November 29, 2000
Volume 2, Issue 48
Midwifery Today E-News
“Intact Membranes”
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  • Quote of the Week
  • The Art of Midwifery
  • News Flashes
  • Intact Membranes
  • Check It Out!
  • Midwifery Today Online Forum
  • Question of the Week
  • Question of the Week Responses
  • Share Your Knowledge: Coming E-News Themes
  • Question of the Quarter: Midwifery Today magazine
  • Switchboard

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Pendle Hill Center for Study and Contemplation

Religion, Justice and Health Care: The Many Connections A Weekend with Charlene Galarneau and Suzanne Seger January 19-21 Join us in exploring health care policy in the U.S. What is health? What is caring? What actions might move us toward a more just health care community? Charlene Galarneau teaches health care ethics and religion at Tufts University. Suzanne Seger is a certified nurse-midwife working with immigrant communities at Mount Sinai Medical Center. (800) 742-3150 or

Quote of the Week:

"The thing that helps more than anything, and I'm speaking as somebody who has given birth both in a hospital situation and at home, is that the person who's helping you, loves you."

- Ina May Gaskin, 1979

The Art of Midwifery

If a woman has a low white blood cell count, she may be prone to infections during her pregnancy. To boost her count, start her on sesame seed oil. Sesame seed butter is a good source or often health food stores stock capsules of sesame seed oil--she can take three to six per day. Vitamin E 400 IU and sesame E combination supplements are also available.

- Midwifery Today conference Tricks of the Trade Circle

Doula tip of the week

One item I take to every birth is a 2-quart pump-style thermos. As soon as I get a birth call I fill a pot with bottled water and begin to heat it. As I finish my last minute activities the water boils; I then transfer it to the thermos. Having an immediate and mobile source of boiling hot water is wonderful! Since I also pack a zip lock bag with herbs, teas, cocoa mixes and instant oatmeal, there is something for everyone at the birth.

- Joni Guadalajara

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News Flashes

Ohio State University researchers report that 75% of mothers say their husband's opinion greatly influenced their decision to nurse their babies. Men who are knowledgeable about the health benefits to the child tend to be more supportive, while those who discourage breastfeeding may fear separation from their partner or envy the special bond between mother and infant. Some believe infant formula is better, and others worry about the effect of breastfeeding on breast appearance.

- Fit Pregnancy, Fall 1998

Intact Membranes

The significant benefits of intact membranes are the maintenance of an even hydrostatic pressure to the whole fetal surface during labour and a reduced likelihood of infection. Fetal hypoxia is less likely because retraction of the placental site and thus impairment of the uteroplacental circulation will not occur (Henderson). Fetal heart rate abnormalities were less common in the amniotomy group in a study by Barrett et al., but there was no difference in this study between the amniotomy and nonintervention groups in regard to the method of delivery, condition at birth and postpartum pyrexia.
Fraser reviewed six trials (Wetrich; Stewart; Franks; Fraser; Barret; Fraser et. al.) that examined amniotomy in spontaneous labour. The main conclusion of this meta analysis was that at the present time there is no evidence that one policy of rupturing the membranes or leaving them intact has a clear advantage over the other. Of course the most important views of amniotomy are those of women who experience this intervention. A large trial conducted by the National Childbirth Trust found that the great majority of women found labour harder to cope with following amniotomy and felt their physiology had been disturbed. Another study (Robson and Kumar) made the unexpected discovery that maternal affection was more likely to be lacking after delivery if the mother had a forewater amniotomy, experienced a painful unpleasant labour, and had been given more than 125 mg of pethidine. In this study most mothers had developed affection for their baby within a week of the birth and no further adverse effects were noted.

- Mayes' Midwifery, 12th ed., Betty R. Sweet, ed.

Barrett, JFR et al. (1992). Randomized trial of amniotomy versus the intention to leave membranes intact until the second stage. Br. J. Obstet. Gynaecol. 94: 512-517.
Franks, SP. (1990). A randomized trial of amniotomy in active labour. J. Family Pract. 30: 49-52.
Fraser, WD. (1988). A randomized controlled trial of the effect of amniotomy on labour duration. MSc thesis. Alberta, Canada: University of Calgary.
Fraser, WD et al. (1991). The Canadian multicentre RCT of early amniotomy. J. Perinat. Med. 2.
Henderson, C. (1990). Artificial rupture of the membranes. In Alexander, J., Levy, V., & Roch, S. (eds) Intrapartum Care-A Research Based Approach. Hampshire: Macmillan Education.
National Childbirth Trust. (1989). Rupture of the Membranes in Labour: Women's Views. London: National Childbirth Trust.
Robson, KM and Kumar, R. (1980). Delayed onset of maternal affection after childbirth. Br. J. Psychiat. 136: 347-353
Stewart, P. (1982). Spontaneous labour, when should the membranes be ruptured? Br. J. Obstet. Gynaecol. 99: 5-10.
Wetrich, DW. (1970). Effect of amniotomy upon labour. Obstet. Gynecol. 35: 800-806.


E-News asked readers, What are the fetal benefits to labor with intact membranes?
I have made it a practice with all my laboring moms to never artificially rupture membranes. This is a result of a birth that I attended nearly 10 years ago. It was the mom's first homebirth; at her two previous births her membranes had been ruptured during early active labor; she felt it was a necessary part of her labor and it helped her progress. She wanted me to rupture the bag this time. I really didn't want to, but it was her birth so I agreed. At 6 cm there was not enough of a bulge to the bag to allow the amnihook to snag it, so I backed off. When she was 8 cm, I made my second attempt. Nothing! I looked carefully at the hook and realized there wasn't a beak on it. I thought, I am not supposed to break this bag.
About 45 minutes later a nice big baby boy was born. When my mentor examined the placenta she said, "This baby is truly a miracle baby." Coursing through the membranes were many vessels from the placenta (vasa previa) and a velamentous insertion of the cord--the Wharton's jelly didn't continue to surround the vessels of the cord all the way to the placenta. The vessels looked like bare wiring the last eight inches to the placenta. If I had been successful in rupturing the membranes, the baby would have been in danger of bleeding to death.
After this experience, I never rupture membranes. I feel the benefits of intact membranes are many: the amniotic fluid protects the cord from compression and prevents fetal distress. It protects the baby's head from the pressure of the birth canal and the bulging bag helps dilate the cervix and birth canal as it presents before the baby's head and opens up a space for the babe to come into. The baby continues to have its watery environment during the labor to continue drinking and breathing the fluid. I believe this helps the baby prepare for life outside the womb.
Leaving the membranes intact also allows the baby to change positions with greater ease, which prevents asynclitic and other cephalic positional challenges from occurring. If the mother's labor stalls or stops, there is no time constraint because the membranes have ruptured. This intervention is irreversible and leads to more interventions and complications. I have seen many babies born in the caul and it is a truly amazing sight. I have seen many bags full of fluid crowning before the baby's head, with vernix swirling around inside it, looking like a picture of the earth from outer space with the clouds moving upon its face.

- Cynthia Luxford, LDM-CPM

I helped with two births where one baby was born with completely intact membranes and the other baby was born where the membranes had ruptured approximately 4-6 hours before the birth. The baby without the intact membranes had tiny, broken blood vessels all over his face, caused by the pushing effort, whereas the baby with intact membranes did not.

- Stephanie Bryant, aspiring midwife
Lumberton, MS

Intact membranes are a marvelous protection for the baby. One incident made me realize exactly how beneficial they are. One of my mothers gave birth to a frank breech baby at home. As everyone knows, when a breech is born, the presenting part gets severely bruised and swollen since it is soft tissue. This breech baby was born in the caul (with the membranes intact). I had to tear open the bag after the buttocks were born. She had absolutely no bruising or swelling as a result of the birth and had a 10-10 Apgar. I firmly believe the intact membranes are what protected the baby from the bruising that normally occurs. I believe that intact membranes provide the same cushioning protection for the head as well.

- Judy Jones, CPM

From my own observations it seems women who labor with intact membranes can have more spurious labours than ruptured membranes. I would imagine that having intact membranes can only be of benefit to the baby inasmuch as they act as a cushion against the pelvic floor, protecting the presenting part to some degree. I also wonder if having intact membranes aids cervical dilatation by gently holding open the cervix when they are bulging. Certainly you see this in pre-term threatened premature labor or malpositions when there may be a question of cervical incompetence or ripeness.
In (small only) defence of ARM or even relief at SROM, having ruptured membranes with regular liquor leakage may be the only indicator of general fetal well being if EFM is not being done (there's no mistaking meconium stained liquor).
Recently a client was in reasonable labour but experiencing severe pain and requested an epidural. Her blood pressure had been rising but she was generally asymptomatic. EFM revealed type 1 intermittants but increased fluid and position changes generally controlled these. She became febrile/ in pain/ ctg EFM questionable/membranes intact. This lady was transferred to theatre for a cesarean. She had an epidural for delivery (platelets later came back at 40), proceeded to a postpartum haemorrhage of 2 litres and the baby had thick meconium liquor and APGARs of 1, 4 and 6. It was one of the most distressing deliveries I have been to and I think had her membranes been ruptured as we would have liked to do I feel we could have acted earlier than we did and maybe had a better outcome.

- Anon.

If the presenting part is uniformly applied to the cervix, the forewaters apply steady pressure to the whole cervix with each contraction, allowing it to dilate uniformly, preventing uneven dilation that can lead to lips of cervix remaining. These can lead to a longer labour. Early artificial rupture of the membranes has not been found to help other than to shorten labour.
The bulge of forewaters also acts as a cushion to protect the fetus's head and to absorb the contraction as it travels along its body. If the membranes rupture early or are ruptured prematurely, the fetal skull will receive the direct pressure of the dilating cervix. This leads to the formation of caput succedaneum.
If the membranes remain intact until dilation is completed they will usually go as there is lack of support from the cervix. This is also emphasised with the action of relaxin upon the placental membranes. If the membranes rupture upon full dilation then the amniotic fluid released acts as a sterile douche of the vagina. The membranes may be resistant enough for the baby to be born in the caul which is thought to be very lucky.

- H.H.

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Question of the Week

A friend suffered with obstetric cholestasis in first pregnancy from 32 weeks and baby was delivered at 36 weeks, fit and well. Now on her second pregnancy it has returned at 16 weeks. At present although she has high phosphate levels, bile salts are not being deposited in areas causing risk to the baby. Does anyone have previous knowledge of this, and any advice, comfort to offer?

- Mags

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Question of the Week Responses

Q: I have a client who has been diagnosed with varicose veins in her vulva. Can anyone give me suggestions on how to help her with this?

- Chrys Holland, doula/massage therapist

A: Speaking from experience--support hose. I used prescription support pantyhose. They were a Godsend! They cost about $100/pair nine years ago and were worth every penny. Insurance will cover the cost.

- Edie, midwife

A: I have seen some pretty bad vaginal and vulvar varicosities, but have never had any problems from them. First, I never encourage those gut-busting breath-holding pushes like I've seen some people do, but for varicosities, I stress a side-lying position and gentle pushes. Also, prenatally, I encourage vein-strengthening herbs. Underwater delivery also eases pressure on the veins. If this is not feasible at least use hot witch hazel/comfrey compresses and a lot of lubrication like vitamin E oil, K-Y jelly or Astroglide (my favorite) on them as the baby comes out.

- Marlene

A: I have seen this only once. The client had a large varicosity on her labia minor, about the size of a sausage. The advice given was to use Tucks or a witch hazel periwash for itching/discomfort, wear support hose, and support with her hand during bowel movements. During labor she was advised to allow her body to push and to support the varicosity with her hand.

- Pam Martin, MS, DONA CD, CM, PMT

A: With some, this condition can get quite uncomfortable as the pregnancy progresses. Others have no discomfort at all. I recommend applying witch hazel compresses, wearing maternity support pantyhose, and using hamamelis homeopathically. When it comes time for delivery the tub offers good support of the vulvar tissues. If delivering on land, having the mom lie on the unaffected or less affected side and supporting the vulva during crowning and delivery of the head seems to be sufficient. I've never had a problem at delivery.

- Liza McKinney, CNM

A: Is there a diagnosis of kidney problems? Of course you know that varices are caused by pressure. So bottom up several times of the day will release the pressure. For giving birth: one of the signs that she will be in labor soon is when the veins become smaller.

- Mary Schefffer
The Netherlands

Coming E-News Themes


2. An E-News reader submitted the following description of her concern for hospital-birthing women. Please share your thoughts on this issue, and let's get some problem-solving dialogue going:

I AM A MIDWIFE WHO ATTENDS TO THE NEEDS OF WOMEN BIRTHING IN THE HOSPITAL. I find that many "modern" (i.e. American women and a large percentage of my Chinese immigrant women have difficulty recognizing and validating their strength and power in the process. I think the midwives who attend the [Midwifery Today Eugene] conference probably identify the same problem, especially those whose clients have the good fortune of being cared for by midwives by virtue of showing up at a clinic that midwives attend and having no knowledge of the issues of philosophy, etc.
I would find it useful and interesting to include "ways to inspire confidence and a sense of the inherent power and brilliance" of women into the section on women who care for women in the hospital. I work hard at this endeavor every day, but because our presence is diluted by all the non-midwives who work in the "institutions," I find it draining.
Your conferences are restorative and invigorating. However, I also feel a sense of disappointment or frustration because I don't attend homebirths and the most glorious stories usually are from homebirths. I fully support homebirth and would love to see a movement to take normal birth out of the hospital and into the home. There are women who don't have a home suitable for homebirth--they live in what the Chinese call "pigeon houses" where many families share a common bathroom and kitchen, are often alone and unsupported. I hope there will always be midwives willing to attend these women in the hospital.

There is a strong need to remind midwives why they are midwives and ways of bringing those midwives back to the fold.

- Zora

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QUESTION OF THE QUARTER for Midwifery Today magazine

Issue No. 57 (Theme: Cesarean Prevention/VBAC) How do you prevent cesareans?

Deadline: Dec. 15, 2000

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I am a student midwife in Chile, where there really isn't any midwifery in existence at all. In this pioneer journey I am calling for educational information IN SPANISH about natural support and care during prenatal, birth, postnatal, breastfeeding, but most of all about menopause and climateria, having to do with natural menopause support as well as information about hormonal treatment with scientific basis and the dangers for health, etc. It is an alternative during the menopausal years. (For the latter, in English would be acceptable, but preferable in Spanish.) Any support, connections, books, authors etc, will be very helpful. The more information in Spanish I find, the less I will have to translate, which is very time consuming.

- Megan Aiyana Gregori

Reply to:


Dear TLK from Canada [Issue 2:47]: I have had what was called prediabetic problems. I found the book Protein Power by Michael and Mary Eades to be helpful. Diabetes is talked about starting on page 307, but I think the whole book is worthwhile. There are also helpful herbs I have not used, but I'm sure you could find them with some research.

- Francie Smith
South Dokota


I tore out an inguinal hernia [Issue 2:47] during my fourth pregnancy. I already had an umbilical hernia from previous pregnancies. Inguinal hernias usually only appear in women if there is a family history. I felt the hernia tear when I was carrying my sleeping five-year-old up the stairs. You need to be careful and not carry heavy things or strain unnecessarily. I delivered my baby without any problems at all after a three-hour labor. The only warning my doctor gave me was to not carry heavy things and get it repaired before I got pregnant again. I did that (both hernias at the same time) and had two more babies after that without event.

I am also a midwife and have cared for one mom who also developed an inguinal hernia during her pregnancy. Her delivery, though longer than mine, was uneventful and she had her hernia repaired between pregnancies.

- Judy Jones, CPM


I am considering becoming pregnant and want a midwife-attended birth. I have previously been diagnosed with Group B strep. I am wondering about the possibilities of having this now or when I deliver, and what can be done for it when pregnant, aside from intrapartum IV antibiotics (i.e. can I use acidophilous to help treat it? I have used it in the past and once had a Pap done when on it and the only thing that came back when cultured was heavy normal flora.). I am not sure on home or hospital birth yet (this would be my first child and I am going to be 32 very soon) but I want as few medical interventions as I can, but want to also make the best decisions for my baby and me.

- M. Irvine
Reply to:


I think you should stop calling PROM premature rupture of membranes and call it prelabour rupture of membranes. Presumably from the point of view of the physiology of the woman to whom it is happening it is prelabour, though not necessarily premature.

- C.R.


In response to Dianant-Sheida [Issue 2:47]: The concerns about longer second stage are a major contributing factor to the high c-section rate in the areas where it exists. Funny that in general the obstetric community does not even acknowledge the dangers of an extremely fast second stage, so long as a doctor is there to catch. From reading and workshops on birth trauma there are also real dangers as far as birth trauma from a fast delivery and also from a c-section as well. Women left to their own pace of delivery push for an average of two hours for a first-time mom. Could it really be that this is dangerous if it is the average if just left alone? Why is it that even shorter time for second stage is allowed for the woman who has birthed before? Yes, it is likely that she will push for a shorter time the second time, but does it really put baby in danger if she takes as long as the first-time mom the second time? I know of several cases of moms who have pushed for four or more hours with perfectly healthy babies. I have seen damage to baby and mom from pushing, but it is much more likely when the pushing is directed by the doctor or nurse rather than the mom's body, and when the mom is instructed to push beyond the point of comfort and hold her breath and push to a count of ten or more.

- Anon

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