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How to… perform a stretch and sweep

Midwives magazine: Issue 1 :: 2012

Supervisor of midwives and University of Chester’s senior lecturer Kim Gibbon provides a step-by-step guide to membrane sweeping.

Membrane sweeping, sometimes referred to as stripping or stretch and sweep of the membranes, is a relatively simple labour stimulation technique. Used by midwives or obstetricians, its intent is to initiate the onset of labour physiologically. This promotes normality and avoids the need for formal induction of labour for prolonged pregnancy using prostaglandins, artificial rupture of membranes and oxytocin (Boulvain et al, 2005).

To perform a membrane sweep, the examining fingers during a vaginal examination are introduced into the cervical os and passed circumferentially around the cervix (Boulvain et al, 1998). This should separate the membranes from their cervical attachment. This process of detaching the membranes from the decidua results in the release of local prostaglandins (Mitchell et al, 1977). This in turn will increase the probability of the onset of labour within 48 hours and of being delivered within one week (Keirse, 1995; McColgin et al, 1990; Weissberg and Spellacy, 1977). Massage of the cervix, around the vaginal fornices, can be used when the cervical os remains closed. This may also cause the release of local prostaglandin (Rogers, 2010). The process can be repeated if labour does not start spontaneously after an appropriate time period, typically 36 hours.

NICE (2008) recommend the routine use of the procedure at 40+ week’s gestation before attempting formal induction. Membrane sweeping is not associated with an increase in maternal or neonatal infection (NICE, 2008), or of pre-labour rupture of membranes (Boulvain et al, 2005; Wong et al, 2002). Although some women report discomfort during the procedure, vaginal blood loss and painful contractions in the 24-hour period post procedure (Boulvain et al, 2005). Since membrane sweeping may not result in the onset of labour, Boulvain et al (2005) argue that the possible benefits in terms of a reduction in more formal induction methods need to be weighed against these known issues.

The midwife has a role in facilitating the woman’s right to autonomy and informed choice. NICE (2008) recommend that at the 38-week antenatal visit, all women should be offered information about the risks associated with pregnancies that last longer than 42 weeks and the post-term management options. This should include membrane sweeping and its potential to make spontaneous labour more likely and so reduce the need for formal induction of labour.

Membrane sweeping is typically arranged and performed by a community midwife in a community setting as no special preparation is required. This could be at home or a midwifery-led antenatal clinic. The environment simply needs to be safe and private. This avoids the need for a visit to hospital for the procedure. Before arranging the procedure the community midwife will have determined an accurate gestation from the booking scan dates.

The membrane sweeping procedure can be performed from 40+ weeks. Local policies will often suggest 41 weeks for routine membrane sweeping as it is more likely to be successful, easier to perform and more comfortable for the woman. If there is any evidence of vaginal infection or spontaneous rupture of membranes then a membrane sweep will not be carried out and appropriate referral will be made (NMC, 2004).

Membrane sweeping will comprise the following steps:

• The midwife will re-explain the procedure before she starts and explain that it will take approximately ten minutes
• The woman will be encouraged to undertake relaxed breathing techniques if any discomfort is felt
• The woman will be asked to empty her bladder and remove her underwear
• The midwife will use a sheet or throw to cover the woman protecting her dignity
• The woman will be asked to lie on a couch or bed, with her hands at her side. A tilt may have to be placed under the mattress or cushions on the maternal left side to prevent supine hypertension
• The midwife will perform an abdominal palpation, listen to the fetal heart rate and document all findings. If there is any deviation from the normal, the midwife will refer the case to an obstetrician and the procedure will be abandoned (NMC, 2004)
• With a gloved lubricated hand, the midwife will perform a vaginal examination and ascertain if the cervix is favourable for the procedure by assessing cervical effacement, consistency and dilation.
o If the cervix is unfavourable, such as uneffaced and high, the membrane sweep may have to be delayed or abandoned
o If the procedure is abandoned, the midwife will make arrangements for induction of labour as per local trust guidelines
o If the cervix is closed but soft, the cervix may be massaged until it allows insertion of a finger
o If the cervix does not open, the effects of massage around the vaginal fornices may be enough to stimulate the release of prostaglandins and stimulate labour
o If the cervix is determined as favourable for labour stimulation, the midwife will begin to insert one finger into the cervix. The finger will be used to separate the amniotic sac from the uterine wall and cervix by making circular, sweeping movements.
• A sanitary pad will be applied after the procedure
• The woman should be advised to have a warm bath and to take paracetamol for any discomfort or painful contractions
• The woman and her partner should be advised that if there is any fresh blood loss, spontaneous rupture of membranes or the woman is not coping with the pain that she should attend the maternity unit
• There is no available evidence to determine the frequency with which membrane sweeps can be repeated, but a sensible suggestion is that they can be undertaken every three days
• The midwife will arrange for a repeat membrane sweep if labour has not started within the timeframe agreed with the woman and according to local trust guidelines
• If labour does not occur spontaneously then the midwife will arrange for formal induction of labour as per local trust guidelines.


Correction

In the last issue of Midwives, reference was made to the fetal side of the placenta being made up of cotyledons. The sentence should have referred to the maternal side. We apologise for this confusion.

Would you like to author a How to page? If so, please email: emma@midwives.co.uk


References

Boulvain M, Fraser WD, Marcoux S, Fontaine JY, Bazin S, Pinault JJ, Blouin D. (1998) Does sweeping of the membranes reduce the need for formal induction of labour? A randomised controlled trial. British Journal of Obstetrics and Gynaecology 105(1): 34-40.

Boulvain M, Stan C, Irion O. (2005) Membrane sweeping for induction of labour. Cochrane Database of Systematic Reviews 1: CD000451.

Keirse MJNC. (1995) Stripping/sweeping membranes at term for induction of labour: In: Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C. (Eds.). Pregnancy and childbirth module. The Cochrane Pregnancy and Childbirth Database. The Cochrane Collaboration 2. Update Software: Oxford.

Mitchell MD, Klint APF, Bibby J, Brunt J, Anderson ABM, Turnbull AC. (1977) Rapid increase in plasma prostaglandin concentrations after vaginal examination and amniotomy. British Medical Journal 2: 1183-5.

McColgin SW, Hampton HL, McCaul JF, Howard PR, Andrew M, Morrison JC. (1990) Stripping membranes at term: can it safely reduce the incidence of post-term pregnancies? Obstetrics and Gynaecology. 76: 678-80.

Weissberg SM, Spellacy WN. (1977) Membrane stripping to induce labour. Journal of Reproductive Medicine 19(3): 125-7.

National Institute for Health and Clinical Excellence. (2008) Induction of labour. London. See: http://www.nice.org.uk/nicemedia/live/12012/41256/41256.pdf (accessed 22 January 2012).

NMC. (2004) The midwives rules and standards. NMC: London.

Rogers H. (2010) Does a cervical membrane sweep in a term healthy pregnancy reduce the length of gestation? MIDIRS Midwifery Digest. 20(3): 315-9.

Wong SF, Hui SK, Choi H, Ho LC. (2002) Does sweeping of membranes beyond 40 weeks reduce the need for formal induction of labour? BJOG 109: 632-6.