The purpose of this debate is not to discuss whether artificial rupture of membranes is a beneficial procedure, but rather to discuss whether L&D staff nurses should be allowed to perform the procedure. Nurses are required to follow the rules and regulations set forth by their state or provincial nurse practice act and must also abide by their institution's policies and procedures. If state or institutional policies prohibit nurses from performing amniotomies, then of course they should not be performed.

That said, in the wrong hands, an amnihook can be a dangerous instrument. In the right hands, it can be a useful tool. As every perinatal nurse knows, there are many compelling reasons for not artificially rupturing membranes, including high fetal station and risk of inadvertent prolapse of the umbilical cord (Hall, 2002). However, these reasons are the same whether it is the RN, advanced practice nurse (APN), or physician who performs the amniotomy. While I do not believe it is appropriate for RN to artificially rupture membranes solely for the convenience of physicians, in my opinion under the right conditions, an RN who has demonstrated competence in the procedure can safely perform an amniotomy. For example, there are times when it is imperative for the labor nurse to accurately determine the fetal heart rate (FHR) in circumstances when it is difficult to do so by external methods. The FHR may be tracing intermittently despite monitoring adjustments and may be suggestive of nonreassuring fetal status. In these clinical situations, the nurse may need to use internal monitoring to evaluate fetal well being. I believe that if the membranes are not ruptured, the RN should be able perform internal monitoring with application of the fetal scalp electrode (FSE). If an intrauterine pressure catheter (IUPC) is also necessary prior to spontaneous rupture of membranes, it may be appropriate for the RN to artificially rupture membranes to insert the IUPC. An FSE and IUPC will give the nurse valuable information about maternal-fetal status that may be unavailable otherwise (Feinstein, Torgersen, & Atterbury, 2003).

Just as the nurse who applies an FSE should have special education, the nurse performing an amniotomy should have received special education and have documented competence prior to performing an amniotomy independently. The competence of any care provider (including residents, medical students, and APNs) should be validated before amniotomy is allowed.

In my opinion, in order to prevent potential harm to the patient or her fetus, the nurse rupturing membranes must have at least 6 months experience performing vaginal exams, and must have demonstrated expertise with this basic skill. Because there is an association between early amniotomy and fetal distress (Fraser, Turcot, Krauss, & Brisson-Carrol, 2003), amniotomy performed by the RN should be reserved for patients in active labor. In addition, to minimize the risk of umbilical cord prolapse, the fetal presenting part should be at zero station or lower. Amniotomy by the RN when the fetal head is not engaged is unsafe and should not be done.

The RN should only perform an amniotomy in a setting where an emergency cesarean birth occurs rapidly. Surgical personnel, anesthesia providers, and physicians must be readily available. Should a cord prolapse occur after an amniotomy, the RN must be able to care for the patient in an appropriate and safe manner. Nurses who artificially rupture membranes should clearly understand the risks, benefits, and alternatives to membrane rupture. They should be able to educate the patient accordingly, and have the patient's permission to rupture membranes. The nurse should have knowledge of the current literature as it relates to amniotomy and should share this information with her peers. In my opinion, when RNs perform amniotomy according to the criteria discussed here, there should be no increase in the likelihood of harm to mother or fetus.

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