1. Amniotomy
CIU 2020

2. • Amniotomy (also referred to as artificial rupture of
membranes [AROM]) is the procedure by which the
amniotic sac is deliberately ruptured so as to cause the
release of amniotic fluid.
• Amniotomy is usually performed for the purpose of
inducing or expediting labor or in anticipation of the
placement of internal monitors (uterine pressure catheters
or fetal scalp electrodes). It is typically done at the bedside
in the labor and delivery suite.

3. Amniotomy is indicated in the
following situations:
• When internal fetal or uterine monitoring is needed[
• For induction of labor, usually in conjunction with an
oxytocin infusion.
• For augmentation of labor, in that amniotomy leads to an
increase in plasma prostaglandins[8] ; data on the
effectiveness of labor augmentation are mixed

4. Indications:
• To speed up dilation if labour fails to progress.
• To speed up delivery once the cervix is fully dilated if
labour fails to progress.
• As an adjunct to oxytocin for induction of labour.
• To try to stop the bleeding during labour in case of partial
placenta praevia (be careful not to perforate the placenta).

5. Amniotomy may be contraindicated in the following situations:
• Complete placenta praevia
• Any contraindications to vaginal delivery
• Unengaged presenting part (although this obstacle may be overcome with the use of a controlled amniotomy
or the application of fundal or suprapubic pressure).
• Transverse lie
Relative contraindications:
• Dilation less than 5 cm, irregular contractions (false labour, latent phase)
• Breech presentation prior to full dilation (keep the amniotic sac intact as long as possible)
• HIV or hepatitis B infection (or context of high-prevalence) prior to full dilation: keep the amniotic sac intact as
long as possible to reduce the risk of mother-to-child transmission.
• Presenting part not engaged: risk of cord prolapse.

6. Equipment
Equipment for amniotomy includes the following:
• Examination gloves
• Vaginal speculum and spinal needle (if a controlled amniotomy is to be performed)
• Amniotic membrane perforator: This may be an amniotomy hook, such as the AmniHook
(Briggs Healthcare, West Des Moines, IA), or an amniotomy finger cot, such as the Amnicot
(Allied Medical, Perth, Australia) or the AROM-Cot (Utah Medical Products, Midvale, UT).*
• The AmniHook is a rigid, plastic device with a pointed tip at the end of smooth curve,
attached to a 10-in. handle.

7. Technique
• Place the woman on her back with knees bent and thighs apart.
• Wear sterile gloves.
• Swab the perineum and the vagina with 10% povidone iodine.
• With one hand, prepare access to the sac (hand well into the cervix). With the other hand, slide the amnihook
between the fingers of the first hand—which spreads the vagina and the cervix and guides the tip—and make a small
cut in the sac as it bulges during a contraction. Let the fluid drain slowly then, use a finger to enlarge the opening
• Note the colour of the amniotic fluid (clear, greenish, or blood-stained). Isolated meconium staining, in the absence of
an abnormal foetal heart rate, is not diagnostic of foetal distress, but requires closer monitoring.
• Make sure the cord has not prolapsed.
• Check the foetal heart rate before and after amniotomy.
• v If an artificial rupture of membranes is performed in a woman with polyhydramnios (excessive amniotic fluid), or if
the presenting part of the fetus has not yet engaged, it should be a “controlled amniotomy.” This means that it occurs
in the operating room, in case an emergency C-section becomes necessary (medical personnel should always be
prepared to perform an emergency C-section after an amniotomy, but especially in these cases). A controlled
amniotomy is also done using a small gauge needle instead of a hook, as this can allow the fluid to drain more slowly
(8).

9. Possible Risks and Complications
• Cord prolapse – This commonly occurs as a consequence of the sudden and rapid flow of amniotic
fluid, which is why the doctor has to control the flow once the sac has been ruptured
• Ruptured vasa previa – If this occurs, the patient will have to undergo an emergency caesarean section
• Cord compression - This refers to a condition wherein the baby’s umbilical cord becomes compressed
or flattened, usually as a result of the movement of amniotic fluid as it is released. When this occurs,
the fetus may not get enough oxygen and blood, and this in turn places him at risk of heart problems
and birth injuries. If mild cord compression is suspected, the patient may simply be given additional
oxygen or asked to change position to relieve the compression. However, if these do not work and the
fetal heart rate changes drastically, the patient will undergo an emergency caesarean section
• Fetal blood loss – This can be a life-threatening complication, one that warrants an emergency
caesarean section to save the fetus.
• Infection – The pregnant patient may need to be given antibiotics preemptively after an amniotomy is
performed. This is because once the amniotic fluid is released, there is a high risk of intrauterine
infection.
• Fetal scalp trauma – If the head of the fetus is positioned too closely to the amniotic membrane, it may
be possible for some scalp trauma to occur, but this is often very mild.
• Chorioamnionitis – This is associated with prolonged membrane rupture.

10. Amniotomy

11. Episiotomy

12. Episiotomy is a surgical cut in perineum (the muscular
area between vagina and anus) right before delivery to
enlarge your baby's exit, second stage of labour.
When episiotomy is necessary ?
While routine episiotomies are no longer recommended, there is still a
place for them in certain birth scenarios. Woman might need an episiotomy
either for her wellbeing or for baby:
• When baby is very large and needs a roomier exit route
• When forceps or possibly vacuum extraction needs to be used
• When baby's shoulder gets stuck in the birth canal during delivery (shoulder dystocia)
• When fetal monitoring of baby's heart rate during the last minutes of labor shows he or she's in fetal distress and
needs to be born right away

13. What happens during an episiotomy ?
• If woman needs an episiotomy, she get an
injection of local pain relief before the cut is made
• The woman may not need a local if there is
already anesthetized from an epidural or if
perineum is thinned out and already numb from
the pressure of your baby's head.

14. Advantages:
Maternal:
• A clear and controlled incision is easy to repair and heals better than a lacerated wound that
might occur otherwise.
• Reduction in the duration of second stage, Need to expedite delivery
• Reduction of trauma to the pelvic floor muscles
• Shoulder dystocia
• Forceps/vacuum
Fetal:
• It minimises intracranial injuries specially in premature babies or after coming head of breech, to
reduce stress and strain on the fetal head
• Large baby

15. Disadvantages :
• Increased risk 3 rd and 4 th degree tears (midline
episiotomy)
• Increased risk of fecal incontinence
• Increased risk of ≥2 nd degree tear in 2 nd delivery
• More post-partum pain
• More complications with healing (mediolateral episiotomy)

16. Types :
• Medio-lateral
• Median
• Lateral
• J-shap

18. Episiotomy steps
• Use local infiltration with lignocaine.
• Wait 2 minutes and then pinch the incision site with forceps.
• Wearing high-level disinfected gloves, place two fingers
between the baby’s head and the perineum.
• Use scissors to cut the perineum about 3– 4 cm in the
mediolateral direction Control the baby’s head and
shoulders as they deliver.
• Carefully examine for extensions and other tears and repair

19. Repair of episiotomy
• Apply antiseptic solution to the area around the episiotomy.
• If the episiotomy is extended through the anal sphincter or rectalmucosa,
manage as third or fourth degree tears, respectively
• Close the vaginal mucosa using continuous 1-0 suture
• Start the repair about 1 cm above the apex (top) of the episiotomy.
• Continue the suture to the level of the vaginal opening.
• At the opening of the vagina, bring together the cut edges of the vaginal opening
• Bring the needle under the vaginal opening and out through the incision and tie.
• Close the perineal muscle using interrupted 1-0 sutures
• Close the skin using interrupted (or subcuticular) 1-0 sutures

20. • An episiotomy should be repaired promptly to reduce
blood loss and prevent infection.
• Repair of an episiotomy is undertaken in three stages:
repair of the vaginal mucosa, repair of the muscle layer
and repair of the skin layer.
• Adequate pain relief should be provided before suturing.

21. Complications
Immediate:
• Extension of the incision to involve the rectum
• Vulval haematoma
• Infection
• Wound dehiscence
• Injury to anal sphincter causing incontinence of flatus or faeces
• Rectovaginal fistula (Rarely)
• Necrotising fascitis
Remote:
• Dyspareunia
• Chance of perineal lacerations
• Scar endometriosis (rare)