umbilical cord or parts of the body of the fetus;
sudden deterioration of the child's condition (acute hypoxia);
the risk of infection of the baby if the instruments or hands of the obstetrician were not processed enough.

If the procedure is carried out correctly, and in compliance with all requirements, most complications can be avoided, but it is difficult to say in advance how the uterus will behave, whether it will contract, whether the necessary contractions will begin at the right pace.

In an ideal birth process, amniotic fluid drains just before delivery itself, when the opening of the uterus is 8 or more fingers. However, if labor induction is necessary, or there are other indications, an amniotomy is prescribed for women in labor.

Description of the procedure

Amniotomy is a painless medical manipulation, which consists in puncturing the bladder before childbirth. The technique is quite simple: with a special device similar to a hook, the doctor opens the fetal bladder, after which water is poured out. The organ itself is covered with a network of blood vessels, so as not to touch any of them, the puncture is carried out when the shell is clearly visible.

After the procedure and the outflow of water, the contractions become more intense and painful. If at the time of opening the bladder they were not there, after the manipulation, labor activity begins.

Indications for bladder puncture

Depending on the period of carrying out, prenatal, early, timely and late amniotomy is distinguished.

Prenatal bladder puncture is used when there is a need to stimulate the birth process, in conditions such as preeclampsia, pregnancy for more than 42 weeks, and chronic diseases of the mother. Early - carried out with weak labor activity to accelerate and strengthen.

Timely and late opening of the amniotic waters is carried out if the bladder did not burst itself during childbirth, since its presence when the uterus opens more than 8 cm is not advisable.

In addition, the amniotic sac is pierced with a low location of the placenta, polyhydramnios and oligohydramnios, as well as to reduce the high blood pressure of the woman in labor.

Contraindications for amniotomy

Despite the apparent simplicity of the procedure, it is a real obstetric operation and has its own contraindications.

This manipulation is not carried out in case of premature birth and multiple pregnancy. Restrictions are also imposed on the weight of the child, a contraindication is a weight of less than 3 kg and more than 4.5 kg.

In addition, a puncture of the bladder before childbirth is not done if there are indications for a caesarean section, for example, scars on the uterus, pelvic or transverse location of the fetus.

Possible Complications

Amniotic sac puncture is safe for both mother and baby and is effective when the cervix is ready for delivery, otherwise additional stimulant medications may be needed.

After how much labor will begin depends on the degree of cervical dilatation. According to reviews, on average, women give birth after an amniotomy within 10 minutes - 6 hours. However, the water-free period should not exceed 12 hours. If during this time the mother did not give birth on her own, an emergency is indicated, since infection of the woman in labor and the baby is possible.

A woman has the right not to agree to pierce the amniotic sac during childbirth by signing the appropriate document that she knows about the possible consequences and voluntarily refuses the procedure.

You can read more about how childbirth goes.

Why is an amniotomy necessary? Is it possible to do without it? Will it hurt mom or baby? We deal with our expert - Yulia DRYOMOVA, an obstetrician-gynecologist at the Avicenna Medical Center.

According to statistics, amniotomy or, simply speaking, puncture of the fetal bladder is used in our country in approximately seven births out of a hundred.

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

In 2015, according to a new survey, amniotomy was performed on 541 of the 1,426 women who filled out (Among them there are those who underwent a caesarean section, i.e. an amniotomy is performed for at least every third woman).

What happens to the fetal bladder during childbirth

The fetal bladder - the first "home" of the baby - is a strong, thin and very elastic "pouch". It's 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 amniotic sac when contractions start? The muscles of the uterus begin to compress it with force. The amniotic fluid begins to move and part of the fluid (about 200 ml) moves down, forming a kind of "water cushion", which, with each uterine contraction, presses on the cervix and helps it open. Normally, the rupture of the bladder occurs when the cervix is already opened wide enough - by 4-6 cm. The lower part of the bladder penetrates deeper and deeper into the internal pharynx of the cervix, the pressure increases, the bladder breaks and the amniotic fluid, which was below, pours 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 happens not only because of increased pressure, but also because the rupture of the bladder is accompanied by the release of biologically active substances - prostaglandins, which stimulate uterine contractions.

Why is an amniotomy necessary?

“Why open the fetal bladder at all if the waters leave on their own, and what if this stimulation will disrupt the natural course of childbirth?” Many women in labor express similar 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 doctors are happy to do it.

The procedure may be required when the condition of the child or mother requires an 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 birth process is violated. The fetal membranes can be so strong that they do not tear and a puncture is required, another common reason for amniotomy during childbirth is the so-called "flat bubble", when there is no liquid in its lower part and the fetal membranes fit the baby's head and prevent it from moving and opening cervix.

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

Expert comment

Indications for amniotomy:

induction of labor activity during overwearing;

weakness of labor activity;

, ;

"flat" fetal bladder (the membranes are stretched over the fetal head, preventing its progress through the birth canal);

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

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

suspicion of hypoxia in the fetus and premature detachment of the placenta;

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

carrying out amniotomy is desirable before anesthesia of childbirth by the method of prolonged .

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

Expert comment

Amniotomy is a fairly common procedure. The urgency of its implementation is determined only by the doctor. It all depends on the condition of the mother and fetus. The procedure does not have any negative consequences if carried out according to the indications and at the same time all the conditions for its implementation are met. The main requirements are the biological readiness of the patient's body for childbirth (mature cervix) and the qualifications of the doctor, allowing him to carry out this manipulation.

How is an amniotomy performed?

Amniotomy itself, although it has the status of an obstetric operation, is considered a simple procedure and takes just a couple of minutes. It is carried out by an obstetrician-gynecologist directly in the gynecological chair: first, he treats the external genitalia with an antiseptic, and then carefully pierces the bladder with a special sterile instrument. By the way, it does not look scary at all: it is made of plastic and looks like a crochet hook.

A bit of physiology

Labor is always preceded by labor. With their onset, the cervix begins to open. The fetus moves along the birth canal, the muscles of the uterus are intensively reduced, and the cervix is smoothed out.

The fetal bladder also contributes to the opening of the cervix, while protecting the head and neck of the newborn from injury. It reliably protects newborns from various types of infections, and labor activity, if present, is almost painless and natural. If the birth is normal, then the amniotic fluid begins to drain on its own, and the bubble breaks painlessly (there are no nerve endings in it).

In some women in labor, the discharge of water occurs before the onset of childbirth. Amniotic fluid is poured out in a small amount (200 ml). If the fetal bladder breaks before exiting the cervix, then water is released in drops.

So why is the fetal bladder pierced during childbirth?

For this, there are the following medical indications:

prolongation of pregnancy;
syndrome of disruption of the work of some body systems and organs of a pregnant woman (gestosis);
irregular contractions;
weak generic activity;
very dense amniotic membrane. A child can be born "in a shirt", that is, in an unruptured bubble. This is dangerous, since the newborn cannot take a full first breath;
polyhydramnios;
various pathological conditions of women in labor.

Often during the passage of any childbirth, the following can happen: childbirth takes a long time, the fetus moves slowly, abundant discharge with blood appears from the genital tract, there is a threat of placental abruption, the occurrence of hypoxia (oxygen starvation) of the fetus. All this also applies to medical indications for opening the amniotic sac.

Bladder opening procedure

The bubble is opened by a doctor during examination with a special sterile instrument. This manipulation should not be afraid, as it is absolutely painless. After the bladder is opened, amniotic fluid begins to drain, mechanical irritation of the mother's birth canal by the baby's head, stimulation of the production of special biologically active substances (prostaglandins). They also begin to intensify tribal activity.

Sometimes the bubble is also opened in order to carry out a diagnostic measure, when there is a suspicion of hypoxia (oxygen starvation) of the fetus. In any case, if the doctor decided to puncture the bladder, then this is necessary for the health of the woman in labor and the baby.

An obstetric operation aimed at stimulating labor is an opening of the fetal bladder. The procedure is painless, does not affect the health of the mother and fetus.

The waiting period for a baby is a wonderful time in the life of every woman, which is accompanied by various problems and not very pleasant moments.

One of these moments is the absence of contractions. If labor activity does not start for too long, then doctors may decide to induce it. The most popular option for inducing labor is the puncture of the amniotic sac. Manipulation is completely safe for the health of a woman, a baby, and does not cause any pain.

Indications for an amniotomy

Amniotic sac puncture is a type of surgical intervention that is completely painless and is performed without anesthesia. It is carried out according to medical indications, under the supervision of a qualified doctor. Amniotomy can be recommended both before the onset of labor, in order to simulate it, and during an inactive (sluggish) delivery process.

Reasons for this operation:

pregnancy lasts longer than expected. If all the deadlines for the start of labor have already passed, but the birth has not begun;
preeclampsia in late pregnancy. This complication threatens with oxygen starvation of the fetus;
chronic circulatory disorders between the placenta and the fetus, when oxygen starvation increases and cannot be eliminated with medication;
a large amount of amniotic fluid. This pathology can cause hypoxia, fetal injuries. For this reason, even with a slight opening of the cervix, doctors pierce the bladder to avoid possible complications;
ineffective contractions;
the bubble is flat;
low attached placenta. A puncture when the placenta is low helps to avoid uterine bleeding, the occurrence of its premature detachment;
Rhesus conflict;
dense shells. If the cervix is fully open, and the bubble has not burst, then doctors perform this manipulation in order to preserve the health of the baby.

How to puncture the fetal bladder

Amniotomy is an obstetric operation that takes a few minutes and is completely harmless. The puncture procedure is carried out exclusively by a gynecologist, not an obstetrician.

Manipulation is carried out directly during a vaginal examination in a gynecological chair. For this, the external genital organs are initially treated with an antiseptic, then the doctor carefully punctures the amniotic sac with a special medical sterile instrument. The tool for this procedure is made of plastic and visually looks like a crochet hook.

At what time

A puncture is prescribed for expectant mothers when they are at 41-42 weeks of gestation, if the uterus is already ready for labor, but there is no activity.

Is it possible to pierce without contractions

The bubble can be pierced before the onset of labor. The main reason for this procedure is the stimulation of contractions in the later stages or when the cervix is fully open.

Puncture process

This type of surgical intervention is carried out exclusively by the doctor who will deliver the baby. The procedure is performed during a vaginal examination, the puncture is carried out with a special medical device. After the manipulation, doctors monitor the baby's heartbeat throughout the entire time.

The puncture process is not dangerous for the woman and her baby. But it stimulates the onset of labor, accelerates contractions, and helps the baby to be born faster.

Does it hurt to pierce the bladder

Obstetric intervention on the puncture of the bladder does not cause pain, since it does not have any nerve pain endings.

How long does it take for contractions to start after rupture of the amniotic sac?

If the bladder was punctured in the prenatal period, then normally contractions should be expected over the next two hours. At this time, doctors connect the woman to the CTG machine to monitor the baby's condition and readiness for labor.

In a situation where, after a set time, the contractions did not occur, the doctors decide to stimulate them with the help of special preparations.

This is due to the fact that for an unborn child, being in an anhydrous state for more than 12 hours is a great danger. If stimulant drugs did not help in delivery, then the expectant mother urgently performs a caesarean section.

Is childbirth different after an amniotomy?

During a natural bladder puncture, oxytocin is released and the uterus begins to contract naturally. After the manipulation of the amniotomy, childbirth takes place, as well as after their stimulation, no difference is observed. But before piercing the amniotic sac, the doctor must:

examine the birth canal of a woman and assess how ready they are for the birth process;
determine the degree of dilatation of the cervix. If a woman is already at 41 or 42 weeks of pregnancy, and no contractions are observed, the cervix is soft, thin and elastic, then this manipulation can be performed. But a puncture is not recommended if the expectant mother's birth canal is not yet prepared for labor;