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 done?

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 some areas, hospitals tell the midwives that work for them to offer it to all women. In other areas, midwives offer it because they know that women will be pressured to undergo 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. However, you do not have to accept any intervention, including a stretch and sweep.

 

Does it work?

It works for some people but not others. 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).

It’s really hard to know whether, if you go into labour following 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?

stretch&sweepStretching 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.

The authors of the Cochrane review were concerned about the downsides of this procedure and concluded 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)

I also occasionally hear from a woman whose midwife or doctor accidentally broke her waters while doing a stretch and sweep. I’m not aware of any data on how common this is. From experience of talking to midwives and doctors, I would say that it’s not common, but it does happen occasionally. When it does happen, it means that, because there is now a risk of infection, 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).

 

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

Like with anything else, if you go and read individual people’s stories online, you will find a range of experiences. And you will find some extreme views. Some people love that they had a stretch and sweep. Others hated it, or what happened as a result of it. Some wish they had said no. There are those people who say they would never have one. And then those who beg their midwife to do one as soon as possible and to repeat it as often as possible.

As with all stories, these are individual viewpoints. Unfortunately, we don’t have any good research which has looked at this and which can 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 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, and if you are not sure about the implications of agreeing to an examination or procedure, then ask. And, if necessary, ask again until you are happy that 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 you don’t ‘have’ to have induction at all, if it’s not right for you.

 

The bigger picture and further information

I’ve been looking and and writing about the stretch and sweep and other induction interventions for a number of years. It raises some fascinating questions which I often discuss with midwives, doctors, doulas, childbirth educators and others.

Is a ‘stretch and sweep’ a useful low-tech intervention which might prevent the need for induction of labour? Or is it an unnecessary interference in pregnancy? A “marvellously effective way of preventing the need for medical induction of labour for post-dates … [or] ineffective at best, and, at worst, an invasion of a woman’s bodies at what is generally considered to be an intensely vulnerable time”? Is it an induction method itself?

If you’d like to look at this in more depth, you may enjoy Unpacking Sweeping Policies (Wickham 2006: 30). That’s an older article, but a good bit of what I wrote in that article is still (at the time of posting) current. The prevalence of this intervention, however, would seem to have increased, at least according to many of those who come to my talks and workshops. In addition, the point at which a stretch and sweep is offered has moved forward. I know of some (employed) midwives who are expected to start discussing this from 37 weeks of pregnancy. And midwifery students tell me that more time is spent teaching them how to carry out a stretch and sweep than on helping them learn how to discuss the pros and cons of this.

 

Getting philosophical…

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 understandably feel it is justified. That’s because, overall, on a population basis, it may reduce the induction rate. (But, again, this is based on the assumption that everyone will agree to induction. Also, as the induction epidemic continues and this is offered earlier and in more situations, the effectiveness of the stretch and sweep as a means of reducing the induction rate may decline).

A stretch and sweep 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, 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.

I sometimes show the ‘stretching and sweeping isn’t benign’ picture in this blog post when I am speaking about induction of labour at conferences. It allows me to share one of my favourite stories. 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…)

 

Where do we go from here?

But 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 (in my humble opinion) 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 this. Indeed, many of those who are offering it are doing so because they know it is preferable to the alternative. But when the evidence on induction for post-term pregnancy 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 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.

 

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

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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