There are four main reasons for performing an amniotomy: 1. To induce labor or augment uterine activity, despite evidence showing lack of effectiveness. A 2013 Cochrane Review concluded, that "the evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended as part of standard labour management and care."[2] Another Cochrane Review could not draw any conclusions about the effectiveness of using amnioitomy as a means of induction when comparing amniotomy alone vs. expected management or amniotomy alone vs. oxytocin alone.[3] 2. To enable the doctor or midwife to monitor the baby's heartbeat internally. A scalp electrode is placed against the baby's head and an ECG of the baby's heart beat can be directly recorded. This provides a much more reliable indication of the fetal well being than external monitoring alone. Internal fetal monitoring is often performed if there is a complication such as maternal disease, or if there is fetal distress or if the mother is being induced. 3. To check the color of the fluid. If there is a suspicion of the presence of meconium (the contents of the baby's bowel), certain preparations must be made. Suctioning must be set up and more personnel are required to be in attendance. 4. To avoid having the baby aspirate the contents of the amniotic sac at the moment of birth. Most often, the amniotic sac will break of its own accord, most often by the beginning of the second stage of labor. If it remains intact, it is sure to break with maternal pushing efforts. But in a rare case, the baby can be born with an intact bag that must be quickly broken to allow the baby to breathe.

1. DR ALKA MUKHERJEE
DR APURVA MUKHERJEE
NAGPUR M.S. INDIA
Amniotomy

2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Life member, IMA, NOGS, NARCHI, AMWN & Menopause Society,
India, Indian medico-legal & ethics association(IMLEA), ISOPRB,
HUMAN RIGHTS
 Founder Member of South Rapid Action Group, Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS Nagpur,
NKPSIMS, ESIS and Treasury, Nagpur for “ WOMEN SEXUAL
HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
 Winner of NOGS GOLD MEDAL – 2017-18
 Winner of BEST COUPLE AWARD in Social
Work - 2014
 APPRECIATION Award IMA - MS
 Past Position
 Organizing joint secretary ENDO-GYN
2019
 Vice President IMA Nagpur (2017-2018)
Vice President of NOGS(2016-2017)
Organizing joint secretary ENDO-GYN
Organizing secretary AMWICON – 2019

3. Introduction
• Amniotomy - artificial rupture of membranes (AROM)
"breaking the water," - the intentional rupture of the
amniotic sac by an obstetrical provider.
• Common procedure during labor management.
• The reasons –
 Multifold and include –
 Influencing the speed of labor,
 Allowing for more direct monitoring of fetal status, and
 Qualitative assessment of the amniotic fluid.

4. Anatomy and Physiology
• The amniotic cavity is an enclosed space within the uterus in which the
fetus develops and is protected during the antepartum period.
• The amniotic cavity is comprised of a dual layer membrane, which
includes an inner layer known as the amnion and an outer layer known
as the chorion.
• This potential space forms early in pregnancy and is filled with serous
fluid during the first few weeks of pregnancy.
• With further development of the fetus, specifically the fetal urinary
system, the fluid in this potential space increases as the developing fetus
excretes urine. Fetal urine comprises most of the amniotic fluid.
• Typically, this barrier remains intact throughout the duration of
gestation, and the amniotic membranes will spontaneously rupture,
releasing the amniotic fluid either immediately preceding spontaneous
labor or sometimes after the onset of spontaneous labor.

5. Indications
• The two principal reasons for artificial rupture of
membranes are
(1) to induce or augment the labor process or
(2) to assist in placement of internal fetal monitoring to
provide the direct assessment of fetal status.
Monitoring of fetal heart rate uterine activity is required during
labor.
(3) The amniotic membrane presents a physical impediment to
this form of monitoring, and to place a fetal scalp electrode or
intrauterine pressure catheter the membranes must
necessarily be broken before placement.

6. Contraindications
 Few and obvious.
 In the case of malpresentation,
 Vasa previa,
 Suspected velamentous insertion of the umbilical cord or
 in case of the unengaged fetal head or
 unstable lie.
 If the fetal presentation is unknown or not fully engaged as
the risk for cord prolapse is increased.
 If the pregnant woman is not in active labor or if the patient
refuses the intervention.

7. Equipment
• Amniotomy hook or amniotomy finger cot
• Sterile gloves and lubricant.
• Personal protective equipment (gloves, gown, drapes, mask,
eye protection)
• Absorbent pads and towels
• Electronic fetal monitor (Cardiotocography CTG)
• Tocolytics

8. Who can do it?
• Obstetrician
• Midwife
• Delivery sister

9. Preparation
The two most commonly used devices are
(1) An approximately 10-inch rod with a hook on the end of the
rod or
(2) a finger cot with a hook on the end of the cot.
 First assess cervical dilation by p/v exam.
 Assess the fetal presenting part, ensure that the presenting part -
the fetal head and
 Assess if that the fetal head is well engaged in the pelvis or not
 After confirmation of both fetal presentation and engagement,
the dr can proceed with artificial rupture of membranes

10. Technique
• If using the rod-hook device –
• The end of the rod that remains outside of the vagina is typically
held with the non-dominant hand.
• The hook end of the rod is then protected between two fingers
when entering the vagina.
• When the practitioner can palpate the amniotic membrane and
the presenting part, the non-dominant hand is used to advance
the hook to the amniotic membrane.
• The membrane is then snagged with the hook, and gentle traction
is applied in a superior direction to tear the amniotic membrane.
• Successful rupture of membranes most commonly is determined
by the immediate return of amniotic fluid from the vagina.

11. STERILE ARM HOOK

12. • This fluid - usually clear and odorless , in certain cases -
meconium or may be blood-tinged.
• It is important to note the color of the fluid at the time of
rupture.
• Typically, following artificial rupture of membranes, the
practitioner should not immediately remove their hand from
the vagina because it is at this point that the highest risk of
potential cord prolapse can occur and will be noted as the
amniotic fluid continues to drain.
• After the immediate flow of amniotic fluid ceases, and there
is no palpable cord in the vagina, the vaginal hand then can
be removed.

14. Complications
• Complications relatively few.
• Rupture of membranes does eliminate the primary barrier
between the fetus and the polymicrobial environment of the
vagina.
• If performed too early in the labor process - increased risk of
intrapartum chorioamnionitis.
• The most common complication - prolapse of the umbilical cord.
Specially when the head is not engaged in the maternal pelvis.
• In the case of an unengaged fetal head, umbilical cord prolapse –
compression of umbilical cord - fetal bradycardia and emergency
cesarean section.
• Easily avoidable - iatrogenic cause of emergency delivery.

15. Clinical Significance
o Artificial rupture of membranes either can assist in inducing
labor or augmenting spontaneous labor.
o It relieves the amniotic sac pressure of amniotic fluid -
induces uterine contraction activity, increases the strength
of contractions, and may augment labor by allowing direct
pressure from the fetal scalp on the uterine cervix which
may assist in dilating the cervix.
o While these are commonly held beliefs of many
practitioners, the data to support amniotomy for these
reasons is uncertain.
o When there is a delay in labor, the meta-analysis suggests
there is a modest reduction in the rate of cesarean section
when the rupture of membranes in conjunction with the use
of oxytocin is used as an early intervention.

17. Enhancing Healthcare Team Outcomes
• Prior to the procedure, the nurse monitors the vital signs of
the patient and reporting any untoward changes to Dr.
• The nurse plays a vital role during the procedure in
monitoring the mother as well as the fetus, she also notes
the color of the draining amniotic fluid and documents the
findings in the medical chart.
• After the procedure -
a. Assess the maternal temperature every two hours and
watches out for any signs of infection.
b. Monitor the fetal heart rate via continuous electronic fetal
monitoring and
c. Communicate the findings to the Dr
d. The nurse needs to frequently change underpads.

18. • Nursing, Allied Health, and Interprofessional Team
Monitoring
• Hemodynamic status of the pregnant woman
• Vital signs
• Any signs of infection
• Any signs of cord prolapse
• Fetal heart rate
• Color of the amniotic fluid (liquor)