What is a stretch and sweep?

medium_2190706806Many women are offered a ‘stretch and sweep’ in late pregnancy, sometimes on more than one occasion. But what is this, why and how is it done, does it work and can you say no?

 

What is a stretch and sweep?

It’s a procedure in which a midwife or doctor will, while doing a vaginal examination, sweep a finger around and/or within the opening of your cervix (the lowest part of your womb).

 

Why is a stretch and sweep offered?

A stretch and sweep is offered in the hope that it will stimulate the uterus and bring labour on earlier than it might otherwise have begun. In other words, it is a way to try to induce labour.

Some hospitals have guidelines that tell the midwives that work for them to offer a stretch and sweep to all women. Stretch and sweeps are discussed in the NICE guidance in the UK. In other areas, midwives offer it because they know that women will be pressured to undergo hospital induction if they do not go into labour by a certain time. This is understandable, because midwives know that many women do not like induction and it can lead to unwanted consequences.

However, you do not have to accept any intervention, including a stretch and sweep.

 

Does it work?

We don’t really know, to be honest. The results of studies that have looked at this have been very varied. Many were deemed to be of low quality and, where there is a difference between the women who had a sweep and the women who didn’t, it was a small difference.

Here’s what I wrote about the evidence in Inducing Labour: making informed decisions:

“The most recent Cochrane review of the research on this topic by Boulvain et al (2005) found that, while these may help bring on labour a bit sooner than otherwise would be the case, eight women need to have a stretch and sweep in order for one woman to go into labour without needing more induction interventions. However, this figure assumes that all women would decide to have induction, which is not the case.” (Wickham 2018).

 

The (lack of) evidence

The Cochrane review that I referred to in there has since been updated, but not much has changed. The most recent review shows that it’s still very uncertain whether or not membrane sweeping makes a difference. Note that, in this quote, they can only say that it MAY help. They also note that the evidence isn’t robust and that there are lots of areas that we need to know more about.

“Membrane sweeping may be effective in achieving a spontaneous onset of labour, but the evidence for this was of low certainty. When compared to expectant management, it potentially reduces the incidence of formal induction of labour. Questions remain as to whether there is an optimal number of membrane sweeps and timings and gestation of these to facilitate induction of labour.” (Finucane et al 2020). More on that review here.

Because there is so much uncertainty, it’s really hard to know whether, if you go into labour after you’ve had a stretch and sweep, it was because of the stretch and sweep or whether your body was about to go into labour anyway.

 

Are there risks, and does it hurt?

Stretching and sweeping isn’t benign, as some people like to suggest.

Here’s another excerpt from my book on Inducing Labour:

“The risks and downsides of a stretch and sweep include discomfort, light bleeding and irregular contractions, which may interfere with a woman’s ability to rest and sleep in the last few days of pregnancy. In some studies, the stretch and sweep intervention only brought the onset of labour forward by about 24 hours.

Vaginal examination always carries a risk of infection, and many women find such intimate examinations embarrassing and/or uncomfortable.” (Wickham 2018).

The authors of the Cochrane review were concerned about the downsides of this procedure and concluded that, ‘Current international guidelines state that induction of labour, as with any intervention, carries risks and advise it be performed only when there are clear indications that continuing with the pregnancy is of greater risk to the mother or fetus than the risk of induction of labour.” (Finucane et al 2020).

 

Balancing risks and benefits

A previous review stated that:

“Routine use of sweeping of membranes from 38 weeks of pregnancy onwards does not seem to produce clinically important benefits. When used as a means for induction of labour, the reduction in the use of more formal methods of induction needs to be balanced against women’s discomfort and other adverse effects’ (Boulvain et al 2005: 2).” (Wickham 2018)

 

How do women feel about it?

In Your Own Time was written to help parents and professionals better understand the issues and the evidence relating to the current induction epidemic. Looks at the evidence relating to due dates, ‘post-term’, older and larger women, suspected big babies, maternal race and more.

It is notable that few studies have asked women how they feel about membrane sweeping. Finucane et al (2020) say that:

“…limited data are insufficient to meaningfully discuss women’s satisfaction with membrane sweeping for induction of labour”.

However, we know from real-world stories and qualitative research that a stretch and sweep is not for everyone. Some women say they wish they had not had this method of induction performed on them, or that they had been given more information about it first. There’s more on this in my book, In Your Own Time.

 

Wider concerns

I also hear from women whose midwife or doctor accidentally broke their waters while doing a stretch and sweep. I’m not aware of any data on how common this is. From experience it’s not a very common problem, but it does happen occasionally. When it does happen, it means that, because there is now a risk of infection, hospital induction will be offered if you do not go into labour within a certain time. This news can come as a rather unpleasant surprise. Especially if you were not told that this was a risk before you agreed to a stretch and sweep.

It is because of this that it is always good to ask about the benefits and risks of any procedure. You may also wish to ask about alternatives and about what your options are if you decide to do nothing. (We call this the BRAN analysis, and you can read about it here. I have also written a book designed to help you make decisions about things like this).

 

What do people say about a stretch and sweep after they have experienced it?

Like with anything else, if you go and read individual stories online, you will find a range of experiences. And you will find some extreme views. Some women love that they had a stretch and sweep. They swear that it works for them. Others hated it, or what happened as a result of it. Some wish they had said no. There are those who say they would never have one. And then some beg their midwife to do one as soon as possible and to repeat it as often as possible. There also lots of viewpoints in the middle, though these might not get shared as often, because we do tend to hear the ones on either end of the spectrum of experiences, especially online.

As with all stories, these are individual viewpoints. Unfortunately, we don’t have any good research which has looked at this and which might be able to give us a more balanced perspective.

 

Why is it controversial?

The stretch and sweep is a controversial procedure for a number of reasons. As above, it isn’t as effective as some people would like you to think. It will only work for a few people and, if it does work, it doesn’t bring labour forward by much anyway.

It has potential downsides as well as potential benefits.

There’s another reason it’s controversial. Some women have found that this procedure is offered or suggested during an antenatal visit without much prior discussion. And, shockingly, sometimes it is suggested while a midwife or doctor is in the middle of a vaginal examination.

This is not OK.

Neither is it OK for someone to do this without your full consent.

A recent review of the literature on this has confirmed some of these things. Roberts et al (2020) found that, “There is a lack of evidence around women’s information needs, decision-making and experiences of membrane sweeping. This is concerning, especially in the context of rising rates of formal induction of labour. Further research is needed to investigate how women are being offered membrane sweeping and what information women need to make informed choices about membrane sweeping to promote spontaneous labour.”

 

Can I say no?

Absolutely.

You can always say no to anything that you do not want, including a stretch and sweep or a vaginal examination for any reason.

If you are not sure about the implications of agreeing to an examination or procedure, then ask. And, if necessary, keep asking questions until you feel you have enough information to be able to make the decision that’s right for you. If you feel you need to know more about that, please see this book.

It’s also important to remember that you can also say no to induction of labour if this isn’t what you want. Sometimes, people present the stretch and sweep intervention as an alternative to induction, and tell you that, if you have a stretch and sweep, you are less likely to ‘have’ to have induction.

But a stretch and sweep isn’t a way of avoiding induction. As I said above, it is itself a form of induction.

You don’t have to have induction at all, if it’s not right for you.

 

Summing it up…

Although the stretch and sweep has side effects and doesn’t always work, which means not everyone who has one will benefit from it, some people feel it is justified. That’s because, overall, on a population basis, it may reduce the number of women who have a hospital induction. But, again, this is based on the assumption that everyone will agree to induction. Also, as the induction epidemic continues and membrane sweeping is offered earlier and in more situations, the effectiveness of the stretch and sweep as a means of reducing the hospital induction rate may decline.

Membrane sweeping is generally seen as less invasive than cervical ripening, artificial rupture of membranes and syntocinon. This does, however, ignore the fact that vaginal examination can be extremely traumatic for some. But a stretch and sweep is still interference. It’s still a form of induction, and it is being offered more often and earlier, when a pregnancy has barely reached ‘term’, let alone ‘post-term’. This results in an overall increase in intervention, and it may have emotional and social impacts that haven’t been considered.

 

In Your Own Time…

And there are other ways of spending the last days of pregnancy. I met a lovely woman who, having heard the term ‘stretch and sweep’, not unreasonably thought that this related to her midwife’s recommendation to relax, follow her nesting (and housework) urge and alternate movement and rest according to how she felt during the last few weeks of her pregnancy. The woman doesn’t mind me sharing this story at all: she hopes it will encourage others to consider alternative forms of this practice. (I look forward to sharing the Cochrane review on housework and yoga to reduce the duration of pregnancy soon…)

But, as I discuss in In Your Own Time, unless you have a genuine medical condition which means that you or your baby needs birth to happen sooner rather than later, there are many advantages to allowing your baby to decide when to be born. And many other things you might like to be doing in the last days of pregnancy.

 

Where do we go from here?

In Your Own Time was written to help parents and professionals better understand the issues and the evidence relating to the current induction epidemic. Looks at the evidence relating to due dates, ‘post-term’, older and larger women, suspected big babies, maternal race and more.

I really do think we need to get a lot clearer on the question of intention.  When I say ‘stretching and sweeping isn’t benign’, I don’t just mean that it can cause bleeding and discomfort. Or that it can be traumatic.

I mean that it is an intervention which is used in a deliberate way to attempt to induce labour, and it should be presented, discussed and evaluated it as such, rather than offering it as ‘just what we do…’

We might also be wise to look at the stretch and sweep within the wider context of what happens around the end of pregnancy. One of the main reasons that the use of this intervention is increasing is because the goalposts around normality at the end of pregnancy are being progressively narrowed.

As a result, induction is offered more frequently, and stretch and sweep is seen in many areas as an attempt to avoid hospital induction of labour. Indeed, many of those who are offering membrane sweeping are doing so because they know it is preferable to hospital induction. But when the evidence for induction is not at all clear, the real question is whether someone wants their labour to be induced at all.

Because for those who do not feel that induction is something that they want, there’s something else that can reduce their chance of having that: the word “no”.

 

If you’d like more information, here are some books and pages which you might find useful. We also offer a monthly newsletter and online courses for midwives and birth folk who would like to stay on top of the evidence and improve their confidence at analysing and communicating the evidence in this and related areas.

 

In Your Own Time

Post-term pregnancy and induction of labour resources

Inducing Labour

References

Boulvain M, Stan CM, Irion O. Membrane sweeping for induction of labour. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD000451. DOI: 10.1002/14651858.CD000451.pub2

Finucane EM, Murphy DJ, Biesty LM et al (2020). Membrane sweeping for induction of labour. Cochrane Database of Systematic Reviews 2020, Issue 2. Art. No.: CD000451. DOI: 10.1002/14651858.CD000451.pub3

Roberts J, Evans K, Spiby H et al (2020). Women’s information needs, decision-making and experiences of membrane sweeping to promote spontaneous labour. Midwifery, in press. https://doi.org/10.1016/j.midw.2019.102626

Wickham S (2018). Inducing Labour: making informed decisions. Avebury: Birthmoon Creations.

photo credit: oreses via photopin cc

 

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