SHOULD MIDWIVES RE-INVENT THE AMNIOSCOPE?

English-speaking midwives might be surprised when visiting the website of the ‘Clinique du Belvédère’, a huge reputable maternity unit in Rouen (Normandy, France).1 They will read about routine admission amnioscopy by the midwife on duty. This means that when a woman in labor (or prelabor) arrives at the clinic, the midwife first checks that the amniotic fluid is clear. An amnioscope is an endoscope, i.e. a tube the size of a finger (there are several calibers according to the situation) equipped with a light at one end. While doing a vaginal exam, the midwife can gently introduce the tube inside the cervix along her finger. Thanks to this rudimentary endoscope she can evaluate through the membranes the color of the amniotic fluid. More often than not she can see a beautiful clear liquid with some flocks of vernix. Then the midwife is completely reassured. Her level of adrenaline can drop. She knows that she can leave this laboring woman in peace for a long time. Since the duration of labor is to a great extent proportional to the level of adrenaline of the midwife, this practice can create the conditions for a fast and easy birth.

 My aim is not to promote routine admission amnioscopy. It is just to stress that midwives, particularly home birth midwives, might occasionally use this simple and cheap technique in a certain number of precise situations. I used it extensively for many years in the Pithiviers hospital in cases of prolonged pregnancies. Amnioscopy was a component of an individualized and selective approach to postmaturity.2  The principle of this strategy is simple. If the baby has been in the womb for more than nine months, its condition is assessed on a day-to-day basis. As long as the baby is in good shape, it is possible to wait. From the time daily assessments have started, only the well-being of the baby is taken into consideration, whatever the duration of pregnancy. By far the most common scenario is that, one day, labor will start spontaneously and a healthy baby will be born. Several methods may be combined in order to check that the fetus is not in danger. An amnioscopy is one of them. As long as the liquid is clear with flocks of vernix it is almost a guarantee that the placenta is still working well.

 I am convinced that a midwife familiar with this technique - which can be learnt overnight - would be happy to use it now and then. I heard of home birth midwives who rupture artificially the membranes during the course of labor just to check the color of the liquid. This is counter-productive. The well-being of a fetus is always better protected when the bag of water is intact; artificial rupture of the membranes is the main risk factor for cord prolapse; furthermore breaking the membranes makes infection more likely for both mother and infant. If these midwives had an amnioscope they would reassure themselves without being too invasive.

 When referring to amnioscopy my ulterior motive is in fact to stress how difficult it is to spread and to maintain the use of what Ivan Illich has called ‘convivial tools’.3 Conviviality is the opposite of industrial productivity. Convivial tools add to individual freedom and to autonomy. More autonomy…this is exactly what midwives need.

Michel Odent

References: 

1 -  http://www.ch-belvedere.fr/zoom/amnioscopie/zoom_detail.asp  (in French)

2 -  Odent M. The Tree and the Fruit. Routine versus selective strategies in postmaturity. MidwiferyToday 2004; 72: 18-19.

3 – Ivan Illich. Tools for conviviality. Marion Boyars 1974.