Membrane Sweeps, “Pink Waters” and Blood in Labour

What’s “normal” when it comes to blood in labour and birth??

That’s the question right now being debated in labour ward handover rooms, triage offices, and in case reviews. The truth? We don’t know. The best solution or answer they can come up with at the moment sounds more like a moto or slogan and less like carefully explored and researched evidence.

“Blood is Blood”

Sure. I get it. We used to say someone’s waters were “Pink”, which meant they were “lightly blood stained” which on it’s own, was noted but did not have a massive impact on a woman’s birth. But are blood stained waters normal?

Personally, I will not even attempt to answer this question, because last thing I want is for it to get back to the powers that be that I am telling women what’s normal and what’s not, because the reality is this.

Blood could be perfectly normal, and Blood could very well NOT be. When I am in triage assessing where a woman should be advised to give birth, I don’t actually KNOW if it’s normal in that exact situation at that time. I can highly suspect that it’s normal based on my clinical judgment, but I can’t know for certain in a way that will not come back to haunt me if anything were to happen.

Welcome to modern maternity care.

So what about membrane sweeps?

Not the procedure itself.

Not whether or not to have one

Not whether or not they work or don’t work

Instead.

COULD having a membrane sweep today, have an irreversible impact on your experience of labour and birth? (this may be even more interesting for you if you had a membrane sweep five years ago)

There is a lot of folklore around sweeps.

Ask a random group of woman at a mum and baby brunch club what their experience was and you will hear everything from “I begged my midwife to give me a sweep at 37 weeks” to “I had five sweeps and nothing worked, I still ended up with an induction and a C section”. You may hear how “the pain was worse than the birth itself” or how it “definitely got my labour going”.

There is plenty of information online describing what a membrane sweep is and why it may kickstart labour. I even did an instagram post about them a while back.

Doulas, midwives, doctors, birth educators, and women in general all have an opinion on whether it’s better to just let your body labour with no interventions, or whether a sweep can be a bit of a helping hand.

I am not adding to the mix of opinions today. I am just going to share something I am observing in current practice.

In recent times, what has always been considered a relatively harmless low risk small scale intervention, safe enough to be done in the comfort of your own home, or a community midwife clinic, has turned into something high risk.

Not the procedure itself but the consequences of it.

Midwives have always advised women that they may experience something called a “bloody show” after a sweep.

A bloody show can be described as mucous tinged with bits of blood.

Sometimes it’s more mucous than blood, and sometimes it’s more blood than mucous.

This is because a sweep inevitably disturbs the cervix, which in many women approaching birth, can be quite a sensitive area. Women would expect this, and when they encountered that inevitable glob of blood/mucous in their knickers within the 48 hours after the sweep they would likely ignore it, (I certainly did when I was a first time mum and not a midwife). If worried, women could double check with their midwife or maternity triage line. Upon hearing they had recently had a sweep, women would be given general reassurance and to of course call back if labour began, or if they had any other concerns, such as excessive or continual bleeding, reduced movements, or their waters broke, or they were feeling unwell.

I remember being a very inexperienced doula with my first client. She was getting into advanced labour, and as we entered the birth centre room, I noticed some of that mucous laden blood trickling down her leg. The midwives smiled encouragingly and said “look, a bit of a show! That’s a good sign”. I remember thinking “wow they are so calm about that blood”, because to me, having no birth experience beyond my own, it looked like a lot!

As I transitioned into my midwifery training, I began to learn to recognise the difference between a bloody show, and actual bleeding that was concerning in labour and that required further invasive investigation (or at times the emergency buzzer).

It always felt like a very nuanced grey area. It could be difficult to assess, and it was good practice to check with a more experienced midwife or a doctor if they were around. It was never just about the blood itself, but rather the full clinical picture. The presence of some blood in labour was something that was generally expected as a result of the cervix opening and getting thinner. Sometimes it’s quite a lot if a labour is progressing quickly.

Blood was never ignored and should never be ignored, but whether or not to intervene or escalate was down to the individual and full clinical picture of the woman involved and the clinical judgement of those caring for her.

However as more clinical guidelines have been created in recent years, (often as reactions to maternity reviews and investigations), there is less and less tolerance of the inevitable presence of blood in labour.

The reasons behind this are of course to avoid any and all poor outcomes.

In pregnancy, blood can be harmless, or it can mean you are sadly miscarrying. It’s probably an over simplification of things, but in labour, blood can be harmless, or it could mean that your placenta is separating prematurely, something called “placental abruption”. This is of course a serious complication which can compromise the life of the baby as well as the mother if not swiftly acted upon.

So have there been cases where a placental abruption was missed and the presence of blood in labour was not fully investigated, and a woman was given false reassurance, only to then experience a serious and terrifying complication?

Sadly yes. This seems to have happened in some cases. This post is by no means about to delve into why that happened. There are plenty of articles in the media pointing blame at all involved. But the reality is, standard maternity practice in the UK has changed and is changing as a result and it’s really helpful to understand this before having a membrane sweep. (just a note to clarify that a membrane sweep can cause bleeding, it does not directly cause a placental abruption, but bleeding can be a symptom of a placental abruption)

Many women will inevitably experience bleeding when their cervix is disturbed.

There have always been practices and protocols to assess a mother and baby when there has been any bleeding in pregnancy and labour. Maternal observations, fetal monitoring, pain, assessing the abdomen, etc. are relevant in diagnosing a placental abruption, and sometimes a placental abruption can be happening with no bleeding at all.

I used to see women assessed in this way, and if a placental abruption could reasonably be “ruled out” the woman was free to decide how she wanted the labour to proceed, ie she could go to the birth centre, or remain at home.

However, what I am now seeing, is that any sort of bleeding experienced in a term pregnancy is met with the advice to be induced, even after it has been investigated and no signs of a placental abruption are present.

Anything but crystal clear waters after they have been broken results in the offer of immediate induction and the strong recommendation to have continuous monitoring in labour. Let’s think about it, If you have a sweep or a speculum examination, there is a much higher chance of your waters being tinged with blood, therefore a much higher chance of you being advised to be induced and/or monitored closely in labour on delivery suite, which is absolutely not an issue if this was always your plan, but if you were planning a birth centre birth, or a home birth, it can be a real shock.

Any bleeding now in early labour or birth is going to trigger more intervention than it may have done a few years ago. If your last birth was straightforward you might not be prepared when you’re being advised to give birth on delivery suite because your waters have some blood in them or because you had large bloody show after your sweep.

One way to decrease the chances of this happening to you is to avoid having someone mess with your cervix in the days leading up to your labour.

I promise you that the body is capable to getting into labour without that.

There is of course more to get in to and understand and plan ahead for if you do happen to experience a rather heavy bloody show, (with or without a sweep) or blood stained waters, but do not wish to be induced, or be continuously monitored in labour based on those things alone. That is down to more individualised care planning, understanding the many options there are for being looked after safely in labour (it’s never all or nothing and the absolute of “safest” does not exist in the context of the full picture of health), as well as understanding the language of the current culture in maternity care.

Does all bleeding in labour mean you are going to have a placental abruption? No.

Could it indicate it could happen out of the blue. Of course.

Sometimes it happens without ANY visible blood.

Anything could happen at any time in any labour in any setting and there simply is no one single way of monitoring, preventing, or managing these possibilities, there are actually many ways, and really, as your care providers, we should be helping you choose which way is right for you.

Birth is never without risk. But what makes your individual labour safe for you and your baby is extremely individualised. Blanket policies and guidelines that are designed to try and avoid one particular risk for the entire population may not be right for everyone. These generalised guidelines, although intending to keep everyone safe, are based on hindsight, and do not always consider the impact and risks of the recommended intervention itself, and the individual mothers and babies involved.

I want to make it clear that the message of this post is NOT to not take advice.

It is just to understand that something as simple as a speculum examination, or a membrane sweep, in what has been a low risk healthy pregnancy, could have implications you were not expecting, leading to interventions you did not wish for, and having to make difficult decisions when you are feeling vulnerable, worried, or overwhelmed.

Navigating your birth can be hard enough. Avoiding a sweep might just make it a little easier, or at least being a little bit more prepared for the consequences of one if you do choose to have one