Artificial rupture of the membranes — MSF Essential obstetric and newborn care

What this guideline says

GMJ summary

This section of the MSF Essential Obstetric and Newborn Care guideline provides detailed clinical guidance on artificial rupture of the membranes (amniotomy) using an amnihook or Kocher forceps. The procedure is indicated to accelerate labour when dilation or delivery fails to progress, as an adjunct to oxytocin induction, or to control bleeding in partial placenta praevia.

The guideline emphasises careful patient selection, noting absolute contraindications including complete placenta praevia and transverse lie, and relative contraindications such as dilation less than 5 cm with irregular contractions, breech presentation prior to full dilation, and HIV or hepatitis B infection in contexts where keeping the amniotic sac intact reduces mother-to-child transmission risk. Sterile technique is mandatory given infection risk from opening the amniotic cavity.

The technique requires the woman supine with knees bent, use of sterile gloves and 10% povidone iodine swabbing, creating a small cut in the sac during contraction to allow slow drainage, noting amniotic fluid colour, checking for cord prolapse, and monitoring foetal heart rate before and after the procedure. Special precautions apply in polyhydramnios due to cord prolapse risk.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Indications include failure of labour to progress during dilation or after full cervical dilation, adjunct to oxytocin induction, and control of bleeding in partial placenta praevia
2. Absolute contraindications: complete placenta praevia and transverse lie
3. Relative contraindications: dilation less than 5 cm with irregular contractions, breech presentation prior to full dilation, HIV or hepatitis B infection prior to full dilation, and presenting part not engaged
4. Use sterile technique with sterile gloves and 10% povidone iodine swabbing of perineum and vagina to prevent infection
5. In polyhydramnios, re-examine immediately after rupture to exclude cord prolapse below the presenting part
6. Make a small cut in the sac during contraction, allow slow drainage, then enlarge the opening with a finger
7. Note amniotic fluid colour (clear, greenish, or blood-stained); isolated meconium staining without abnormal foetal heart rate requires closer monitoring but is not diagnostic of foetal distress
8. Check foetal heart rate before and after amniotomy and ensure the cord has not prolapsed

Indications and contraindications for artificial rupture of membranes

Table extracted from the guideline

Source: Médecins Sans Frontières, Artificial rupture of the membranes — MSF Essential obstetric and newborn care. Reproduced in summary form.

From the guideline

Verbatim

“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.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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