*6.2.1 Stripping or sweeping of the fetal membranes*

Stripping or sweeping of the fetal membranes refers to the digital separation of the chorioamniotic membrane from the wall of the cervix and lower uterine segment by inserting the examiner's finger beyond the internal cervical os and then rotating the finger circumferentially along the lower uterine segment [31]. Sweeping of the membranes is simple, safe procedure and could be used as both labor induction and cervix ripening method. It is thought to cause ripening of the cervix and eventually labor by inducing the release of endogenous prostaglandins from the membranes and decidua. It also triggers Ferguson reflex, which promotes oxytocin release from maternal pituitary. It is usually done prior to ARM as a preliminary step or could also be used as an isolated procedure for induction, provided the cervical score is favorable [38].

Compared with oxytocin induction, recent trial studies have suggested that membrane stripping increased the rate of spontaneous vaginal delivery and shortened the induction to delivery interval [57].

Giving the potential risks of membrane rupture and associated maternal and neonatal infection, undertaking membrane stripping should be carefully weighed before performing the procedure in known GBS carriers [58, 59].

**Prerequisite for membrane stripping:** In order to use membrane stripping for induction or as a cervical ripening agent, there are criteria that need to be fulfilled. These are:

a. The fetal head must be well applied to the cervix.

b. The cervix should be dilated so as to allow the introduction of the examiner's finger [38].

#### **Advantage and limitation of membrane stripping**


#### *6.2.2 Balloon devices: Foley Catheter*

Another non-pharmacological option for labor induction is the insertion of balloon catheter, which includes the introduction of a single or a double balloon catheter under sterile technique into the intracervical canal past the internal os. The bulb is then inflated with 30–60 cc of water, and it applies pressure on the internal os of the cervix to stretch the lower uterine segment and increase the release of local PG [32].

The catheter is left in place until either it falls out spontaneously or 24 hours have elapsed. Some practitioners apply a small degree of traction on the catheter by taping it to the inside of the leg [61].

#### **Limitation of balloon device**


#### *6.2.3 Artificial rupture of membranes (AROM)*

Amniotomy, also known as artificial rupture of membranes (AROM), is the intentional rupture of this amniotic sac by an obstetrical provider. This procedure is common during labor management and has been performed by obstetrical providers for quite a long time. The principal reasons for artificial rupture of membranes are to ripen the cervix, induce or augment the labor process, and assist in the placement of internal fetal monitoring devices to provide the direct assessment of fetal status [32, 62–64].

Rupture of the membranes causes cervical ripening and labor onset by different mechanisms, which include stretching of the cervix, separation of the membranes (liberation of prostaglandins), and reduction of amniotic fluid volume.

The effectiveness of ARM depends on the state of the cervix, station of the presenting part, and use of other methods, with shorter induction delivery interval when amniotomy is combined with oxytocin than used singly [38].

#### **Advantages of amniotomy**

