#3 Early AROM for Induction of Labor

Justine:

There was a recent study that came out this year in 2022, about early AROM after a foley bulb induction. And there has been some talk about it. I’ve had a lot of messages about it, and Sarah and I just wanted to get on the podcast and talk about different recommendations. What does the study say? Why do they want early arom after foley and or a cooks balloon. And so we’re gonna talk about that today, but just a reminder, all of these opinions are our own. We did not. We did not conduct this study nor did we definitely not publish it. We’re just gonna walk through it because sometimes these studies, when you read them, you’re like, what is this even saying? And Sarah and I love research and we read research for fun practically at this point. So we wanted to talk about it a little bit. Maybe break it down, have like a real talk. If you’re in mentorship, you know what that means and discuss early Arom after foley inductions.

Sarah:

Well, and I have some opinions about this a little bit, you know, I’ve been a nurse for over 10 years. So I remember the day when like every doctor would come in at two, three centimeters for every induction or even just spontaneous labor or whatever that they would come in and they would early AROM. And I remember being so annoyed by that and so if you’ve been around for a second, we wanna talk about the data of what this actually says, because for me it was a little bit surprising. And then we also want to give you practical advice on like, what this means at the bedside, because we’re not the AROMing I hope. And so that will hopefully guide your practice, help us understand what’s happening in the birth room so we can help navigate these scenarios. Justine, tell me some of the data, I have uptodate, ready to read for the recommendation, which actually was a surprise. Because I did not look this up until today.

Justine:

So let me just break down what AJOG did. They came out with a study with 160 patients. They put 79 of them in the early rupture group and 81 of them in expected management and expected management means they just let them labor and didn’t do anything to them. Intervention wise, it was randomized. It showed that for people undergoing an induction with the Foley and that had early AROM, they delivered 2.3 times faster than people that didn’t have this intervention. So the first time someone sent this to me, I remember being surprised by it because I was similar to you, Sarah, like early AROM annoys me. I remember running to a resident one day being like, do you know that the amniotic fluid acts as a cushion to help baby flex? And she was like, yeah. And I was like, then why are we AROM before babies are at zero station? I was so confused. So concerned that no one did know this information, but a lot of people did. And so I, I was a little hesitant on this, on this article, which I’m sure you were too.

Sarah:

A lot of thought about this article.

Justine:

Okay, Sarah. So before our opinions, let’s talk about some of the data that we did pull from the worldwide web to talk about early AROM. We have the AJOG that we just talked about and that one showed that people that had an early AROM after a foley bulb expulsion delivered 2.3 times faster than people that were in the expected management group that didn’t have these interventions.

Sarah:

And by early AROM, we’re talking either less than four centimeters or less than three depending. So like early meaning early labor. They’re not that dilated.

Justine:

Perfect. Thank you for inductions. In general, not just fully bulb inductions, there was a green journal article in 2018 that said that with early AROM in nulliparous people undergoing induction may have shorter, active phase of labor, but it does not increase their neonatal or obstetric adverse outcome. So it doesn’t increase this area and it doesn’t increase Apgar scores, etc. There was a 2012 study of 500 birthing people showing that early AROM puts patients at an increased risk of C-section for failure to progress. Then those with late AROM it was 18% C-section vs 8% in the patients that didn’t have the early AROM

Sarah:

Now mind you did that have to do with the foley bulb induction, because what we’re looking at at the, and the 2022 data that specifically was after a fully bulb induction.

Justine:

Correct. And so this, this one was a foley bulb induction. It seems like to be one of the only ones with the foley bulb induction. The, the ones I’ve been reading off to are just early AROM in general but a lot of them do mention that like with any kind of ripening agent. So that could include, now all of a sudden you did three doses of cytotec and now they’re 3/90/-2 and you do an an AROM. It could be considered an early AROM, but that’s with an induction.

Sarah:

So I’m seeing a difference just in, in terms of data pulling, like if we’re talking early AROM, like, say they come in and they’re having contractions. And the doctor’s like, well, let me just rupture you. Or they’re induced. They’ve had nothing, early AROM. They’ve had some sort of cervical ripening, which in most, they’re talking about a foley balloon as one of those early “ripening agents.” So I just wanna make that distinction that like, maybe there’s maybe there’s something there.

Justine:

And then if we go outside of inductions and just use spontaneous labor, cause that’s always a question too. The Cochrane library pulled 15 studies, which had over 5,500 birthing people and they found no statistically significant difference between the length of labor, the percentage of patients going to C-section, Apgar scores or patient satisfaction, which I love that they added that. They actually suggest that to not provide amniotomys to everyone, just because, because these patients aren’t delivering faster and they’re not going to C-section less if you do so in that spontaneous group. So Sarah, you wanna read what uptodate says, if you don’t know, we are up to date junkies over here.

Sarah:

Oh, I uptodate everything. If you don’t uptodate everything, look at your institution and see if they have an uptodate subscription. It’s usually on the intranet and this is like basically Google for medical people. It makes it so much easier. So uptodate, when we’re looking at labor induction without initial use of oxytocin. So you’re not starting with oxytocin or Pitocin that when they talk about amniotomy alone in patients with a favorable cervix, so that’s a Bishop score of six or above the use of amniotomy is an option to initiate labor. If the head is, well, it says, opposed, I’m gonna say applied to the cervix. However, the combination of amniotomy with IV oxytocin administration is more effective. So they want ’em together in a meta-analysis of randomized trials this combination resulted in a substantial reduction in pregnancies, undelivered at 24 hours compared with amniotomy alone. So they’re saying, and that was the ultimate recommendation was that if you’re gonna perform an amniotomy throw some pit at them as well and oh, and they actually recommend early versus late amniotomy if you’re gonna compare the two.

Justine:

Why do you think

Sarah:

I honestly, when we were pulling this data, I’m like, I just see a lot of early amniotomy and it’s sort of like, I think in my opinion, I think there’s enough data out there that says that I early amniotomy is a safe option that they’re like, just get this show on the road. And if you can say that you’re gonna rupture them and give ’em some pit, if that’s gonna make labor go faster, then that’s gonna be the recommendation. Now in all of this, what I see is we’re talking about length of labor, right? We’re not necessarily talking about the risk of amniotomy which I’ll have you explain in a second Justine. So let’s talk about risk of amniotomy, but also like, are we, and, and if we’re not changing outcomes, the goal, then the ultimate goal. What I hear here is that we want them to deliver super fast, right?

We want them delivered within however long, this says 24 hours. Now the longer the length of labor, the risk increases in that way as well. And then you get into the hospital side of like cost of stay and all of that, that like in general and who wants to be in labor for six days? Like no one, you know, so that’s beneficial, but are we really talking about the greater picture? What about the other use of other interventions or, you know, the actual risk of cord prolapse versus not? Or are we looking at labor dystocia? Where’s the labor dystocia, and that in theory could be related to cesarean risk, but, you know, was there a slowing, did you, did you end up with more acyclinitic babies? Did you end up with more, you know, OP babies? Did they push for three hours versus one? Like, you know, those are all the questions that I would have that we just don’t have data on that we were able to find.

Justine:

It would be very fun to design that study

Sarah:

Feel free.

Justine:

No, not like actually to design it, like in theory, like I’ll tell my idea to people. I’m even thinking I had an asyclinic baby, the other day, you know, where you can tell on the side of their head, it’s like the little cone. And I’m like, imagine if we had that data too, like all the babies I delivered with the cone, like on the side and like, oh, that baby was ascynclitic for a while. Talking about risks, if you want me to go into that, I found a, I found a resource which will share all these resources in the show notes, but I liked how they worded the disadvantages of early AROM. Okay. So they said potential increased risk chorioamnionitis which makes sense. Potential risks for increased neonatal sepsis, which is potentially related to chorio.

Potential increased risk to NICU admission, which would be related to the top two. And then it says slight increased risks for cord prolapse. And that’s why I like it because I like the slight, I think that, and we know we’ve talked about this in many different things that cord prolapse is just seen as this like overwhelming event that’s gonna happen on every one of your patients and the, the risk is not that high. It says right here in the Cleveland clinic that it’s reported to be, 0.16 to 0.18% of the overall incidence rate, which is not common. There’s one other studies here showing or article here saying that it occurs about one, one in every thousand births. And so I think that’s just something, I think that there’s some nurses out there that hate AROM specifically, because they’re so worried about a cord prolapse, which I love that they’re like operating in the lens of safety. But if that’s the biggest thing they’re worried about. That’s something that we don’t have to worry so much about the it’s at release that stress of our body.

Sarah:

The concern also is for spontaneous rupture membranes, right? That like, oh, once their, once their water’s broken, we can’t get ’em outta bed. That’s a whole nother podcast episode, you know? Yes, but that like the concern for cord prolapse is so much that it really potentially guides what we “allow” versus not.

Justine :

And if there’s gonna be a cord prolapse, I think during an AROM is the best, the best place to have it fair with the providers hand in there.

Sarah:

Yep. That’s totally fair.

So what I’m hearing here is that early amniotomy is not an unreasonable intervention from a provider in the case of an induction of labor. So for us, we need to know that this data is out there rather than the upset DM’S that you’re getting about hh my goodness every provider’s now aroming early with my inductions or whatever. This is why it’s happening because there’s enough out there that says it doesn’t increase the risk of cesarean. It shortens the length labor without other increased risks, other than just like the risks of amniotomy alone to really guide care elsewhere. Now this is where the physiologic birth lady in me is like, okay, but this is also sort of this push towards medical interventions, right? That like, I mean, you even, we even talked about this outside of this episode about how like, well, this is just the residents or this is just the doctors wanting to like snap, snap, get this done, which there’s nothing necessarily wrong with that.

If you sign up with a, for a labor induction, like you’re there to be induced and receive medical interventions. Right. But where does it end? Right. That in terms of early amniotomy. It’s like, that’s now there, there are three centimeters. They were one, two hours ago. Let’s just rupture ’em and get this show on the road versus sort of going back to our main mission. One of the things we talk about so much as moving the culture towards a more physiologic birth mindset where we’re trusting the body, we’re letting it do it on its own time, sort of trusting in nature in that way. And then intervening when things slow or if there’s a dystocia or if there’s fill in the blank necessity.

Justine:

I love that you say that because I do get a lot of messages. I got one this morning saying this is just residents chomping at the bit. And I, I don’t want us to feel that way. Right. And I don’t want us to have that in our heads because they’re operating in the best way they know. And based on the research they have and what their, their educators are teaching them. And so we’re all a collaborative team. And so we just need to be on the same page.  But I wanted to talk about at the end of this episode. Well, so it is the reality, right? We do have providers performing early AROM. I don’t see induction stopping anytime soon. And so what are we gonna do to work through it? And I made a little list thinking about this podcast. And I think that like the first thing that came to my mind is patient satisfaction.

And so when you early AROM before three centimeters, an induction, even a prime, you have hours to go and you have hours of leaking. Right. And I’ve come up to so many patients where they’re wet, the pads are wet. They’re uncomfortable. This is where I get into #teamunderwear. This is where I’m thinking, if they don’t have an epidural and they’re mobile, why can’t they have underwear on, they can change their pad. You know? And I, I, for myself, I put new pads in the bathroom and we talk about it and they can change it as they go a lot of units, not a lot, I would say, but some units have told me it’s their policy that they can’t wear underwear because of risk for chorio in that sense, so I think flex and flow on based on what your policies and procedures are, but it doesn’t make sense to me. I’ve seen towels in there. Right. I’ve seen like it’s, I think that’s kind of,

Sarah:

Especially a pad, a pad’s like a diaper, like the, the moisture stays in the pad it.

Justine :

Totally, totally. So keeping them comfortable and dry, keeping them moving if you can. And like Sarah said, we will die on that hill in another episode. Cause that’s like, we’re very passionate about that. Helping them cope because as we’ve seen in practice that once, you know, they’re ruptured, their contractions can become more intense. And so being there to help them cope and understand like why does this feel different? Or if it does, and then limiting, cervical exams, which we know we’re supposed to do, but then how do we assess fetal position? And I think starting to understand leopolds and asking your patient about their sensation and paying attention in other ways, not just on the vaginal exam, if you come to our physiologic birth class, you know, that we’re all about getting away from the vagina and looking more towards the body when it comes to fetal position

Sarah:

Away from the vagina.

Justine:

Right. And then just to keep them safe. I think that we should be tracking not only temperatures, but fetal heart trends. I think that we kind of forget sometimes that baby’s gonna show up tachy, like if chorio is gonna happen and, and you can see the subtle baseline increase throughout the hours of care. And so I think looking back to be like, what were they did? They come in at 120 with moderate variability, and now they’re 160 with minimal. It’s just something to track and keep on your mind to work. As we work together, to keep these patients safe and have a successful, beautiful birth memory.

Sarah:

Well, and knowing that there is an increased risk for chorio once the, the membrane is ruptured, that that should put some fire under you to help them keep progressing, right. That we’re not just sitting on these patients, that we are actively involved in their care. We’re helping them, them identify their sensations, keeping them moving motion is lotion helping this baby navigate the pelvis. The other sort of component that I see in there is even prior to amniotomy. What’s the patient education that we’re doing. What’s the expectation we’re setting so that they are making the decision for themself and they know exactly what they’re getting themself into. Are they stuck in bed based on your “hospital policies” or based on your own comfort level, let’s be honest. They can do whatever they want, but are you gonna recommend that now they’re stuck in bed when that’s not their preference and they wouldn’t have known that, are they okay with an IUPC later and an amnioinfusion later, if there are decels because they’ve been leaking now for 24 hours, like, do they understand the increased risk of cord prolapse?

Which really, I’m not worried about that usually with an amnio, because I trust the provider’s assessment in terms of if the head’s applied, but, you know, and do they recognize that, like that once you’ve broken the water, other than pit, if they’re not on pit yet that that’s it like we’re waiting. You know, and to me, there’s sort of like, in my mind, I love having AROM in the back pocket of like, let’s keep them progressing. And then the moment things, if they were to stop progressing, we break the water, you know, and I, I have to sort of get on this little hill because from a physiologic birth perspective, we need the head super well applied on the cervix in order to continue to help release prostaglandin that helps release oxytocin from their brain continues the labor cycle forward. But, you know, and which helps with an AROM.

So that’s good. But if the head is not descended into the pelvis, that what happens with an AROM a lot of times is you have this rapid, like, Ugh, down into the pelvis, right? That if they haven’t flexed their chin, they haven’t rotated and sort of allowed the pelvic floor and the pelvis to help them down into that launch Cardinal movement position with their chin tucked those early AROMs when the baby is like, it’s low enough, you know, not super well applied, like I’ll do it. I think it’ll be fine type AROM. Then to me, we’re gonna, I would love to see data. This is totally my theory, but it makes a lot of physiological sense that are we gonna see more asynclitic babies where you end up with the labor dystocia? Not because of amniotomy of course, but because of a malposition and that’s the baby’s fault, but did we cause it by the amniotomy or early amniotomy you know? So I want us to be aware that sometimes there’s more to the picture than that. Now, usually my recommendation after an amniotomy, because we’re not the ones that are jumping in and being like, oh, sorry, doctor, no, we must engage the baby more. Right. But in anticipating what’s happening with our providers, you know, this provider’s gonna come in at three, four centimeters and they will a on them regardless the situation like it’s just what’s gonna happen,

Justine:

Right. Or at 7:30 AM every single day.

Sarah:

Exactly. Exactly. But prior to that, one of our primary nursing goals on our fake care plans that are in our heads that we’re actually making, even though we’re not writing down is to help engage the baby. That if the, if the patient is awake and they are down, that we are upright, that we are knees wide, that we are moving things out, that we are making space. You know, that we are trying to get that baby low enough that when the amniotomy happens, that baby is already in that launch position. Now, if they’re not/even if they are, I just did this with my sister, that it was that she got her amniotomy, they broke her water and I was like, let’s get up. And she wanted to be in a squat position. We got her in a squat position, supported and things increased. Then I was like, all right, you asked for epidural, let’s get you out of bed until you got your epidural. And that really, she delivered like an hour and a half later.

Justine:

I think that’s a great point, Sarah, about anticipating the providers, you know, your providers, you know, what’s gonna happen, I guess, unless you’re a travel nurse like, and you don’t know the providers well enough, but you know what to do. And

Sarah:

If you don’t learn, you know, and sort of start to pay attention, you can kind of put together these profiles in your head of what, not only what do they like, how do they practice that, then that can help you support them and have a better working relationship with them. But then also you can start anticipating some of this stuff for your patients.

Justine:

Before we go, I thought I was thought of something that you said once on a mentorship call of how to teach a patient. Especially when you, they get an AROM and then they have to get an amniofusion. And they’re very confused. Like you took, why did you break my water? And now you have to put more water in. I don’t get it. You said you had an explanation of how you explained the benefits of AROM versus doing an amniofusion. Do you remember?

Sarah:

No, but I can just kind of wing it if you want.

Justine:

That’s what you do best.

Sarah:

Oh boy. So the case is that they have broken the water and now they need an am fusion. And the question from the patient is why did you break my water?

Justine:

Yeah.

Sarah:

Just, I’m just gonna need more fluid inside.  So I would use my hands or I draw on the, on the whiteboard or on a napkin or a paper towel or something and show the cervix, the water bag and the head. And how the really in order to help keep your labor progressing, especially if there was say like, oh, now we’re not dilating our cervix anymore. And so we gotta keep things moving. And the goal with an induction is that we wanna get you to the finish line. We wanna get you to that vaginal birth. And so at this point, your cervix has stopped dilating. We have this other intervention. That’s a part of the flow for your induction, where that removes the water bag between the baby’s head and your cervix. And I would use my hands as a fist for the cervix and my fist for the head and say, when there’s that gap, there’s less pressure on the cervix when we break the water bag.

So now there’s pressure directly from the head on the cervix that that actually helps release your natural hormones, prostaglandin tells your brain oxytocin to create stronger contractions and help your cervix go away. Now, the byproduct of that is that every time you have a contraction, baby wiggles, you move around a little bit of water slips out. Now, most of the time that head is the plug, keeping that water inside. But given that it’s a long time, or depending on how much fluid you had inside that water’s gonna keep leaking out over time. And if we see that starting to affect the baby, we have this amazing intervention and tool where we place this what’s called an IUPC, intrauterine pressure catheter. That’s just this little plastic tube. Show them in the thing that goes alongside your baby, and that can replace the water inside so that there can be continued space around the umbilical cord. So baby gets all that juicy blood flow that they love and need. And then also we get the, the added benefit of the baby’s head on the cervix to help your cervix dilate.

Justine:

That was it. It was beautiful.

Sarah:

Oh, perfect. Glad I can deliver. I hope this conversation was helpful for you and your practice. I think the biggest takeaway for me is that we need to know what the up to date data is. We need to know why our providers are practicing the way that they are and be able to quote/reference some of that information. Where do you find it Cochrane, uptodate, ACOG, AWHONN, all of our major governing organizations. If you’re not members, then you should be checked online to see if your organization has uptodate that you can access. And then for us, what’s our nursing interventions. How do we navigate these early AROMs or even late AROMs. How do we have these conversations with our patients? How do we answer the questions and allow them to be a part of their care. So they know exactly what to expect, and then we can continue to help them have the most positive birth memory.

Thank you all for spending your time with us today. During this episode of happy hour with bundle birth nurses, if you liked what you heard, it helps both of us. If you subscribe down below, give it a rating, leave a raving review, and then share this episode with your other labor and delivery nurse friends, to help them continue forward in their practice and be the best nurse they can be. If you want more from us, you can head on over to bundle birth nurses.com or follow us on Instagram. Everything’s in the little Linky thing on Instagram or in the show notes down below. And so now it’s your turn to take what you learn today, apply it to your life, giving honorable evidence based care to every single patient that you care for. We’ll see you next time.