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Stretch and Sweep: It’s Still an Intervention
As pregnancy approaches the estimated due date, many women are offered a stretch and sweep, also called a membrane sweep. It is often described as a simple, gentle or “natural” way to encourage labour to begin and may be offered before a medical induction of labour is discussed.
Stretch and sweeps have become such common language in pregnancy care that many women have come to see them as simply a normal part of reaching the final weeks of pregnancy. “Would you like a sweep?” can be mentioned so casually at an antenatal appointment that it may feel like just another routine step – something that naturally happens as the due date approaches. Over time, we can become conditioned to expect certain procedures as part of pregnancy care without necessarily stopping to ask what they involve, why they are being offered, whether they are actually needed, or what happens if we simply choose to wait.
Because it does not involve medication, many women do not necessarily think of a stretch and sweep as an intervention.
But it is.
The Cochrane Review describes membrane sweeping as a mechanical technique for induction of labour. So while it may be less medicalised than prostaglandins, artificial rupture of membranes or synthetic oxytocin, it is still an intervention intended to influence when labour begins.
That does not mean it is inherently good or bad, or that women should avoid it. It means it deserves the same things as any other intervention:
Common practice does not make something non-interventional. Women deserve to understand what a stretch and sweep involves, its potential benefits and risks, and whether it is right for them before consenting to the procedure.
What is a stretch and sweep?
A stretch and sweep is performed during a vaginal examination. If the cervix is open enough, the midwife or doctor inserts a finger through the cervix and uses a circular sweeping movement to separate the membranes of the amniotic sac from the lower part of the uterus.
If the cervix is closed, the practitioner may massage or stretch the cervix instead, although an actual membrane sweep may not be possible.
This mechanical action is thought to stimulate the local release of prostaglandins, hormones involved in cervical ripening and the initiation of labour.
It is therefore important to distinguish between a cervical examination and a membrane sweep. They are not the same thing. Consent to a vaginal examination does not automatically mean consent to a stretch and sweep.
Why are stretch and sweeps offered?
The aim is generally to increase the likelihood that labour will begin spontaneously, particularly as a woman approaches or passes her estimated due date.
Evidence suggests that membrane sweeping can increase the likelihood of labour beginning without additional methods of induction and may reduce the need for formal induction of labour. However, it is not a guarantee.
Some women will labour soon afterwards. Others may experience cramping, contractions or spotting without progressing into established labour, while some notice very little at all.
A 2020 Cochrane Review involving 44 studies and 6,940 women found that membrane sweeping may increase the likelihood of labour beginning without further induction methods and may reduce the need for formal induction. However, the certainty of this evidence was rated as low. Importantly, membrane sweeping did not appear to meaningfully change the likelihood of caesarean birth or spontaneous vaginal birth.
This is worth considering when deciding whether the potential benefit is important to you.
What are the potential benefits?
For a woman who wants to encourage labour while hoping to avoid pharmacological or hospital-based induction methods, a membrane sweep may be an option worth considering.
Potential benefits include:
For some women, these potential benefits make a stretch and sweep an acceptable intervention. For others, particularly when there is no medical reason to encourage labour at that point, waiting may feel more appropriate.
What are the risks and disadvantages?
A stretch and sweep is often spoken about casually, but women should still be informed about what they may experience afterwards.
Pain and discomfort
For some women, a sweep causes only mild discomfort. For others, it can be painful. Experiences vary depending on cervical position and readiness, individual sensitivity, previous experiences and the technique used.
NICE specifically recommends that women are informed before consenting that membrane sweeping can cause pain, discomfort and vaginal bleeding.
A woman can ask the practitioner to stop at any time.
Bleeding or spotting
Light spotting or blood-stained mucus can occur because the cervix is highly vascular and may be irritated during the procedure.
Vaginal bleeding is one of the possible consequences NICE recommends discussing before a membrane sweep is performed.
Heavy bleeding is not an expected consequence and should be assessed.
Cramping and irregular contractions
A sweep may cause period-like cramping, pelvic discomfort and irregular contractions. These contractions do not necessarily mean established labour has begun.
For some women this can mean hours, or occasionally longer, of uncomfortable contractions that eventually settle but do nothing.
This can also mean disrupted sleep, discomfort and uncertainty without labour actually becoming established.
Emotional discomfort or distress
Vaginal examinations and procedures can be particularly difficult for women who have experienced sexual trauma, birth trauma or previous distressing medical procedures.
Consent should therefore be ongoing, not simply a quick “yes” before the procedure begins. A woman should know what is being done and be able to ask for the examination or sweep to stop immediately.
Accidental rupture of the membranes
There is a possibility that the membranes may rupture during or following a sweep. This appears to be uncommon, but it is an important consideration because once the waters have broken, management options and recommendations may change, particularly if labour does not begin.
This matters because once the membranes have ruptured, recommendations around management may change if labour does not begin, particularly as the length of time since the membranes ruptured increases.
Infection
Infection is a possible outcome following a membrane sweep, although the available evidence suggests the risk is low. Current research has not demonstrated a clear increase in serious maternal or neonatal infection associated with routine membrane sweeping, which is reassuring, but this does not mean that infection cannot occur.
A membrane sweep involves inserting fingers through the cervix and separating the membranes from the lower part of the uterus. As with any procedure involving vaginal examination and manipulation of the cervix and membranes, there is the potential for bacteria from the vagina to be introduced higher into the reproductive tract. Individual circumstances also matter, particularly if the membranes have already ruptured or rupture during or following the procedure.
So while infection should not be presented as a common consequence of a stretch and sweep, it is still a potential outcome that women may want to consider as part of making an informed decision.
It may not work
A stretch and sweep may simply have no meaningful effect. It may also produce cramping, spotting and irregular contractions without establishing labour.
Some women are offered repeated sweeps, so it is reasonable to ask what evidence supports repeating the procedure in your particular circumstances and whether you want another one.
The Cochrane authors noted that questions remain about the optimal timing, frequency and number of membrane sweeps. So if another sweep is offered, it is reasonable to ask what evidence supports repeating the procedure in your individual circumstances.
Is a stretch and sweep “natural”?
This is where language matters.
Labour that begins following a membrane sweep may progress physiologically without medication, but the sweep itself is an intervention intended to alter the timing of labour.
Calling it “natural” can minimise the procedure and may affect how women perceive their choices.
Dr Sara Wickham has challenged the way membrane sweeping is sometimes presented as an alternative to induction. A sweep is itself an attempt to encourage labour to begin earlier than it otherwise might. The fact that it does not involve medication doesn’t make the onset of labour entirely spontaneous.
A more useful question is not:
“Is it natural?”
but:
“Do the potential benefits of this intervention outweigh the potential disadvantages for me?”
You don’t have to have a sweep because you’ve reached your due date.
An estimated due date is exactly that – an estimate.
NICE recommends discussing whether women would like a vaginal examination for membrane sweeping after 39+0 weeks, rather than presenting the procedure as something that automatically needs to happen at a particular gestation.
Reaching 40 weeks does not mean the body has failed to go into labour, nor does it automatically mean labour needs to be encouraged.
There may be circumstances where bringing birth forward is recommended because continuing the pregnancy is thought to carry greater risk. In other situations, a sweep may be offered routinely because a particular gestation has been reached.
Those situations are not necessarily the same.
This is why individualised discussion is so important.
Questions to ask before agreeing to a stretch and sweep
If you are offered a sweep, you might ask:
You can also use the BRAINS framework: Benefits, Risks, Alternatives, Intuition, Nothing/Not now and Space to discuss and decide.
Consent matters
Perhaps the most important issue surrounding stretch and sweeps is consent.
A membrane sweep should never be performed without the woman’s knowledge and explicit consent.
NICE guidance specifically states that membrane sweeping should be discussed with the woman and verbal consent obtained before it is carried out.
Before the procedure, the practitioner should explain what they are proposing, why it is being offered, what it involves, the potential benefits and disadvantages, and what alternatives are available.
Agreeing to a vaginal examination does not mean agreeing to a membrane sweep.
A woman may say:
“I consent to the cervical examination, but I do not consent to a membrane sweep.”
She may also change her mind at any point.
There is no universally right decision
A stretch and sweep can be a useful option for some women. A woman approaching induction may decide that she would prefer to try a membrane sweep first. Another woman may decide that she does not want anything done to encourage labour unless there is a clear medical reason.
Both decisions can be reasonable.
The important point is that a stretch and sweep should not be dismissed as “just a sweep”.
It is an intervention.
It has a purpose, potential benefits, limitations and possible unwanted side effects. Women deserve to understand these before deciding whether the intervention is right for them.
Informed consent isn’t about convincing a woman to accept or refuse an intervention. It is about giving her the information, time and space to make the decision that is right for her.
What about the baby’s safety?
The Cochrane Review found no clear difference between membrane sweeping and expectant management in serious illness or death of mothers or babies, and little or no difference in caesarean birth rates.
Overall, membrane sweeping appears to be a relatively low-risk intervention for appropriately selected women. However, low risk does not mean no risk, nor does it mean every woman needs or will benefit from the procedure.
Resources:
https://www.cochrane.org/evidence/CD000451_membrane-sweeping-induction-labour
https://www.nice.org.uk/guidance/NG207/chapter/recommendations
https://www.sarawickham.com/riffing-ranting-and-raving/labour-onset
https://www.sarawickham.com/articles-2/what-is-a-stretch-and-sweep
https://birthaims.com.au/stretch-and-sweep
https://vickihobbs.com/induction-methods-stretch-sweep/
https://birthsavvy.com.au/stretch-and-sweep-at-38-weeks
https://www.rachelreed.website/blog/induction-of-labour-for-prolonged-pregnancy
https://www.sarawickham.com/research-updates/membrane-sweeping-for-induction-of-labour
https://www.pregnancybirthbaby.org.au/labour-and-birth/labour-complications/stretch-and-sweep
If you have any questions or would just like more information please don't hesitate to get in touch by clicking the button below and filling out the contact form.
Contact Vicki