Induction of labour involves stimulating uterine contractions artificially to promote
the onset of labour. There are several pharmacological, surgical and mechanical methods
used to induce labour. Membrane sweeping is a mechanical technique whereby a clinician
inserts one or two fingers into the cervix and using a continuous circular sweeping
motion detaches the inferior pole of the membranes from the lower uterine segment.
This produces hormones that encourage effacement and dilatation potentially promoting
labour. This review is an update to a review first published in 2005. To assess the
effects and safety of membrane sweeping for induction of labour in women at or near
term (≥ 36 weeks' gestation). We searched Cochrane Pregnancy and Childbirth’s Trials
Register (25 February 2019), ClinicalTrials.gov , the WHO International Clinical
Trials Registry Platform ( ICTRP ) (25 February 2019), and reference lists of retrieved
studies. Randomised and quasi‐randomised controlled trials comparing membrane sweeping
used for third trimester cervical ripening or labour induction with placebo/no treatment
or other methods listed on a predefined list of labour induction methods. Cluster‐randomised
trials were eligible, but none were identified. Two review authors independently assessed
studies for inclusion, risk of bias and extracted data. Data were checked for accuracy.
Disagreements were resolved by discussion, or by including a third review author.
The certainty of the evidence was assessed using the GRADE approach. We included 44
studies (20 new to this update), reporting data for 6940 women and their infants.
We used random‐effects throughout. Overall, the risk of bias was assessed as low or
unclear risk in most domains across studies. Evidence certainty, assessed using GRADE,
was found to be generally low, mainly due to study design, inconsistency and imprecision.
Six studies (n = 1284) compared membrane sweeping with more than one intervention
and were thus included in more than one comparison. No trials reported on the outcomes
uterine hyperstimulation with/without fetal heart rate (FHR) change, uterine rupture
or neonatal encephalopathy. Forty studies (6548 participants) compared membrane sweeping
with no treatment/sham Women randomised to membrane sweeping may be more likely to
experience: · spontaneous onset of labour (average risk ratio (aRR) 1.21, 95% confidence
interval (CI) 1.08 to 1.34, 17 studies, 3170 participants, low‐certainty evidence).
but less likely to experience: · induction (aRR 0.73, 95% CI 0.56 to 0.94, 16 studies,
3224 participants, low‐certainty evidence); There may be little to no difference between
groups for: · caesareans (aRR 0.94, 95% CI 0.85 to 1.04, 32 studies, 5499 participants,
moderate‐certainty evidence); · spontaneous vaginal birth (aRR 1.03, 95% CI 0.99 to
1.07, 26 studies, 4538 participants, moderate‐certainty evidence); · maternal death
or serious morbidity (aRR 0.83, 95% CI 0.57 to 1.20, 17 studies, 2749 participants,
low‐certainty evidence); · neonatal perinatal death or serious morbidity (aRR 0.83,
95% CI 0.59 to 1.17, 18 studies, 3696 participants, low‐certainty evidence). Four
studies reported data for 480 women comparing membrane sweeping with vaginal/intracervical
prostaglandins There may be little to no difference between groups for the outcomes:
· spontaneous onset of labour (aRR, 1.24, 95% CI 0.98 to 1.57, 3 studies, 339 participants,
low‐certainty evidence); · induction (aRR 0.90, 95% CI 0.56 to 1.45, 2 studies, 157
participants, low‐certainty evidence); · caesarean (aRR 0.69, 95% CI 0.44 to 1.09,
3 studies, 339 participants, low‐certainty evidence); · spontaneous vaginal birth
(aRR 1.12, 95% CI 0.95 to 1.32, 2 studies, 252 participants, low‐certainty evidence);
· maternal death or serious morbidity (aRR 0.93, 95% CI 0.27 to 3.21, 1 study, 87
participants, low‐certainty evidence); · neonatal perinatal death or serious morbidity
(aRR 0.40, 95% CI 0.12 to 1.33, 2 studies, 269 participants, low‐certainty evidence).
One study, reported data for 104 women, comparing membrane sweeping with intravenous
oxytocin +/‐ amniotomy There may be little to no difference between groups for: ·
spontaneous onset of labour (aRR 1.32, 95% CI 88 to 1.96, 1 study, 69 participants,
low‐certainty evidence); · induction (aRR 0.51, 95% CI 0.05 to 5.42, 1 study, 69 participants,
low‐certainty evidence); · caesarean (aRR 0.69, 95% CI 0.12 to 3.85, 1 study, 69 participants,
low‐certainty evidence); · maternal death or serious morbidity was reported on, but
there were no events. Two studies providing data for 160 women compared membrane sweeping
with vaginal/oral misoprostol There may be little to no difference between groups
for: · caesareans (RR 0.82, 95% CI 0.31 to 2.17, 1 study, 96 participants, low‐certainty
evidence). One study providing data for 355 women which compared once weekly membrane
sweep with twice‐weekly membrane sweep and a sham procedure There may be little to
no difference between groups for: · induction (RR 1.19, 95% CI 0.76 to 1.85, 1 study,
234 participants, low‐certainty); · caesareans (RR 0.93, 95% CI 0.60 to 1.46, 1 study,
234 participants, low‐certainty evidence); · spontaneous vaginal birth (RR 1.00, 95%
CI 0.86 to 1.17, 1 study, 234 participants, moderate‐certainty evidence); · maternal
death or serious maternal morbidity (RR 0.78, 95% CI 0.30 to 2.02, 1 study, 234 participants,
low‐certainty evidence); · neonatal death or serious neonatal perinatal morbidity
(RR 2.00, 95% CI 0.18 to 21.76, 1 study, 234 participants, low‐certainty evidence);
We found no studies that compared membrane sweeping with amniotomy only or mechanical
methods. Three studies, providing data for 675 women, reported that women indicated
favourably on their experience of membrane sweeping with one study reporting that
88% (n = 312) of women questioned in the postnatal period would choose membrane sweeping
in the next pregnancy. Two studies reporting data for 290 women reported that membrane
sweeping is more cost‐effective than using prostaglandins, although more research
should be undertaken in this area. 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. Membrane sweeping
for induction of labour What is the question? The aim of this Cochrane Review is to
find out if membrane sweeping is a safe and effective way of inducing labour at or
near term and if it is more effective than the formal methods of induction. Why is
this important? Most commonly, formal induction of labour is offered to women when
continuing with a pregnancy is considered probably more harmful for the mother or
baby than the adverse effects of induction. The most common reason for formal induction
of labour is post‐term pregnancy (pregnancies that continue past 42 weeks' gestation).
Membrane sweeping is a relatively simple, low‐cost procedure that seeks to reduce
the use of formal induction of labour and it can be performed without the need for
hospitalisation. It involves the clinician inserting one or two fingers into the lower
part of the uterus (the cervix) and using a continuous circular sweeping motion to
free the membrane from the lower uterus. Formal induction of labour involves artificially
stimulating the uterus with drugs such as prostaglandins or oxytocin or by breaking
the amniotic sack that holds the baby (breaking the waters). What evidence did we
find? We searched for evidence on 25 February 2019. We included 44 randomised studies
that reported findings for 6940 women from a wide range of countries including high‐,
middle‐ and low‐income countries. Studies compared membrane sweeping with no intervention
or sham intervention, and also compared membrane sweeping with vaginal or intracervical
prostaglandins, oral misoprostol, oxytocin and repeated membrane sweeping. Of the
seven studies that reported financial funding, two studies reported funding from pharmaceutical
companies. Overall, the certainty of the evidence was found to be low. Key results
Compared with no intervention or a sham sweep (40 studies involving 6548 women), allocated
to membrane sweeping may be more likely to have spontaneous onset of labour, but we
found no clear difference in unassisted vaginal births. Women may also be less likely
to have formal induction of labour. We also found no clear differences between the
groups for caesarean section, instrumental vaginal births or serious illness or death
of the mother or baby. Compared with vaginal or intracervical prostaglandins (four
studies involving 480 women), we found no difference in any outcomes although data
were limited. We found insufficient data to draw any conclusions in the studies comparing
membrane sweep with intravenous oxytocin, with or without breaking the waters, or
with vaginal/oral misoprostol. Similarly for the comparison between different frequencies
of membrane sweeping. What does this mean? Membrane sweeping appears to be effective
in promoting labour but current evidence suggests this did not, overall, follow‐on
to unassisted vaginal births. Membrane sweeping may reduce formal induction of labour.
Only three studies reported on women’s satisfaction with membrane sweeping. Women
reported feeling positive about membrane sweeping. While acknowledging that it may
be uncomfortable, they felt the benefits outweighed the harms and most would recommend
it to other women. Further research is needed to confirm our review findings and to
identify the ideal time for membrane sweep and whether having more than one sweep
would be beneficial. Further information on women’s views is also needed.