Stretching of the cervix and stripping of the membranes at term: a randomised controlled study

doi:10.1016/0301-2115(96)02405-0

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 66, Issue 2, June 1996, Pages 129-132

https://doi.org/10.1016/0301-2115(96)02405-0 Get rights and content

Abstract

Objective: To determine whether routine antepartum stretching of the cervix and stripping of the membranes at term would shorten the length of pregnancies, and whether this correlated with cervical status and fetal and maternal parameters. Design: A prospective, randomised, controlled study of 293 term gravidas, free of medical complications, divided into two groups: stretching/stripping, and non-stretching/stripping. Digital separation of the fetal membranes from the lower uterine segment, and cervical stretching, were performed during routine vaginal examination of the first group. In the second group, only routine vaginal examination was performed. Results: Of 293 patients, 152 underwent a trial of stretching and stripping; 141 served as a control group. The mean interval (hours to delivery after the procedure) was 136 h (S.D. 10), compared to 161 h (S.D. 11) in the control group. The mean interval (hours to delivery after the procedure) was 136 h (S.D. 10), compared to 161 h (S.D. 11) in the control group (P = 0.095; not significant), but with only a trend towards the shorter interval in the first group. When patients were matched according to weeks of gestation and fetal and maternal parameters, only those at 41 weeks' gestation or more had a significant reduction in the interval from the procedure to delivery (mean 91 h (S.D. 8) compared to mean 125 h (S.D. 10) in the control group; P < 0.007). This observation was independent of cervical status and other maternal or fetal parameters. Conclusions: Only patients ≥ 41 weeks' gestation benefitted from stretching of the cervix and stripping of the fetal membranes. The effect was not dependent on the cervical status or other maternal and fetal parameters.

References (13)

M. Porto
The unfavorable cervix: methods of cervical priming
Clin Obstet Gynecol
(1989)
S.M. Sellers et al.
Release of prostaglandins after amniotomy is not mediated by oxytocin
Br J Obstet Gynaecol
(1980)
J.K.W. Ferguson
A study of the motility of the intact uterus at term
Surg Gynecol Obstet
(1941)
J.P. Lenihan
Relationship of antepartum pelvic examinations to premature rupture of the membranes
Obstet Gynecol
(1984)
A.P.F. Flint et al.
Control of utero-ovarian venous prostaglandin F during labor in the sheep: acute effects of vaginal and cervical stimulation
J Endocrinol
(1974)
A. Vasicka et al.
Plasma oxytocin in initiation of labor
Am J Obstet Gynecol
(1978)

There are more references available in the full text version of this article.

Cited by (23)

No. 214-Guidelines for the Management of Pregnancy at 41+0 to 42+0 Weeks
2017, Journal of Obstetrics and Gynaecology Canada
Citation Excerpt :
The results of membrane sweeping are not predictable and should not be used alone for induction if the indication for induction is urgent. In several small trials, membrane stripping has been an effective outpatient method to reduce the number of patients with pregnancies exceeding 41+0.41–44 Again, membrane sweeping is generally most efficacious in nulliparous women with unfavourable Bishop scores.
To provide evidence-based guidelines for the management of pregnancy at 41+0 to 42+0 weeks.
Reduction of perinatal mortality associated with Caesarean section at 41+0 to 42+0 weeks of pregnancy.
The Medline database, the Cochrane Library, and the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists, were searched for English language articles published between 1966 and March 2007, using the following key words: prolonged pregnancy, post-term pregnancy, and postdates pregnancy. The quality of evidence was evaluated and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care.
- 1.
  First trimester ultrasound should be offered, ideally between 11 and 14 weeks, to all women, as it is a more accurate assessment of gestational age than last menstrual period with fewer pregnancies prolonged past 41+0 weeks (I-A).
- 2.
  If there is a difference of greater than 5 days between gestational age dated using the last menstrual period and first trimester ultrasound, the estimated date of delivery should be adjusted as per the first trimester ultrasound (I-A).
- 3.
  If there is a difference of greater than 10 days between gestational age dated using the last menstrual period and second trimester ultrasound, the estimated date of delivery should be adjusted as per the second trimester ultrasound (I-A).
- 4.
  When there has been both a first and second trimester ultrasound, gestational age should be determined by the earliest ultrasound (I-A).
- 5.
  Women should be offered the option of membrane sweeping commencing at 38 to 41 weeks, following a discussion of risks and benefits (I-A).
- 6.
  Women should be offered induction at 41+0 to 42+0 weeks, as the present evidence reveals a decrease in perinatal mortality without increased risk of Caesarean section (I-A).
- 7.
  Antenatal testing used in the monitoring of the 41- to 42-week pregnancy should include at least a non-stress test and an assessment of amniotic fluid volume (I-A).
- 8.
  Each obstetrical department should establish guidelines dependent on local resources for scheduling of labour induction (I-A).
No. 214 - Guidelines for the management of pregnancy at 41+0 to 42+0 weeks
2017, Journal of Obstetrics and Gynaecology Canada
Fournir une directive clinique factuelle sur la prise en charge de la grossesse entre la 41^e+0 et la 42^e+0 semaine de gestation.
Baisse de la mortalité périnatale associée à la césarienne effectuée entre la 41^e+0 et la 42^e+0 semaine de gestation.
Des recherches ont été menées dans la base de données Medline, la Cochrane Library, ainsi qu’auprès du American College of Obstetricians and Gynecologists et du Royal College of Obstetricians and Gynecologists, afin d’en tirer les articles publiés en anglais entre 1966 et mars 2007, au moyen des mots clés suivants : prolonged pregnancy, post-term pregnancy et postdates pregnancy. La qualité des résultats a été évaluée et les recommandations ont été formulées conformément aux lignes directrices élaborées par le Groupe d’étude canadien sur les soins de santé préventifs.
- 1.
  L’exécution d’une échographie devrait être offerte au cours du premier trimestre (idéalement, entre la 11^e et la 14^e semaine de gestation) à toutes les femmes, puisqu’il s’agit d’un moyen de déterminer l’âge gestationnel plus précis que le recours à la date des dernières règles; l’utilisation de l’échographie du premier trimestre à cette fin donne, en effet, lieu à un nombre moindre de grossesses prolongées au-delà de 41+0 semaines (I-A).
- 2.
  Lorsque plus de cinq jours séparent l’âge gestationnel déterminé au moyen de la date des dernières règles et l’âge gestationnel déterminé au moyen de l’échographie du premier trimestre, la date prévue de l’accouchement devrait être modifiée en fonction de résultats de l’échographie du premier trimestre (I-A).
- 3.
  Lorsque plus de dix jours séparent l’âge gestationnel déterminé au moyen de la date des dernières règles et l’âge gestationnel déterminé au moyen de l’échographie du deuxième trimestre, la date prévue de l’accouchement devrait être modifiée en fonction de résultats de l’échographie du deuxième trimestre (I-A).
- 4.
  Lorsque l’on dispose d’échographies tant du premier que du deuxième trimestre, l’âge gestationnel devrait être déterminé en fonction des résultats de la première échographie (I-A).
- 5.
  Les femmes devraient se voir offrir l’option du décollement des membranes à partir de la période se situant entre la 38^e; et la 41^e semaine de gestation, à la suite d’une discussion sur les risques; et avantages d’une telle intervention (I-A).
- 6.
  Les femmes devraient se voir offrir un déclenchement entre la 41^e+0 et la 42^e+0 semaine de gestation, puisque les données actuelles indiquent que cette pratique entraîne une baisse du taux de mortalité périnatale sans hausse du risque de césarienne (I-A).
- 7.
  Le dépistage prénatal utilisé dans le cadre de la surveillance des grossesses se situant entre la 41^e et la 42^e semaine de gestation devrait comprendre au moins un examen de réactivité fœtale et une évaluation du volume de liquide amniotique (I-A).
- 8.
  Tous les services d’obstétrique devraient, en fonction de leurs ressources locales, formuler des lignes directrices quant à la planification du déclenchement du travail (I-A).
Amniotic membrane sweeping
2015, Seminars in Perinatology
Citation Excerpt :
Logistically, in order to complete the procedure the internal cervical os must be open sufficiently to accommodate at least a single digit of the practitioner.2,5,12 If the cervix is not favorable enough to perform the procedure, some practitioners may choose to manually stretch the cervix or perform cervical massage to promote cervical ripening.14 Vaginal exam alone has been shown to increase the plasma level of prostaglandins, but not to the extent of membrane sweeping.18
Amniotic membrane sweeping or stripping is a safe and effective method of labor induction supported by national obstetrical organizations. While its use dates back to antiquity by both midwives and physicians there are still areas that need further research to define its role in induction of labor. A review of the literature reveals that amniotic membrane sweeping is a safe, effective, and inexpensive method of labor induction. It can be done in the outpatient setting with minimal risks so long as it is avoided in patients with contraindications. Amniotic membrane sweeping can be performed in Group B Streptococcus-positive women with studies showing no increase in untoward outcomes. However, there is no data in women infected with HIV or hepatitis.
Guidelines for the management of pregnancy at 41+0 to 42+0 weeks
2008, Journal of Obstetrics and Gynaecology Canada
Fournir une directive clinique factuelle sur la prise en charge de la grossesse entre la 41^e+0 et la 42^e+0 semaine de gestation.
Baisse de la mortalité périnatale associée à la césarienne effectuée entre la 41^e+0 et la 42^e+0 semaine de gestation.
Des recherches ont été menées dans la base de données Medline, la Cochrane Library, ainsi qu’auprès du American College of Obstetricians and Gynecologists et du Royal College of Obstetricians and Gynecologists, afin d’en tirer les articles publiés en anglais entre 1966 et mars 2007, au moyen des mots clés suivants : prolonged pregnancy, post-term pregnancy et postdates pregnancy. La qualité des résultats a été évaluée et les recommandations ont été formulées conformément aux lignes directrices élaborées par le Groupe d’étude canadien sur les soins de santé préventifs.
- 1.
  L’exécution d’une échographie devrait être offerte au cours du premier trimestre (idéalement, entre la 11^e et la 14^e semaine de gestation) à toutes les femmes, puisqu’il s’agit d’un moyen de déterminer l’âge gestationnel plus précis que le recours à la date des dernières règles; l’utilisation de l’échographie du premier trimestre à cette fin donne, en effet, lieu à un nombre moindre de grossesses prolongées au-delà de 41+0 semaines. (I-A)
- 2.
  Lorsque plus de cinq jours séparent l’âge gestationnel déterminé au moyen de la date des dernières règles et l’âge gestationnel déterminé au moyen de l’échographie du premier trimestre, la date prévue de l’accouchement devrait être modifiée en fonction de résultats de l’échographie du premier trimestre. (I-A)
- 3.
  Lorsque plus de dix jours séparent l’âge gestationnel déterminé au moyen de la date des dernières règles et l’âge gestationnel déterminé au moyen de l’échographie du deuxième trimestre, la date prévue de l’accouchement devrait être modifiée en fonction de résultats de l’échographie du deuxième trimestre. (I-A)
- 4.
  Lorsque l’on dispose d’échographies tant du premier que du deuxième trimestre, l’âge gestationnel devrait être déterminé en fonction des résultats de la première échographie. (I-A)
- 5.
  Les femmes devraient se voir offrir l’option du décollement des membranes à partir de la période se situant entre la 38^e et la 41^e semaine de gestation, à la suite d’une discussion sur les risques et avantages d’une telle intervention. (I-A)
- 6.
  Les femmes devraient se voir offrir un déclenchement entre la 41^e+0 et la 42^e+0 semaine de gestation, puisque les données actuelles indiquent que cette pratique entraîne une baisse du taux de mortalité périnatale sans hausse du risque de césarienne. (I-A)
- 7.
  Le dépistage prénatal utilisé dans le cadre de la surveillance des grossesses se situant entre la 41^e et la 42^e semaine de gestation devrait comprendre au moins un examen de réactivité foetale et une évaluation du volume de liquide amniotique. (I-A)
Guidelines for the Management of Pregnancy at 41+0 to 42+0 Weeks
2008, Journal of Obstetrics and Gynaecology Canada
To provide evidence-based guidelines for the management of pregnancy at 41+0 to 42+0 weeks.
Reduction of perinatal mortality associated with Caesarean section at 41+0 to 42+0 weeks of pregnancy.
The Medline database, the Cochrane Library, and the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists, were searched for English language articles published between 1966 and March 2007, using the following key words: prolonged pregnancy, post-term pregnancy, and postdates pregnancy. The quality of evidence was evaluated and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care.
- 1.
  First trimester ultrasound should be offered, ideally between 11 and 14 weeks, to all women, as it is a more accurate assessment of gestational age than last menstrual period with fewer pregnancies prolonged past 41+0 weeks. (I-A)
- 2.
  If there is a difference of greater than 5 days between gestational age dated using the last menstrual period and first trimester ultrasound, the estimated date of delivery should be adjusted as per the first trimester ultrasound. (I-A)
- 3.
  If there is a difference of greater than 10 days between gestational age dated using the last menstrual period and second trimester ultrasound, the estimated date of delivery should be adjusted as per the second trimester ultrasound. (I-A)
- 4.
  When there has been both a first and second trimester ultrasound, gestational age should be determined by the earliest ultrasound. (I-A)
- 5.
  Women should be offered the option of membrane sweeping commencing at 38 to 41 weeks, following a discussion of risks and benefits. (I-A)
- 6.
  Women should be offered induction at 41+0 to 42+0 weeks, as the present evidence reveals a decrease in perinatal mortality without increased risk of Caesarean section. (I-A)
- 7.
  Antenatal testing used in the monitoring of the 41- to 42-week pregnancy should include at least a non-stress test and an assessment of amniotic fluid volume. (I-A)
- 8.
  Each obstetrical department should establish guidelines dependent on local resources for scheduling of labour induction. (I-A)
Nitric oxide metabolites in cervical fluid during pregnancy: Further evidence for the role of cervical nitric oxide in cervical ripening
2003, American Journal of Obstetrics and Gynecology
Objective: Cervical tissue expresses all the isoenzymes of nitric oxide synthase. We studied the concentrations of nitric oxide metabolites in the cervical fluid in nonpregnant (n = 11) and pregnant women (n = 106). Study Design: Cervical fluid was collected into a Dacron polyester swab, and nitric oxide metabolites were eluted into physiologic saline solution, which was assayed for nitric oxide metabolites with the Griess reaction. The detection limit of the method is 0.2 μmol/L. Results: Cervical fluid nitric oxide metabolite was detectable in 46% of nonpregnant women (median, <0.2 μmol/L; 95% CI, 0-49), in 63% of women in early pregnancy (median, 11 μmol/L; 95% CI, 0-23) and in 82% of women in late pregnancy (median, 128 μmol/L; 95% CI, 21-276). In late pregnancy, the cervical fluid nitric oxide metabolite level was higher in women with Bishop score of ≥6 (median, 163 μmol/L; 95% CI, 105-276) than in women with Bishop score of <6 (median, 86 μmol/L; 95% CI, 21-99). Cervical fluid nitric oxide metabolite concentration before the onset of labor in parous women (median, 97 μmol/L; 95% CI, 78-283) was higher (P =.008) than that in nulliparous women (median, 28 μmol/L; 95% CI, 0-95). Cervical fluid nitric oxide metabolites before the initiation of labor (median, 33 μmol/L; 95% CI, 0-95) rose to 3.5-fold (median, 115 μmol/L; 95% CI, 78-284) after the commencement of uterine contractions and showed a significant relationship to Bishop score (r = 0.39, P =.01). Cervical fluid nitric oxide metabolite concentrations were not relative to simultaneous plasma nitric oxide metabolite levels (n = 41 women, r = 0.14, P =.41). Rupture of fetal membranes tended to decrease cervical fluid nitric oxide metabolite levels, whereas gentle cervical manipulation elevated it 6.6-fold in 1 minute. The administration of glyceryl trinitrate (0.5 mg, nitric oxide donor) intracervically resulted in a significant rise in the cervical fluid nitric oxide metabolite level in 2 minutes. Conclusion: Cervical fluid nitric oxide metabolite level rises after cervical ripening, nitric oxide donor administration, or cervical manipulation, which supports a role for cervical nitric oxide in cervical ripening. (Am J Obstet Gynecol 2003;188:779-85.)

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Stretching of the cervix and stripping of the membranes at term: a randomised controlled study

Abstract

The unfavorable cervix: methods of cervical priming

Clin Obstet Gynecol

Release of prostaglandins after amniotomy is not mediated by oxytocin

Br J Obstet Gynaecol

A study of the motility of the intact uterus at term

Surg Gynecol Obstet

Relationship of antepartum pelvic examinations to premature rupture of the membranes

Obstet Gynecol

Control of utero-ovarian venous prostaglandin F during labor in the sheep: acute effects of vaginal and cervical stimulation

J Endocrinol

Plasma oxytocin in initiation of labor

Am J Obstet Gynecol