Pre-labour Rupture of Membranes: impatience and risk

Edited and updated: July 2014

Amniotic sac and fluid play an important role in the labour process and usually remain intact until the end of labour. However, around 10% of women will experience their waters breaking before labour begins. The standard approach to this situation is to induce labour by using prostaglandins and/or syntocinon (aka pitocin) to stimulate contractions. The term ‘augmentation’ is often used instead of ‘induction’ for this procedure. Women who choose to wait are often told their baby is at increased risk of infection and they are encouraged to have IV antibiotics during labour. In my experience most women agree to have their labour induced rather than wait. I wonder how many of these women would choose a different path if they knew there was no significant increase in the risk of infection for their baby?

The rush to start labour and get the baby out after the waters have broken is fairly new. When I first qualified in 2001 the standard hospital advice (UK) for a woman who rang to tell us her waters had broken (and all else was well) was: “If you’re not in labour by [day of the week in 3 days time] ring us back.” Over the following years this reduced from 72 hours to 48 hours, then 24 hours, then 18 hours, then 12 hours and now 0 hours. You might assume that this change in approach was based on some new evidence about the dangers involved in waiting for labour. You would be wrong.

This post is mostly based on a couple of Cochrane reviews because hospitals are supposed to base their policies/guidelines on research evidence. Obstetricians also have great respect for research evidence – certainly more than other forms of knowledge midwives also use (experience, intuition, witchcraft etc.). I’ve found that a ‘good’ research review waved about with a smile works wonders when going against an institutional norm. However, please note that research reviews are only as good as the research reviewed. Research is not conducted in a vacuum, and the questions that are asked, and the methods used, tell us a lot about the social and cultural context of knowledge, and what is valued. For example in most trials the ‘doing nothing’ group is the experimental group and the ‘routine intervention that was previously introduced without evidence’ is the control group.

Outcomes: induction vs waiting 

For Baby

A Cochrane review comparing planned (induced labour) vs expectant (waiting) management concluded that:“Fewer infants went to neonatal intensive care under planned management although no differences were seen in neonatal infection rates.”

Let’s take a closer look at this. More infants went to the neonatal intensive care nursery if their mother waited for labour to start. Not surprising really considering that it’s policy to routinely send newborns to the nursery for observation after ‘prolonged rupture of membranes’ in most hospitals. What is significant, is that there was no significant increase in infection rates for these babies. Basically, babies were separated from their mothers for no reason at all – to be observed, just in case. The implications of this unnecessary separation for the baby, mother and breastfeeding are ignored despite the available evidence supporting skin-to-skin contact. Allowing uninterrupted skin-to-skin contact could reduce the chance of infection due to colonisation of the baby by mothers bacteria, reduced stress levels and early breastfeeding initiation. Even if there are concerns about a baby, the mother is probably the best person to ‘observe’ her baby’s well-being.

For mother

The Cochrane review did find a slight increase in the chance of uterine infection for mothers who waited for labour. The chance is small and you would need to induce labour in 50 women to avoid 1 case of infection. In addition, these studies were done in hospitals which are not the best setting when attempting to avoid infection. If a uterine infection is identified early it can usually be effectively treated with antibiotics. I used to see quite a few uterine infections as a community midwife in the UK doing postnatal home visits – mostly after forceps or ventouse births. If the symptoms are missed, or the woman does not have access to antibiotics, or the infection is antibiotic resistant a uterine infection can be life-threatening.

The experience: induction vs waiting

Only one of the trials in the Cochrane review bothered to ask women what they thought of their experience (no surprises there). In this trial, women who had their labour augmented were more likely to tick the box saying that there was ‘nothing they disliked in their management’. There are huge limitations when using surveys to assess experiences, and a good qualitative study is needed here. For example, how can a woman compare one experience (induction) against an experience they did not have (physiological labour) – you don’t know what you don’t know. Also, if a woman believes she is protecting her baby against infection by inducing labour this may influence her perception of the management. The Cochrane review states that no trials reported on maternal views of care, or postnatal depression.

Antibiotics – just in case?

A Cochrane review of antibiotics for pre-labour rupture of membranes at or near term concluded that: “No clear practice recommendations can be drawn from the results of this review on this clinically important question, related to a paucity of reliable data. Further well-designed randomised controlled trials are needed to assess the effects of routine use of maternal antibiotics for women with prelabour rupture of the membranes at or near term.”

The National Institute for Clinical Excellence (UK) guideline states “If there are no signs of infection, antibiotics should not be given to either the woman or the baby, even if the membranes have been ruptured for over 24 hours.”

oral thrush

So it appears that women and babies are being given high doses of antibiotics during labour without sufficient evidence to support the practice. In addition, these antibiotics may have short term, and long term side effects. As a student midwife I was asked by a mother what would happen if her unborn baby was allergic to antibiotics. I had no idea and asked the Consultant… after a long and complex answer I realised he didn’t know either. I am guessing that most side-effects are more subtle than anaphylaxis. The effect I most often see is oral thrush in the baby and co-existing nipple thrush – and subsequent breastfeeding problems. However, more worrying are the potential long term problems associated with antibiotic exposure – most likely due to the disruption of gut microbiota and the integrity of the immune system. Another issue is the development of antibiotic resistant bacteria due to the overuse of antibiotics, which can result in infections (e.g. uterine) being difficult to treat.

Choosing to wait

According to the Cochrane review of planned vs expectant management: “Since planned and expectant management may not be very different, women need to have appropriate information to make informed choices.” I’m not sure most women get this information and instead are told their baby is ‘at risk’. As we know, you can get a mother to do anything if she believes it is in the best interests of her baby. So what happens if a woman chooses to wait for labour?

Most women (95%) will go into labour within 24 hours of their waters breaking. A small minority will wait much longer than this. Ashlee whose birth I recently attended has given me permission to share her experience and photos here. Ashlee’s daughter Arden taught both her family and her midwives about patience and trust. We waited 63 hours from waters breaking to welcome her into the world. After a 2 hour, 20 minute labour she was gently born through water and into her mothers arms (notice the nuchal cord). I wonder how different this birth would have been if Ashlee had chosen to follow hospital guidelines. Instead she weighed up the small chance of uterine infection (which could be treated if it occurred) with the risks of syntocinon + continuous CTG for her baby. She chose to stay at home amongst her own familiar bacteria, and let her daughter decide when she was ready to be born.

Suggestions for waiting:

  • View the situation positively – we are all getting time to prepare for the birth and the arrival of baby. She can use the time to relax, sleep and be pampered.
  • The vagina self cleans downwards. Reduce the chance of infection by not putting anything into the vagina ie. no vaginal examinations. If a vaginal examination is absolutely necessary sterile gloves must be used.
  • Some women like to boost their immune system with nutritional supplements (eg. vitamin C, echinacea, garlic).
  • Be self-aware, connect with your baby and let your midwife/care provider know of any changes eg. feeling unwell, a high temperature, if the amniotic fluid changes colour or smell, any reduction in the baby’s movements etc.
  • I have observed Acupuncture and Bowen Therapy encourage contractions. However, if the cervix is not ready the contractions will fizzle out. If the cervix is ready, it may be enough to kick start labour. Nipple stimulation will also stimulate oxytocin (and clitoral stimulation will too).
  • Most importantly trust the process. Birth will happen.
  • Once the baby is born – keep baby skin-to-skin with mother to reduce the chance of infection by allowing the baby to become colonized by his mother’s bacteria (this applies to all births).
  • After birth be aware of signs of infection. Mother: fever, raised pulse, feeling unwell, smelly vaginal discharge, uterine pain. Baby: fever, noisy breathing, change in colour (pale), listless.

Summary

The notion that the baby is at an increased risk of infection following pre-labour rupture of membranes is not supported by research evidence. However, there is a slightly increased chance of a uterine infection for the mother.  Giving antibiotics in labour ‘just in case’ is not supported by current evidence, and may cause problems for baby and mother. Women need adequate information on which to base their decisions regarding the management, or not, of this situation. Women who choose to wait for labour should be supported and to do so. Babies should not be removed from their mothers following birth on a ‘just in case’ basis.

You can read this post in French here.

About midwifethinking

independent midwife, lecturer and student of all things birthy
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157 Responses to Pre-labour Rupture of Membranes: impatience and risk

  1. Sara says:

    I wish that I could go back in time and make my friend read this before she went to the hospital after her water broke. I don’t know if it would have changed anything…but I was so disappointed in her doctor who almost immediately augmented her (told her she was in labor but she probably wasn’t because she wasn’t having contractions- so what she was 3 cm?!) and 8 hours later, sectioned her for FTP. I think that women really need to read this before they go into labor and have decided what they will do if their water breaks and labor doesn’t start. I had already decided not to go anywhere until labor was really going, but as it was I still don’t know when my water broke, but it definitely wasn’t at the beginning.

    thanks for the informative article- I think this might be my favorite new blog.

  2. milk&bread says:

    Wonderful post! More women need to read this so that they can experience the wonder of a natural birth. Keep spreading the good word!

  3. Donna says:

    My waters were broken for a week and no infection. The reason they let me go that long was because I was only 33+5, so they wanted to let baby cook for as long as possible. So besides antibiotics, steroids and 4 hrly checks (blood pressure, temperature, asking how the lochia was, any bleeding) it was just wait and see. I could have gone home if I lived closer to a major hospital (that could deal with any complication in a premature baby). If I could have that care for at that gestation I can’t see why a full term pregnancy can’t. Unfortunately my birth did not end in a natural one (an ‘emergency’ classical c-section due to slight bleeding, and no amniotic fluid), but it could for others if they were given time and observation by a combination of family/doula/midwife/clinic visits. (I have had a VBAC since – yay!!!!)

  4. Sam says:

    I felt compelled to reply! In both my labours (I do not consider the extraction of my first child a labour or a birth) my waters broke before labour began. In my first labour with my second child my mebranes released at around 2pm in the afternoon prior to labour begining and my son was born at 5.45am the following morning around 5.5 hours after my IM deemed labour to have begun based on nothing more than outward signs and her professional opinion based on my behaviour. A friend of mine was astonished that I was ‘allowed’ to labour for over 12 hours given that I had had a previous section as she quite knowledgably informed me that ‘everyone knows that labour is deemed to have started when your waters break’. Thank goodness I avoided hospital is all I can say. A first time mother I knew well during my second pregnancy chose a hospital birth under the ‘team’ I would have been assigned to. Her waters broke, she was immediately oredered into hospital where she was advised that she should not eat or drink. After 12 hours her babies heart rate increased and she felt hot (classic signs of dehydration) she was given synticin to try to spped things up as nothing had happened and guess what she had a section for FTP or as we know it ‘failure to piss off’. I know when my babies were ready to be born and for many women, my mother and aunt included, the membranes release long before actual contractions begin. Thanks muchly for this article Liz.

    Much love and best wishes

    Sam xxxx

  5. I experienced pre-labor rupture of membranes with my first birth. Mine was a slow leak from an opening in the hindwaters. I wish I had known more about it then. I followed the hospital’s recommendations and had a pitiocin induction, ending up with a much more interventive birth than I had hoped for. Thank you for putting this information together in such a clear way.

  6. Jessica says:

    What role do you feel pre-labor ROM would play in cunjunction with sudden (not diagnosed until labor began) pre-eclampsia (post 40 weeks)? I had a situation like this with a doula client recently, and it began with augmentation/antibiotics/the whole shebang, they wouldn’t allow her to get out of bed (though I had her switch from side to side and get up to pee as often as possible), and it ended in a c-section. :*( Was there anything we could have done differently, or is this just one of “those situations” that aren’t preventable/treatable?

    • Hi Jessica
      I can’t really comment without all the facts. Real pre-eclampsia ie. abnormal blood results not just a high BP is a dangerous situation and medical management is most likely necessary. Staying in bed is not a necessity. I’ve looked after women with pre-eclampsia requiring Mag Sulph IV treatment (ie. very severe) but they were able to move about.

      • Rachel, but do you think make sense to augment or induce labor in Pre-Eclampsia diagnostic? I have my doubts. My instinct say no to that “protocol”…why not monitoring mother-baby in sted of “press” mother-baby to a situation is already under “pressure”? I would say is putting the risk more dangerous…Is like the fetal stress test medical model do, to confirm a baby can stend labor contractions, when they doubt about it :( . I hope you understand me, as I’m Portuguese ;)

        • If there is real pre-eclampsia ie. determined by a blood test and it is escalating then the safest option is to get the baby out (for mother and baby). Often when pre-eclampsia is real the woman labours very quickly. The main problem is that women end up being induced due to high blood pressure and/or protein in the urine – which are symptoms – not necessarily of pre-eclampsia.

          • What blood test is there to determine pre-e?? I am a Doula (and had pre-e myself) and I have only heard of blood tests to determine HELLP syndrome (blood test for elevated liver enzymes) but not pre-e. my blood work was normal (so doc said its wasn’t HELLP) but I had very high blood pressure (160/110 and my norm is 100/70) and protein off the charts so was diagnosed with severe pre-e.

          • A significantly high BP + high proteinurea + oedema are all indicative of pre-eclampsia. The diagnostic blood tests = Full blood count, urea creatinine, liver function test including urate and lactate dehydrogenase. These tests will be abnormal long before HELLP occurs.

  7. Rachel says:

    I have a couple questions.

    1. I have seen and heard of research that talks about how infection increases once the water has broken for 18 hours. Unfortunatley, I don’t remember where it is I saw that. Do you happen to know of this research ,and what your thoughts are about it?

    2. We have had women who tested positive for amniotic fluid ,but then don’t leak at all. I have heard from other midwifes of the bag resealing itself. Do you know anything about this being a possibility?

    Thanks.

    • Hi Rachel. In answer to your questions:
      1. I’m sure there is an elusive research study that found an increase in infection after 18 hours. You can find a single piece of research to back up pretty much anything which is why reviews such as those in the Cochrane database are a higher standard of evidence than a one-off trial. They look at all studies on a topic and combine the results to avoid one-off findings influencing the overall findings. Also remember that research is only carried out to answer particular questions – often those that can get funding eg. pharmaceutical companies sponsorship. Therefore there have been no studies looking at the effect of prophylactic antibiotics on mothers and babies or many other important questions. Research is expensive (I know I am doing some) and funding is often only available from industry sponsors. There is no profit in finding out that birth works best when no routine equipment or medications are used = let’s not find that out.
      2. I’ve heard of amniotic sacs ‘re-sealing’ themselves, especially in the case of hindwater leaks. Again no-one has researched this area… probably no funding to do so because there is no profit in the findings.
      Rachel

  8. Katie says:

    Thank you for sharing this information. I often find myself thinking back to my daughter’s birth 6 months ago and wondering why it went wrong.

    At 40 weeks pregnant I woke up to find that my water had broke (all over the bed). I couldn’t believe it! I wasn’t feeling any contractions. I called my midwife and she told me to rinse with Hibiclens after using the restroom from then on (for GBS) and to just wait for labor to start on its on. I spent that day preparing my house for the homebirth, hanging out with family, and walking around the mall. My contractions were pitiful. That evening my midwife’s apprentice came over to check on me and everything was fine. The next day I started to feel some contractions though they were still few and far between. My midwife came over and started me on a regimen of black and blue cohosh to jump start labor. My partner helped me with plenty of nipple stimulation too. By that afternoon I was finally in Laborland. It was intense! I tore off my clothes, did every position imaginable, got in and out of the water, moaned, cried, shook uncontrollably….for two days….then my labor stalled. My water had been broken for 70 hours and I was 6 cm dilated up to the point when my midwife threw in the towel and advised me to go to the hospital and get an epidural (to rest) and pitocin (to speed up contractions). I was showing no signs of infection. My daughter’s heart rate was perfect, so was mine. It was hard to give up on my homebirth, but I was completely exhausted and trusted my midwife’s advise. Looking back on this moment I feel so much regret. I should have just stayed home and toughed it out for as long as it took. I should have trusted my gut.

    Upon arrival to the maternity ward I lied to the staff and told them my water had broken an hour beforehand. I had to lie in order to buy time so that I could at least still have a vaginal delivery. If they knew how long I’d actually been in labor I’d go straight to the O.R. When they checked me I was at 8cm. I was SO excited but SOOOOO tired. I asked for an epidural and pitocin right away so I could rest for a little while. I fell asleep in the hospital that night thinking I’d wake up in an hour or so, having to push. A nurse woke me up the next morning to change my bedsheets. Apparently I had leaked meconium all over the place and this old, wise, nurse was trying to hide the evidence before a doctor could see it. In her experience meconium leakage wasn’t the emergency situation doctors made it out to be. I totally agreed! When the doctor came in later to check me I was still at 8 cm. He started talking c-section because I hadn’t progressed in the 12 hours I’d been there. A few times during the night my daughter’s heart rate had dropped and that was a bit concerning too. Oh, and he also found out about the meconium. I asked for more time. He said he’d come back in an hour. That’s when I really went to work! Epidural and all… I managed to get out of bed and do squats. Some wonderful nurses came in to observe and help me get into different positions to open up my pelvis more. I was sure it would work! An hour passed, the doctor returned, checked me, and I was still 8cm. His shift was almost over and he was ready to cut me open. I demanded a second opinion. It bought a little more time but the second doctor wanted to cut me too. My family, my partner, everyone had given up on me and I was out of options. I called my midwife and even she agreed that I should go ahead and have a c-section.

    So, four days after my water broke, I had a c-section. It still bothers me. My daughter was born perfectly healthy. We had no problems breastfeeding. I recovered quickly. But I didn’t get to hold her to my chest when she was born. I had to wait an hour before even touching her and will never get that time back.

    I wish I had stayed home, not tried to rush things, and let labour progress naturally. I shouldn’t have listened to anyone else’s fears about infection due to PROM. I should have trusted my instincts.

    • Thanks for sharing your story Katie. Many of us have questions about our births and how they might have been. You should never blame yourself – it’s not what happens but how we move on with/from it that matters most. You put up a great fight despite being in a place (labour) where no one should have to fight.

  9. Becky says:

    I just love this blog! Could you do a post someday about induction in order to prevent stillbirth? Seems no goes past their due dates anymore or else “the baby will die!!”. Thanks for the great info!

  10. I just love coming here and read all those things in a scientific manner that I know in my heart already. But knowing something in your heart doesn’t get you far in the medical system. This does!!!! Thank you Rachel.

    • Thanks Pernille
      Unfortunately the hospital system and professionals don’t usually listen to intuitive knowledge. In fact they usually totally disregard it. That’s why I learned the language of medical science. When speaking to ‘foreigners’ it helps to speak their language. And if the system is supposed to be evidence based (research evidence) then research speaks louder than the heart. My aim is to make the evidence more accessible to those who want to use it to back up their heart : )

  11. Jean says:

    Hi there! Just stumbled across this blog. Very interesting post, thank you!

    I am curious, though – how dangerous is a uterine infection? From your post it sounds like there’s about a 2% of chance of uterine infection if labor isn’t augmented. I know that back in the day (before people realized that washing your hands was a good idea), “childbed fever” was one of the biggest killers of mothers. Of course, they didn’t have penicillin then, either. So, can a uterine infection still be a big scary life-threatening thing, or is it very easily taken care of with no harm done?

    (No attack or cynicism here, just an honest question. :))

    • Thanks Jean. I love questions!
      Uterine infection used to be, and still is in parts of the world, one of the major killers of women during the childbearing period. However we can diagnose it and treat it very effectively with antibiotics. So yes there is a small risk of uterine infection if the membranes have ruptured (more so if things are put into the vagina). Women will feel hot and unwell and have a tender uterus. Antibiotics can be given and it clears up very quickly. It just seems a bit of a risk and a waste to give antibiotics to all women in case they get something that is unlikely and very treatable if they do. Also augmentation is often ‘sold’ on the idea that the baby is at risk rather than the mother being at a small risk of an easily treatable condition.
      The last mother i know who had a uterine infection (not prolonged rupture but ventouse birth) showed symptoms at day 3 and was better within days of taking antibiotics.

  12. As always, you hit the nail right on the inadequate medically managed births’ head. It is such a sad-state-of-affairs for us doulas, concerning pre-labor rupture. We can continue to give the researched “it’s OK to wait” message; however, it is heartbreaking to see a new mother succumb to the bullying -fear message she is getting instead, that takes her running to the hospital. Thank you again, for sharing your wisdom and encouragement with us.

    • It is very hard for doulas – all you can do is share information and support the woman. There is little control you have over the powerful fear that thrown at them. Keep offering an alternative perspective.

  13. Kerry Rushton says:

    Hi Rachel. I just thought I would let you know how much I love this blog, it helps me come up with clear and concise ways of advising women of their options. I am a midwife working in an MLU, and have to confess that I sometimes feel the women under our care are given less room for manoeuvre, as it were, than the women who book under consultant- led care. If we have a query regarding a woman’s care we are immediately told by the tertiary referral unit, “If they (the midwives of the MLU) are concerned, the woman needs to be transferred”, and that makes me very frustrated. In the area of the country where I work if women want a home birth, sometimes regardless of their identified “Risk factors”, they are invited in to see the obs, the risk factors explained and possible outcomes discussed and then they have their home birth. However, the women who choose to have their birth experience in an MLU are so tightly restricted by inclusion/exclusion criteria that their numbers seem to be dwindling, and the faith in the MLU in the surrounding population is becoming affected. The MLU invites women in who have had pre-labour ROM and we make sure the women are aware of the small risks you have mentioned, but we also have to book them in for IOL at their choice of hospital. There is a choice of two, one of them will leave the women 24 hours to go into spontaneous labour, the other, which is the one you used to work in, will now give them less than 12 hours, and as far as I am aware this is to avoid the cost of their routine use of antibiotics in labour which used to occur in women with prolonged (?) rupture of membranes. The irony is they were the ones who decided to use the antibiotics in the first place, and then became disillusioned with the whole cost implication.

    In conclusion I have to say I completely admire the way you work, and your attitude towards pregnancy, labour and birth, and, if I was to have another baby I would like you to come and look after me in England, if that would be OK!!

    • Kerry if you have another baby come over here and birth in the sun. I’d be happy to attend : )
      Thanks for your nice comments. MLUs and Birth Centres do seem to have strict inclusion/exclusion criteria and often not very sensible or evidence based. It is the same with homebirth models of care ‘in the system’ here (there are a few). Women outside of the inclusion criteria cannot have a homebirth full stop. There is no duty of care. So, she must find an independent midwife, have an unassisted birth or head to hospital. If an independent midwife attends the birth she is outside her scope and guidelines and risks being reported. It’s crap.
      I think it is very interesting that my old workplace has increased the waiting period from srom to induction based on cost. This is madness. Are they going to stop doing interventions that cost money and result in more interventions/outcomes that cost money. Say goodbye to induction, epidural… even hospital birth. Keep midwifing. It’s the women birthing in the system that need the best midwives. Rx

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  16. sara says:

    I had to revisit this because of a comment made at a childbirth ed class tonight- a story was told of a mother who refused antibiotics after her water had been broken for more than 18 hours and her baby became septic. Is that possible? You only mentioned an increased risk of infection for the mother. It kind of seemed like a hospital scare tactic.

  17. The story may well be true. However the stats are that there is no increased risk. I also know of a baby who became septic with the membranes intact. Being in hospital and having things put into your vagina after your membranes have ruptured = increased risk of ascending infection. Infection rarely comes without signs ie. increased heart rate, temperature, feeling unwell – then you can start antibiotics. I would want to know more about this story – was she in hospital, was she induced, was she examined vaginally, did anyone apply a scalp electrode to the baby…
    There are always scare stories available for every step you take outside the standard practices. Even when risks are small 1 in a million – there will always be that ‘1’ and for them it is 100%.

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  19. Sara in AZ says:

    Hi there! I have 3 children and with each one I had PRM. Went to the hospital each time, they put me on the PIT to help with contractions. My first came 16 hrs later, second was 22 hrs, and my third only 12hrs. And I got an epidural in each case but waited longer to get it with each subsequent child. I also tested positive all three times for GBS. With my last child I only had an epidural for about an hour and I have to say I felt fantastic afterwards. Until then I couldn’t even imagine how some women just bounce right back and get to cleaning house shortly after giving birth. So to my point, my husband and I are trying to get prego with #4 and I’m seriously considering a home birth this time around. What can I do, in order to make this possible, if i test positive for GBS again? And what are my risks?

    • Hi Sara
      GBS is very common and rarely causes a problem. However, in countries where it is screened for it becomes a ‘problem’ to be managed. I suggest doing some research into GBS and routine antibiotic treatment. Cochrane carried out a review:

      http://www2.cochrane.org/reviews/en/ab007467.html

      The risk of infection to baby is around 1-2%. Find yourself a good homebirth midwife for information and support.

      • Sara in AZ says:

        okay, so I’ve read it but I have a question. All of my babies have come more than 12 hours after my membranes rupture. Is this study telling me that I SHOULD be on some kind of antibiotic? Or is it just saying that my babies will have a higher risk of contracting GBS because of the length of my labor after my membranes rupture?

        • The review questions the use of prophylactic antibiotics for GBS. In theory the longer your waters are broken the more time there is for infection to track up into the uterus. But still the risk is small.
          I’m not sure where you are but in the US some midwives can administer AB at a homebirth if you wanted this. It really depends on if you want to treat for something that probably won’t happen… or wait until there are signs/symptoms it is happening before treating it.

  20. jessie says:

    I am a student midwife wondering about diagnosing ruptured membranes. Nitrazine paper, I feel, can be unreliable. I know someone who turned nitrazine paper blue/black with her urine. I have been trained to press the paper just inside the vagina to be sure to get fluids from the vagina so as to avoid getting urine, and to not bother testing “puddles” or soaked pads. I have seen so many situations where a woman thinks she is ruptured and then does not leak at all but does not go into labor. There can be all kinds of variables, and I wonder what your take on diagnosing ROM before labor looks like.

  21. Hi Jessie (is that the Jess I know?)
    My understanding is that Nitrazine paper is not reliable. I haven’t research this myself – just was never taught to use it in the UK and was told that was why. So, I have never used it! For some women ROM is obvious and their pad is full and smells like amniotic fluid = no problem. For some, as you have noticed the leak is minimal and often gets missed or mistaken for urine (and vice versa). Generally at homebirths I don’t worry about diagnosing ROM. It only becomes significant with other factors or a woman who would not want to await spontaneous labour.
    I know that in hospital it can be important to diagnose ROM otherwise women get augmented for leaking urine. This is common and results in unnecessary intervention and risk. If a decision to augment is made, a diagnosis of ROM must be accurate. The only accurate way to determine if fluid is coming from the uterus is to use a speculum. If the membranes have ruptured you will see fluid leaking from the cervix, especially if you ask the woman to cough. It is invasive but so is augmentation of labour. It also involves putting something into the vagina which increases the risk of infection. So, I would only do this if the woman definitely wanted her labour augmented. If not – it doesn’t matter and leave well alone. Just my thoughts/practice :)

    • pauline says:

      I find a standard urine test works best; all the fluids you can find there differ in acidity and amount of protein. If there’s protein and the pH is around 7 (ie neutral) it’s amniotic fluid (if around term, amount of protein changes during pregnancy). If no protein, then it’s vaginal discharge or urine (those are likely acidic so pH 7 could be semen, protein and pH<7 probably urine, either sign of pre-eclampsia or contaminated with vaginal discharge.

  22. Rachel M says:

    @ Sara in AZ: How about not testing positive for GBS? There are plenty of ways to naturally and safely treat GBS colonization. I wouldn’t hesitate to use a clove of garlic:

    http://www.midwiferytoday.com/articles/garlic.asp

    There are other things to try to to change the outcome of your GBS screen if you do a little digging. Lots of luck to you with your next pregnancy & birth

  23. Peanut says:

    Thank you! Two years ago my waters broke at 38 weeks. Contractions came almost immediately every 5 minutes, fairly regularly. 8 hours later when I first saw a midwife I was told if I hadn’t delivered within 10 hours I would have to transfer to hospital for antibiotics. Naturally my labour progressed no further because of my anxiety over this. 35 hours after my waters went my son was delivered by ventouse because of the epidural I was persuaded to have because of the syntocinon I was put on for failure to progress because of the pethidine I was given that slowed labour after it had started to perk up in the pool when I was told it must be transition and to try pushing (at 3cm) but was taken out of after not knowing how to push.

    After having a swab taken without my knowledge this pregnancy and being told it was GBS positive I started researching antibiotics and read this Cochrane review. How enlightening! I now plan to have no antibiotics unless there is real indication of infection whether my waters have been gone 18 hours or not at all. I am going ahead with my homebirth.

    It’s so refreshing to read things like this that confirm everything I have experienced, read and concluded.

  24. In this post you state, “Most women (95%) will go into labour within 24 hours of their waters breaking.” Can you please provide the citation for this figure? Thank you-Warmly, Jennifer

    • Hi Jennifer
      The citation is from the Cochrane review (link in blog):
      “Spontaneous onset of labour after term PROM usually follows within 24 hours (Cammu 1990), with 79% of women labouring spontaneously within 12 hours, and 95% within 24 hours (Conway 1984; Zlatnik 1992). Even when the state of the cervix is unfavourable, the majority of women labour spontaneously within 24 hours (Hannah 1998).”
      You can access the review if you are interested in the individual studies cited.

  25. Liz says:

    Hi! Love your blog.
    Just wanted to pick you up on your summary in this post. You say “There is no increased risk of infection for the baby following pre-labour rupture of membranes. There is a slight increased risk of uterine infection for the mother. ”

    However, the cochrane review said “Similar number of babies developed infections whether intervention was early or whether women waited”

    This doesn’t mean there is no risk of infection for babies after PROM, just that the risk is that same whether labour is induced straightaway or not. I was just wondering if you could change this in your summary because I think the summary is a bit misleading.

    I’m sure you read it yourself but adding up the figures in the Cochrane review (graph 1.27) the rate of neonatal infection was 2.3% in the planned management group and 2.9% in the expectant management group.

    • Hi Liz

      Thanks for your comment – you got me thinking! I have tried to stick with the overall findings of the cochrane review. ie. that:
      “No difference was seen for neonatal infection (RR 0.83, 95% CI 0.61 to 1.12; 9 trials, 6406 infants)”

      I’m not a statistician but I’m guessing the tiny difference you found was not considered statistically significant and is therefore not reflected in the overall findings of the review. In addition Wagner 1989 reported that the mothers of the five infants (in their study) who developed neonatal infections (all from the expectant management group) had undergone digital vaginal examinations. So, perhaps this influenced infection rates? Not sure, and not maths minded enough to review a review so I have to trust the overall findings which is “…no differences were seen in neonatal infection rates”

      My summary states there is ‘no increased risk’ rather than ‘no risk at all’. There will always be risk, in any situation. But waiting for labour does not increase the risk of infection for baby.

      I’m not sure how I could re-word this or if others also interpret it as ‘no risk’ (please others let me know). I’m not trying to be misleading – only provide an alternative to the ‘you need to be induced or your baby will get infected’ information currently given to women.

      Thanks again for reading and asking :)

      • Liz says:

        Hi! Sorry for worrying you. It’s not a big deal.
        OK, I admit I’m a medical researcher with a stats & psychology background so I’m going to put my super picky hat on just for a moment (please don’t think I’m like this all the time).
        The summary says “There is no increased risk of infection for the baby following pre-labour rupture of membranes.”
        What you could say to be clearer is:
        “There is no increased risk of infection for the baby following pre-labour rupture of membranes if you wait for labour to started naturally compared to inducing labour straight away”.
        By not adding the clarification on the end, it sounds like there is no increased risk of neonatal infection following PROM, but the risk is actually 2.3-2.9% according to the cochrane review.
        I don’t know how this compares to neonatal infections with no PROM? Is it similar or is it higher? I saw one study suggesting a rate of 1.3% in babies of low risk mothers (Korst et al 2005, Maternal and Child Health Journal).
        Anyway, it was just that I didn’t want women to go away from your post thinking that if they PROMed there was no increased risk of infection at all… I know you meant that there was no increased risk of infection if they waited for labour to start naturally, but as I said, I’ve got my picky hat on…. am I making any sense?
        BTW, I love your blog because I did a PhD in birth trauma, trying to show that it was the lack of support and listening, and inflexibility from health care professionals that massively contributed to post-traumatic stress following birth. I can send you through some bits if you want to do a blog on it ;-).
        I had a lovely home water birth with NHS midwives for my baby… after my PhD I wasn’t going anywhere near a hospital :-)

  26. idahotaplins says:

    Thank you for this blog. I have read the Cochrane Review study and your post was great at breaking it apart. I am a midwife and recently have had PROM become a very personal experience. I am 33+3 weeks pregnant right now and had PROM at 30+3 weeks. I had polyhydramnios and that night my water broke there was a good amount of water that came with it. I stayed home for a bit and ended up going to the hospital to make sure everything was ok. I politely declined antibiotics, did have the steroid shots 24 hours apart, a GBS swab (which came back negative), and a anatomy scan on baby. Everything looked great and baby was even measuring ahead of dates to my enjoyment. They wanted to keep me on bedrest at the hospital until labor, infection or 34 weeks in which they would induce me. They would monitor me every 4 hours for temp and BP and listen to baby for 30 min every 8 hours until labor, infection, or 34 weeks. I was at the hospital for about 30 hours and decided that it would be better to be among my own germ environment where I could monitor just the same, if not better. I left the hospital and have been home since. I have had no signs of infection, baby is great, no contractions, and I have stayed in bed. Lord willing I will go a few more weeks or at least a couple. If signs show up or I go into labor before I am term I will be heading straight back there because for the same reasons I am doing what I am doing now, I only want was is best for my baby.

    I wanted to share this because of my unique situation. When I left the hospital I was told that all their mothers that go home with PROM come back within 48 hours with an infection. That was 3 weeks ago. I do want to make clear that I have had nothing inserted vaginally, I have a designated bathroom at home that I am the only one to use, I wash after each bowel movement, I am taking an increased amount of vit C, and I am meticulous about my hygiene. I have the ability and equipment to monitor myself and baby at home. I also have a wonderful amount of great midwives at my fingertips to pick the minds of. So, I am no way saying that this is something routine, but… I have no infection and a baby still inside my womb.

    I believe that if we listen to our bodies and the bodies of the women we serve combined with knowledge and research backing that knowledge we can do a lot for birth and the whole process. In my whole situation I am amazed how fear has been thrown at me in all directions. Where I understand the risks involved and especially being premature preterm I don’t understand why fear has to be the driving force. Fear causes so many more problems in its wake. Can’t calmly informing and educating people of risks and outcomes be a better protocol?

  27. Lisa says:

    I’m apparently one of those women who have pre-labour ROM for every pregnancy, no matter supposedly effective things I do to try to stop it (vitamin C & higher protein during pregnancy being the main 2). With my oldest, I failed to go into labour on the hospital’s clock, despite massive doses of pitocin. I was 1 cm & had no real contractions when they cut me open 22 hours after my water broke.

    With my middle son, I stayed home. Contractions finally started about 90 hours after my water broke & he was born about 20 hours later. With my third, I started getting very infrequent contractions a few hours after my water broke, went into active labour about 18 hours after it broke & he was in my arms about 4 hours later. I think some of us just need some time for our bodies to figure out what needs to be done. I can’t help wondering if my first labour wouldn’t have wound up like my 2nd if I had just waited.

    • Lisa says:

      If anyone is interested, I went on to have a 4th baby and I finally didn’t have pre-labour rupture of my membranes. I felt a pop just after I got into the birth pool, a few hours after labour started. I have no idea what the difference was this time, if any. I did take zinc and vitamin D in the 4th pregnancy, which I didn’t for the others.

  28. Anna says:

    I’m not a midwife, my waters have just started to leak but labour hasn’t begun yet and, wishing to avoid another induced birth, I came online to search for some meaningful words surrounding the topic of membranes rupturing, from midwives themselves. I found the article reassuring and it seems to favour my own instincts which are to stay at home, observe how I get along and not rush to the hospital where I fear being induced if labour does not start within the next 12 or so hours. I trust nature will take it’s course in it’s own time. Thank you for writing the article.

  29. Pingback: Induction: a step by step guide | Midwife Thinking

  30. Alisa says:

    I wish I had read this article before my last labour! I had fought for a homebirth in spite of the fact that my previous babies had been ‘too big’ and my iron levels were ‘too low’. The fact that my waters broke before labour completely threw me, as in my previous 3 labours, I had ARM. I was checked at my local MLU, and told that I would be booked in for induction in 24 hours time at the main hospital. The midwife was confident that I would have gone into labour by then.

    Contractions started about 12 hours after my waters breaking, (lots of unpleasant gushes during the day!), and two hours later I decided they were strong enough to call out a midwife. Only to be told by a different midwife from the one I’d seen that I would have to go to hospital if I hadn’t had the baby in 4 hours’ time, as it would then be 18 hours since ROM. I was gobsmacked. Noone told me that, otherwise I’d have researched it like I’d researched the size and iron issues.

    The community midwife came out, and when she examined me (16 hours after ROM), I was 6cm dilated with an OP baby. I reluctantly agreed that if the baby wasn’t imminent by 2am (the 18 hour mark), then I’d transfer to hospital. With contractions still quite irregular, I felt I had no choice but to transfer in.

    Baby no.4 was born 3 hours after I arrived at hospital, and to be fair, the birth was good. I had the IV AB’s (I was told if I didn’t have them 2 hours before delivery, then I would have to stay in for 3 days so the baby could have AB’s).

    6 months on I still look back and wonder what would have happened if I’d refused to go in. This is my last baby. I planned homebirths with babies 2, 3 and 4, and ended up in hospital with all of them, so it was my last chance to have the homebirth I wanted. My son ended up with jaundice on day 1, so we stayed the extra days in hospital – we would have gone to hospital, I suppose, at that point anyway, but it would have been nice for my older children to meet their baby brother at home, rather than in a cramped and busy ward, 40 minutes from home.

  31. April says:

    This article makes me so sad. Its been almost 2 years since my son was born and still every day I think about how I failed to give birth to him. Everyone around me is sick of hearing me talk about it over and over, though time is healing the wounds. I was GBS + and my membranes ruptured at around 11am, so the hospital told me to come in. I stalled until 5pm, then finally went to the hospital, where I still wasn’t really having any contractions. Pitocin at midnight, epidural at 3am, pushing started around lunch, and then fetal distress caused them to rush me in for an emergency section, but when I moved off the table I must have moved off the cord because the heartrate went back to normal. So they sent me back to push some more. Obviously contractions had stopped cold, so they upped the pitocin again. After more pushing, they said I had developed a fever (it was only 38C) and that my son’s head was starting to swell. Cue C-Section for real.

    He was born and I never got to hold him, they whisked him away to the NICU for 2 days and treated us both for infection, but his blood cultures came back negative 2 days later. We never did get breastfeeding….he wouldn’t latch, despite consultations with everyone and their dog. I was so stressed and anxious that, after failing at birth, I’m also failing at nourishing him. So perhaps if I had labored at home, none of this would have happened…….

    NO one understands how I feel. I didn’t give birth; he was cut from me. I feel so guilty that he was in the NICU and I couldn’t hold him (and I was so tired I didn’t visit as often as I should have), and we never “bonded” at the beginning or “bonded” through breastfeeding. I just hope that if I have another child, I can have the birthing experience every mother deserves.

    Thanks for listening.

  32. https://www.facebook.com/groups/promsupport/ heres a link on face book for women going through prom x

  33. Pingback: Vyčkávací přístup při předčasném odtoku plodové vody | Přirozený porod = normální porod

  34. ashlee says:

    Oh my thank you so much for this post!!! It is EXACTLY what i was looking for, after prom with both my previous pregnancies and being induced after only 24hrs with my babies not engaged n my cervix closed and hard I do not want to go through that again this time.
    I am hoping to labor at home until I HAVE to go to hosi, and a hopefully natural drug free labor. I know I can do it because I managed with only gas n pethadine through my hard long induced labours, and over 3hrs of pushing with my daughter who was born sunny side up, I managed to get her out on my own just before they decided I needed an emergency c-section.
    I am hopeful and a lil excited about this labor because I know so much more this time round.

  35. Thanks Rachel
    Thanks for your blogs, they are a real source of inspiration for me.
    Its an interesting one, stats, isnt it? I run private antenatal classes, and NHS antenatal classes and homebirth info sessions in the UK. I find myself wanting ‘absolutes’ when it comes to stats in order to make the issue of ‘risk’ clear, but we know it’s not that simple. Within the culture I find myself though, many clients want ‘absolutes’. I sometimes feel i’m being a bit vague, when I say something like…’a very small increase in risk of…’
    Anyway, i’m wittering on, but I mainly wanted to say thank you.
    Anouk

    • Unfortunately we live in a culture that values statistics and evaluates risk according to numbers. Birth is not an absolute and is complex, chaotic and uncertain. I’m not sure how we can encourage women to focus back on themselves as the expert and to value intuition and instinct in knowing/feeling what is right for them. There is research demonstrating that the more information and choice someone is given = they are more likely to be unhappy with their choice and feel that they made the wrong decision. The right decision is probably best arrived at simply and intuitively. :)

      • anouk says:

        Thank you for your comments Rachel. Again, too often the ‘choices’ women are given are actually a lengthy menu of interventions, often without a strong scientific base.I guess that untill birth is truly brought back to where it belongs, in the home, then the predominant medically managed ‘low risk’ pregnancies and birth will continue to shape our cultural expectations.
        I’m beginning to really attenpt to wok with the power of storytelling and art for pregnant women. We inherit so much, subconsciously through others stories and the media. Maybe it’s important to see whats underneath all those layers before you can move and make decisions intuitively. just a few thoughts. :)
        Anouk

  36. Pingback: The WHO Recommendations Series: Managing Complications in Pregnancy and Childbirth (Part 2) | Cranbrook Doula

  37. luke says:

    To provide some balance. The people who perform studies on infection rates in babies and mothers don’t work for antibiotic manufacturers (the drugs are all cheap and off patent) and they don’t get paid more for taking mums to theatre (the majority of studies in these reviews are british and hence the NHS doctors and nurses involved are paid the same regardless of time in theatre, they just care if they’re patients live or die). I found this blog when googling to find out what motivation our midwives had for delaying induction of our son for 80 hours, and then prolonging a prolonged labour for 6 further hours after his heart rate slowed, then refusing to ask for an epidural, then avoiding medical staff’s opinion, then ignoring mum’s fever and low blood pressure and dehydration, then deriding medical staff’s opinion after they examined and found baby’s lie to be an issue, then delaying theatre even after being told that baby needed to come out as soon as possible. As much as emotion is wrapped up in the feelings of those who feel there babies were unnecessarily brought into this world with extra help…..the feelings we have from having help actively avoided come from having our baby still in the intensive care unit. I have no concerns with people discussing the available evidence with parents so they can make an informed decision about their own care but the impression as ever is that these are just two competing idealogies of how to birth a child and its the parents and babies who get hurt when people like yourself disagree so vehemently and personally with evidence produced by those looking to actually present objective numbers to parents so they can make their own decisions. The statement “The right decision is probably best arrived at simply and intuitively” is the biggest abrogation of a significant responibility I have heard in a long time. Parents deserve accurate information before choosing what is right for them and their children. Choosing to take this away and ‘simplify’ things is worse than the worst medical paternalism.

    • I am sorry you have had such an awful experience. There were clear signs that this was not an uncomplicated situation. Heart rate abnormalities, maternal pyrexia, etc are not normal. It seems that the institution and it’s staff let you down. I am assuming that this experience has led you to read this post in a particular light. I have attempted to provide the evidence as it relates to normal labour ie. no clinical signs of complications (unlike your situation). The statement you quote is not in my post nor does it reflect the message in the post. Intervention is necessary in some births and I am in full support of the use of intervention to ensure safe outcomes when birth becomes complicated… Intervention should have been offered to you MUCH sooner than it was. I hope you can heal from this experience – you were let down by the system.

  38. Joseph says:

    Hubby here posting. My wife’s water broke this past Saturday morning at about 6:30am. She was 36 weeks. The midwife at the hospital told us to come in after about 12 hours. We packed in a hurry and excitedly drove off to the hospital. She was checked and was only 1cm. We refused AB (my wife has terrible reactions to ab) and any interventions. After a few hours we left the hospital ama (against medical advice). They gave us all sorts of threats.
    A day or 2 later a doctor called and made serious threats. He tried his best to manipulate me to put my wife on the phone. I found out later that he reported to others that he felt I was keeping my wife from the hospital against her will.
    We read in numerous places that after PROM labor begins for 80% of women in 24-48 hours. It was sometime around this point that I became really discouraged. For the most part I’ve been supporting my wife through the tears and anxiety. Then I found this story – an answer to prayer. http://www.drmomma.org/2008/02/birth-story-premature-rupture-of.html
    As I read certain parts of the story, I burst into tears. I was greatly inspired by her story and it built my faith to believe we were going to make it too.
    Today (over 72 hours past prom) we went in for a checkup with my wife’s favorite midwife from the hospital. She berated us. She went to far as to compare us to “crack heads that live under the bridge” that bring their crack baby in the last minute. She refused to touch my wife and told us 100% of prom cases result in infection. I believe she was warned by superiors to avoid any potential litigation. Just a few days earlier, I asked the head nurse if we could just stay at the hospital and wait for labor without inducing. The nurse told us that if they permitted us to do that it puts the hospital at risk of litigation.
    Needless to say, my wife was a nervous wreck on the way home. I immediately took action when we got home. I began calling midwives from birth centers to see if they would take us this far past prom. We are meeting with one Thursday morning who has done over 2,000 births. She even had a prom case where she waited 2 weeks for labor. TWO WEEKS!!!
    If our baby girl doesn’t show up before then, I think we have found our midwife. Please keep us in your prayers.

    • Joseph says:

      …oh and just to clarify, we are checking my wife’s temperature regularly and the baby’s heart rate. She is leaking amniotic fluid now and then but she’s still nice and big. She changes her pad frequently and is avoiding public restrooms.
      I’ve been off work all week and I’m ready to take a month off if I need to. My wife originally chose the hospital only b/c they took medicaid. Now, I’m fairly certain that I will never step foot into a hospital again unless I’ve had some sort of physical injury.

      • Lisa says:

        She might want to start taking Vitamin C & using clean towels instead of a pad. (my story is up a few comments)

        • Joseph says:

          She’s taking vitamin c and echinacea. We’re at about 125 hours and counting. Our new midwife had a prom case where the mom waited and got an infection. The baby was fine. Mom was treated with ab after birth. It was close but she had the baby vaginally.
          I hope that story doesn’t discourage moms from waiting after prom. It’s important to be as objective as possible when researching.

          We are having a home birth. Here’s a funny comedian talking about home births…

      • Joseph says:

        Anya was born yesterday morning into our loving arms. Both mommy & baby are in excellent health. She was born 9 days after prom. We had a home birth and I’m fairly certain we’ll stick to home births from here on out. God is faithful!

        • Congratulations Joseph. I have been away from my blog teaching and then being ill. This was a lovely ‘story’ to come back to. Nine days is a pretty impressive wait. Enjoy your baby :)

          • Joseph says:

            Thank you! It was a roller coaster of emotions for my wife and me but we made it. Actually the first midwife that initially agreed to meet with us called us on July 4th saying that she would not take us. We called another midwife the same day. She met with us almost immediately. After she confirmed that Laura was healthy and that we had “done our homework”, she accepted.

            Home birth was a wonderful experience. We paid for everything out of pocket and the total expense was reasonable.

  39. My additional thought on why women who were induced immediately were more likely to “like” the experience…if you were trapped in a hospital being poked and prodded every few hours for several days…would you really like that experience? Well that is likely what happened to the “expectant management” women!

  40. Shannon says:

    Good early morning to you! I just wanted to say thank you, and how happy I am to have come across this article at this moment in time. I am currently at 41 weeks and 4 days and I am planning a home birth. I have had 2 beautiful home births in the past, and this is my dream as well for this one!

    However, this evening my midwife asked that I meet her at the hospital to do a stress test on my baby and everything went really well! Heart beat and all activity was great, my blood pressure perfect and no signs of fever, etc…

    The past couple days though (since yesterday afternoon), I have been experiencing a slow leak and I was not sure whether it was just vaginal fluids or amniotic fluids, as it was clear with no odor what so ever. She did test me this evening and yes, it is AF. And from discovering that out, she shared with me all the different options, choices, legal protocols, studies, etc… and it`s amazing how instantly I felt afraid for the safety of my baby (obviously only natural!). So, she gave me some homeopathy to help kick start contractions, and told me to go home and use nipple stimulation etc. I did do it when I got home (and there was even a small amount of pink show, this was the first time, but since then has gone back to clear), however it started becoming really late (way past my bedtime) and my partner and I were starting to feel really tired, so I decided after my 2 hours of homeopathy to get some rest as no major or steady contractions were beginning.

    It is now 5 a.m. in the morning and I awoke feeling hungry so I made myself some delicious millet and blueberry deliciousness to eat and decided to read up… and I am thankful that I did because it is very reassuring, in that I continue to TRUST in the divine powers and KNOW this baby will come when the time is right! I know it is going to happen really really soon, I can feel it…

    And I WANT to have my natural home birth experience, without any side effects of antibiotics (she did give me some to have at home in case I was wanting them administered at the time of my birth), which my gut tells me no.

    I feel as if this is the universe testing me, and how will I react. Will I continue to trust and have faith like I have had all along, or will I succumb to my fears… I know trusting my instinct is VERY important, and as long as baby and me are healthy, and showing no negative signs… then I believe everything will work itself out perfectly, in the perfect time!

    Thanks again for sharing this information!
    Much Love, Shannon

  41. Danica says:

    Thank you for this article . Unfortunately I live in a part of Canada (province of New-Brunswick) where no mid-wives/homebirths are available. I am currently trying to move on from my last birthing experience. Altough I would like to have another child, at the moment I am too scared to do so. I was looking online for some alternative ways of dealing with my PROM situation if I do decide to have another child. I can not imagine going through what I did a second time.

    My water broke at 10pm and I was immediately admitted to the hospital to be monitered (hospital policy) . I had no contractions for the next 21 hours. I spent this time in a hospital room listening to other mothers screaming as they gave birth to their babies. The whole time the doctors kept on pressuring me to accept the induction. I had a doula try reflexology on me but it didn’t work. One doctor even came in an explained to me a study which found that infection rates in newborns increased after 18 hours. I finally caved after 21hrs and reluctantly accepted the pitocin. After having endured cramps for 6 hours, I asked for the epidural altough the nurse told me I was only 1-2cm dilated. In the 45 min it took the anesthesiologist to get there, I dilated from 2cm to 10cm. The doctors hadn’t noticed I was dilated so they gave me the epidural twice, because I kept on saying that it wasn’t working. Before they went to try a third time, they decided to check me again, and that’s when they told me it was time to push and that the epidural had not worked. I was so disapointed that I had received the epidural but got no pain relief from it. I was completely exhausted by the time they told me to push. I had been awake for more than 48 hrs by then.I actually asked for a cesarian. The doctors laughed at me and told me they could see the head. Even with this information, I did not want to push. I just wanted to leave my body. 7 hours after receiving the pitocin and only one hour of pushing later my healthy baby boy was born.

    It comes as no surprise that, for someone who had wished for a natural home birth but had settled for a hospital hypnobirth with a doula, what I endured was, at least in my eyes, traumatizing. I found the hospital doctors to be completely dismissive and rude. At one point, the doctor lost his patience with me and told me I had 5 minutes to make up my mind if I wanted to receive the indcution. This was just after having trying to scare me with his newborn baby infection rates study.

    The following days after giving birth I did a lot of crying over my experience. I don’t believe I suffered from post traumatic stress but I definitely was traumatized by the events. I believe it affected my bonding with my son. 11 months later I still have nighmares of being pregnant.

    With all of this being said, I don’t beleive my past experience should stop me from having another child. There has got to be another way. I would like to stay home for as long as possible if I have another child. From what I can understand, I will be forced to lie to the hospital if this is what I decide to do. But i do have a few concerns about being unassisted at home.

    I have a few questions:

    1) What are the risk of a prolapsed cords from PROM? Is there any way to diagnose this myself from my house? Would it be unwise to stay home without being monitered until my active labour beings?

    Thank you so much for this wonderful post. It give me hope.
    2) It seems to me (based on observaton) that there is a greater chance you’ll get PROM with a second child if you had it with your first child. Is this the case? Do we know what causes this and what we can do to try and prevent it?

    • I am sorry to hear you had such a traumatic birth experience. You did an amazing job of birthing your baby despite what was going on around you and to you. I am not sure about the law in Canada but I am guessing it is similar in regard to consent. It seems that you did not give consent for the administration of pitocin because consent must not involve the use of cohersion or misrepresentation of risks… which clearly happened in your case. In answer to your questions.
      1) The risks of a prolapsed cord are very very small ie. around 1% and even less if your baby’s head is ‘fixed’ in your pelvis which it usually is at term. If a cord prolapse happened you may feel the cord in your vagina, or see the cord, or it may just be nipped at the top ie. you would not know. If there is a cord prolapse the baby dies very quickly ie. within minutes due to pressure on the cord cutting off blood/oxygen. This would happen before you were admitted and assessed in hospital for ROM – so that is not the reason hospitals ask you to come in – it would be too late to save the baby. The rationale for you coming in is for them to run various tests (ctg, etc.) and organise an augmentation of labour. So, if the baby is moving and the fluid is clear and there are no other concerns there is no reason to go into hospital unless you want to be induced.
      2) No, each baby and birth is different. I don’t see a pattern with women ie. PROM with each baby. You can’t prevent it, so it is probably easier to just accept that this is a common variation and make informed choices about how you want to deal with it.

  42. Hi thanks for a great blog. I am 32 weeks and my waters broke yesterday and am still trickling fluid, I am in hospital and have finished a course of steroid injections and am on antibiotics in case of infection. I have been very active during my pregnancy and have had a totally normal pregnancy with very positive feedback at all scans and appointments. My concern at the moment is that my baby isn’t as active as it was, it’s still moving but not as often and not with as much force. Could this be a side affect of the drugs I’m taking or the fact that I’m a lit less active just lying down really? The doctors want to make sure I can keep he or she in for as long as possible, they have said to aim for 35 weeks, do you think if I am fine still I should prolong? My fluid is clear, no bleeding and no pain so far. I am very concerned at the thought of my baby being whisked away from me at birth if it comes early is this something I can put my foot down on as I believe skin to skin contact is so important in those first few hours, i don’t want the baby to leave me unless it is a genuine reason, not just a precaution. Any advice you could give me would be much appreciated. Also will I continue to leak now, I’ve read that sometimes the sac can heal itself but I don’t know where it has ruptured should the doctors be able to tell me?
    Thanks Christina

    • Hi Cristina
      I can’t give individual advice/recommendations. Your care provider should be discussing your options with you and supporting your decisions. If your baby is born pre-term he/she may need some support with breathing and feeding. However, it is possible to delay cord clamping and in some hospitals it is standard practice for pre-term babies because the evidence supports it. I think you need to work out a plan with your care provider and write down your preferences. It is difficult to know where a ‘leak’ in the amniotic sac is coming from… and sometimes they just stop leaking… mostly they continue until the placenta and membranes (and baby) are out. Good luck – and please come back and let us know what happens :)

  43. Marie says:

    Such a powerful article with inspiring stories!

    I’m 41+2 today. Had a very happy and healthy pregnancy (1st baby). I planned a home water birth but always felt that I would agree to a hospital delivery if I became “high risk”.
    My water broke last Monday 5/11/12 at 9pm. I had loads of irregular contractions since but no real labour. It’s now been 78 hours since PROM and after two hospital visits where test results were absolutely fine (clear water, good CPG, ok blood analysis, normal temperature, good heart pressure… no vaginal exams by the way), we are back there tomorrow morning for more monitoring.
    I was ready to give up last night but after reading more stories and your article again, if everything is still fine, I hope to find the strength to say no to induction tomorrow and to be patient with my body. I just need to convince my hubby and my family !!!
    Marie

  44. Laurie says:

    My partner was due on 20/12/12. She had PROM at 00:01 on 20/12/12. We went in to hospital for monitoring, and a GBS swab was taken (self administered). The hospital requested that we come in for daily monitoring, with an induction time/date of 7am on the 23rd (roughly 55 hours). We reluctantly agreed. Sometime on the morning of the 22nd there was meconium staining in the waters. Still no contractions at this stage. Plenty of nipple stimulation and acupuncture. On presentation at the hospital for the monitoring and upon hearing about the meconium they said we would need to have an induction sooner.
    GBS negative, no vaginal examinations, no other risk factors, perfect FHR.
    Induction with oxytocinon occurred at 10pm (on the 22nd). By 2.30am a doctor came in and said we should have an epidural as she was ‘only’ 2cm dilated. I said she was fine and that is was early days (already beginning to get angry and frustrated with the medical team at this point as we had specifically requested in our birth plan not to be offered pain relief or intervention drugs unless medically necessary). She continued to labour, with no pain management except for my massage until 2pm (23rd), at which point she had been 8cm for 2 hours and was running low on energy. We were offered the option of an epidural or to wait another two hours to see what would happen and then have a c-section. We succumbed and an epidural was provided to relax her cervix, and after 2 hours she was 10cm. We waited another hour to give the baby a chance to move down the birth canal, and then started pushing. After 2 hours of pushing the baby still wasnt born, and at this point the doctors said they would need to use a suction cup, and to be in theatre in case it wouldn’t work so that they could resort to c-section. This is because they couldn’t work out which way she was facing, and she was clearly finding it difficult to make her own way down. I challenged them on this and the consultant did another internal, and quickly changed her mind due to the strength of my partners pushes, and in the end our baby was born vaginally with the assistance of some very vigorous perineal stretching and an episiotomy.
    To top things off, my partner had a retained placenta, and after 20mins of skin to skin and a first short feed, she was taken off to theatre, given another dose of the epidural, and had the placenta removed and the episiotomy stitched up. Meanwhile I had the baby skin to skin on my chest.
    I was overwhelmed when my baby was born, and very happy that at the very least she was delivered vaginally, however I was extremely unhappy with the way in which the medical team behaved. APGAR scores of 8 and 9.
    I will always wonder what would have happened had we let the PROM go on for longer, and whether her own contractions would have got going and been strong enough, and what the risk was of the meconium stained waters and extended PROM time.
    Similarly, I will always wonder whether the synthetic oxytocin would have been enough on its own, had we waited, or whether the epidural really was needed in order to get us over the line.
    I am certainly not convinced that any of this intervention was necessary, and that we were the victim of the classic ‘spiral’ of intervention that so many people experience.
    In essence the only risk factors were:
    1. PROM
    2. Light meconium staining at 36 hours.

    All in all though it all seems irrelevant now that we have this little bundle of joy!

  45. Jill Spencer says:

    I am so happy I found this blog as I have had pPROM with boy/girl twins at 18 weeks. Just the girl’s sac ruptured. I came home from the hospital after iv antibiotics, started a healthy does of probiotics and supplements. At 21 weeks, my boy’s sac ruptured. I am still at home feeling fine. I am terrified of going to the hospital at viability (24 weeks) for fear of hospital infection. We have decided to wait it out at home until 26 or labor. They give women steroid shots before 34 weeks to help expand the lungs but they are only effective if given 48 hours before delivery. I am hoping to do these on an outpatient basis so as not to be checked into hospital. I haven’t read much on the risks of waiting to go into the hospital till the initial signs of labor. I suppose if I waited and got infected it would be more emergent as I would still be at home vs the hospital. I am 1.5 hours away from the hospital so I would have to wait at least that long.

    If you had any advice I would greatly appreciate it :)
    Thanks,
    Jill

    • This must be a worrying time for you. I guess you need to weigh up the risks of being at home with a delay in treatment if needed and minimal monitoring with being in hospital and potential infection. The post is about PROM at term rather than premature ROM… which can be more problematic. I can’t give you advice as I’m not your care provider and don’t know enough about your circumstances. But I wish you well and hope you will come back with an update when your little ones arrive :)

  46. Nicola Perry says:

    Hi, My name is Nicola and I live in the UK. I have found this article very interesting.
    This is my Third baby and had nothing but issues from the start. I actually fell pregnant on the coil so had to have that removed while in early pregnancy with twins. We unfortunately lost one of the babies. The pregnancy progressed until I was 17wks and again I began to bleed; fortunately he survived. I also developed gestational diabetes at 31 wks. At 33+3 weeks my waters began to leak. and still Leaking. I was given the choice of an induction there and then or wait up to 2wks for an induction. I have had the two steroid injections for his lung development and I am taking antibiotics. The consultant has said that labour usually starts within 10 days; although I have been have contractions they are so irregular and not unbearable that I have stayed away from hospital. I have a plan of care for the next to weeks I will be going into hospital twice a week for baby monitoring and swabs.
    My main concern is that I dont feel him as often but I also remember from my two previous births that they tend to quite before coming into the world. But I fear that I express my concerns they will have me deliver me earlier and a higher risk of staying in special care which I dont want to do.
    Interesting Article I must say as the Health professionals told me the antibiotics were for baby’s protection not my own.
    Thank you I feel more informed.

  47. Crystal says:

    Im 19 weeks pregnant will be 20 the day after tomorrow. My water broke 3 days ago i leak a little all the time and im obviously in the hospital, they keep trying to get me to let the doctor induce and let my daughter die. I know only what they say but her heart is good everything other than the water rupture is good am I doing the right thing by giving her a chance? My youngest child was born at 28 weeks after a rupture two weeks prior and he is great now no problems at all like they expected. Is there anything I can do to boost her chances?

    • Hi Crystal
      You must do what feels right for you and your baby. I don’t know your full clinical picture and I’m not sure why they are recommending induction if your baby is currently healthy. I guess it is important to avoid infection… putting things in your vagina and keep an eye on your temperature (which I’m sure they are doing). The amniotic sac can seal back up in some cases… and babies can survive in the uterus when the membranes have broken… the sac keeps replacing the fluid. I can’t give you any advice except that you are the decision maker here. Good luck x

  48. rachel sj says:

    Hi, some great advice here thanks. I’m term + 7 and my waters seem to have been trickling out quite a bit since Tuesday (5th day today), getting Braxton hicks as I have Been for weeks but no contractions, I think I should call hospital in morning but scared of being talked into interventions. Any advice would be helpful, would I still be allowed a pool birth also? Thanks

    • The hospital staff can only offer suggestions and inform you of their policies/guidelines. You make the decisions. I am guessing that if they will consider a pool birth ‘not appropriate’ with ‘prolonged rupture of membranes’. Good luck :)

  49. Bettina says:

    My water broke the Thursday morning before the birth of my daughter early Sunday morning . I wasn’t afraid just excited that there was a light at the end of the tunnel. I went and got checked out at hospital and as we were moving to another state in Australia, they admitted me but I was allowed to come and go as I wanted (I still had a house to pack up!) Saturday the doctor examined me and all was well, and he said that if nothing happened that day, he would induce me the next day. That evening everything got back on track and my daughter was born at 12.59 am Easter morning. I was an RN and had worked with the midwives and the doctor and had complete faith in them. At no time was there ever a question of inducing me sooner. Of course we discussed the slim chance of infection, but common sense won out.

  50. Yen says:

    What if the membrane ruptured more than 24 hours? Do mom needs to take antibiotic in that instance or take alternative medicine like garlic, manuka honey to reduce the risk of infection for the mom?

    • The Cochrane review quotes in the post does not recommend antibiotics for ruptured membranes after 24 hours ‘just in case’. The mother needs to do what she feels is right for her. Some women take vitamin C, garlic and/or manuka honey as natural methods of reducing the chance of infection occurring. These alternative methods have not been researched… but that does not mean they don’t work… or that they do.

  51. Ruth says:

    My water broke early with both of my pregnancies sadly with the second my son was born septic from an infection he acquired after the pprom and he passed. So Infections do happen and waiting for labor is risky. I lost a beautiful baby boy that I wish was delivered the same day my water broke.

    • I am sorry that you lost your son. Infections do happen (sometimes even when the membranes are intact throughout labour). When you are the ‘rare’ statistic it is devastating.

  52. I’m writing my dissertation on the evidence supporting to recommendation to IOL at 24 hours post-SROM. I can’t find where they got the ‘IOL is appropriate after 24 hours’ from??

    Does anyone know what RCOG/NICE based this timeframe on? It’s driving me mad trying to suss it out :(

    • Good luck… I couldn’t find any research to support his either. Lots of guidelines are based on what is considered ‘best practice’… based on what practitioners think is best, or have always done. Many of the ‘written in stone’ guidance has no supporting research. However, they will not change the guidelines until research demonstrates it is safe not to do something – and even then they often don’t change it. Not sure what your dissertation is about, but discussing ‘authoritative knowledge’ and ‘cultural practice vs research based practice’ might be relevant.

  53. Jo Durdin says:

    Great post Rachel – topic close to my heart after two of my labours saw waters breaking first. Please clarify your opinion on waiting where labour hasn’t started AFTER 72 hours as you’ve not mentioned this and one gets the message “just wait, birth *will* start”. One of mine took 56 hours for labour to start, the other labour had not started after 72 hours and I went in for induction but declined antibiotics. A comment also – uterine infection is not always easily treatable! Can be life threatening. One case in mind was a woman I helped care for in a hospital with a uterine infection who despite triple broad spectrum IV antibiotics very nearly lost her life. Turning point came when cultures finished growing and gave a more narrow spectrum antibiotic we could treat her with. Infection of an internal organ is often serious.

    • My message is not ‘just wait and birth will start’… I don’t recommend any course of action. However, birth will happen at some point… I’m fairly sure that a woman won’t still be pregnant a year from waters breaking ;) When to throw in the towel is the woman’s decision, whether that is after 2 hours of 72 hours – only she knows what is right for her – that’s my opinion regardless of length of time.
      The idea of the post is to provide information about the benefits of augmentation (reduced uterine infection) vs the risks (outlined in post). Mostly because I am sick of women being told that their baby will get infected if they don’t agree to augmentation. Uterine infection is not always easily treatable – especially when antibiotic resistance is an issue. However, it usually is if caught early – and you observe for signs particularly with ruptured membranes. The rare, awful experience always sticks in our minds… and unlike you I have never encountered a uterine infection that did not respond to treatment…But, women need to take the risk of uterine infection into consideration which is why I include it in the post. As I always say “there is no risk free option”.

  54. thebirthmuse says:

    Hi! Thank you so much for this post which is a great service to many women who are planning natural births! As a doula, I see this as one of the most important scenarios to plan for. It’s one of the few birth scenarios over which a woman has a LOT of control and a lot of time to think through her options. Knowing what you want before this happens is the key, I think. I wrote a LOT about this in my book “Natural Hospital Birth” because it is so important for women who want a natural birth to be proactive in planning for this contingency. Getting the facts and reading up on this situation is really important. Thanks again!

  55. Reblogged this on nctkentdoulas and commented:
    Really interesting post about the evidence behind current hospital policy to augment a woman’s labour if her water’s break prior to labour starting.

  56. Firefinch says:

    I too had a very similar experience. Planned home birth, early waters breaking 36+ 5 or thereabouts, after a stressful day at work. We held out for 48 hrs, 24 of those AMA. Bless my partner, he signed the paperwork and never told me so l wouldn’t get even more stressed. Monitoring, induction, partial epidural, epidural, episiotomy, moments from theatre, we managed to deliver vaginally. IV ABs and light therapy for jaundice later, we escaped hospital at 10pm on day 4 of our 5 day course of ABs. The longer we stayed in hospital, the more seemed to go wrong. I feel sad that the pressure was so great, the threats so dire, that we caved in and allowed it to happen this way. I firmly believe if left alone, we would have reached term and had the peaceful home birth we wanted. I really regret deciding we couldn’t go into debt to pay for independent midwives. If we had, l think the experience would have been very different.

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  58. kimberly says:

    My waters started leaking at 31 weeks and 6 days. I immediately came into the hospital and was swabbed for GSB of which I tested positive. I was given magnesium, steroids and antibiotics. The magnesium I was told was to protect babies brain, the two doses of steroids for lung development and antibiotics for possible infection. I had 2 days of iv antibiotics and 2 weeks of oral antibiotics. They say the antibiotics are precautionary and that I need to stay on them too keep infection away. At first they wanted to induce me at 34 weeks. I told them I wasn’t comfortable with that and now they said they would let me wait until 35 weeks. I am currently at 33 weeks and 5 days . I am still leaking fluid, but the babies vitals and ultrasounds all look good. My fluid level has gone from 3 cm back up to 9 cm, and I have had no other complications besides my leaking. The decision to choose an induction date is rapidly approaching and I am getting very nervous about it. I really wanted a spontaneous natural birth , but that seems to be quickly disappearing. It is however most important me that my baby be healthy above any birth plan ever would be. I made them prescribe me a probiotic to try and offset this bombardment of antibiotics. As they are wreaking havoc on my body. I am currently on ampicillin 3x a day and 2 Zithromax once a day. I even asked one of the dr’s if taking these antibiotics guaranteed that I wouldn’t get an infection. He said no. I asked if I stop taking them is it guaranteed that I WILL get an infection. He said no. I want to stop taking the antibiotics and start boosting the good bacteria in my gut with probiotics. I also want to get out of this hospital room and back to my 3 1/2 yr old daughter whom I miss desperately. I just don’t understand why I can’t go home on bed rest with a super high dose of probiotics to help ward off infection and go into the ob’s office for monitoring and ultrasound a few times a week. I am being made to feel like the risk of infection is too great and that I am putting my baby in jeopardy if I don’t induce. Is my thought of going home and fighting bacteria with good instead of bad a foolish or risky notion? Any advice at all would be greatly appreciated at this point!

    • Hi Kimberly
      I can’t give individual advice or recommendations. Can you ask your care providers for more information ie. what exactly is the risk if I do not follow the recommended treatment – what are the stats? I am not sure where you live, but you can self discharge against medical advice regardless of whether it is a ‘foolish or risky notion’. You are right to be worried about the effects of antibiotics but you also need to weigh this against the risk of infection. You also need to weigh up the risks of continuing the pregnancy with the risks of early induction and prematurity for your baby. Is there someone who can sit down with you and work through your options to help you decide what is right for you in your situation?

      • kimberly says:

        The doctor came in yesterday and told me that baby and I are very well. All of my stats are completely normal as well as the 2 white blood cell counts they have taken. Doing so well they want to move me out of high risk and into low risk. However, he can not give me the ok to go home because of “hospital procedures”. My insurance company will not pay for my stay if I go home without the doctors approval. Now they want to do an Amniocentesis and inject blue dye into my amniotic sac, put a tampon in me and see if blue dye comes out. That is their solution to letting me go home. They did let me stop the constant antibiotics, but now they are pushing for an induction.

        • I’m pleased you and baby are doing well. I am shocked that your insurance company has this much power over your autonomy. I am guessing you are in the US? Very scary stuff! It seems that insurance companies determine health care by restricting what practitioners can do and people’s rights by restricting what they can choose. There are benefits to a public health system. I am sorry that you are stuck in this situation.

          • kimberly says:

            Yes, I am in the US, and YES it is very scary how much control my insurance company has. Still hoping baby decided to come on his own in the next couple of weeks. If not I will have to consider an induction at 37 week. I may loose my mind if I stay in this hospital longer than that. I am currently at 34 weeks 2 days. Still leaking bits of fluid, but ultrasounds show my fluid levels at 9.5 cm. Just have to keep us healthy a little longer. I will definitely give an update with the outcome of all this.

        • Lisa says:

          Unless you have really bizarre insurance, it’s a lie. I have heard so many women told that if they don’t follow doctors “orders” their insurance won’t pay and never once has it actually been true. It’s just another way to try to manipulate/control you and keep you from making a true choice for yourself. I’d call your insurance to double check, but if they really wouldn’t pay for your stay, it would be the first time I’ve ever heard of that actually happening.

          I, personally, would sign out AMA if you’re doing that well. You can monitor your temperature at home for signs of infection, or even agree to return regularly for check, but the plain fact is that hospitals are places full of germs and hospital infections are deadly. Your body is used to the germs at your home. My husband got infection after infection in hospital and they finally sent him home before he got one that killed him. The risk of infection in hospital if far higher than at home.

          But that’s just what I would choose. Only you can make a decision about what the best course of action is for you and your baby. You’re the one who has to deal with the outcome of whichever choice you make.

  59. Sheree says:

    Articles like this are the reason more and more babies are being rushed to emergency rooms! As a mom of an angel baby I can say antibiotics SAVE lives when the waters have been broken! My son passed away 9.5 hours after birth due to an infection because I went 17 hours without antibiotics after my water was broke. I had a perfectly healthy pregnancy and anyone who recommends a mom to have a baby outside of a level 3 NICU and to NOT get antibiotics after a her waters have been broken for a prolonged time period needs to find a new line of work!

    • I am sorry you lost your baby. Antibiotics save lives when an infection is present and are an important intervention when used appropriately. I never make ‘recommendations’ to women about their options. I hope my post does not come across as a recommendation, but rather a discussion of the current research and options.

  60. Jen says:

    At the time this happened to me, I just listened to what the doctors at my OB-GYN told me to do – I went straight to the hospital without question. Only in recent months did I start to think about the process and if it was necessary for me to be induced and have a long, hard labor for the birth of my beautiful daughter. I think she would probably have come a day or two after I gave birth but as someone who feels strongly that babies pick when they want to be born, it makes me a little bit sad that I blindly listened and pushed (literally and figuratively) her to enter the world a few hours/days too early.

  61. Erika831 says:

    I had my children before becoming a labor and delivery nurse (USA)…my water broke with my last child and there was meconium…I was also GBS positive and had no idea…I’m glad I went to the hospital when I noticed brown thick fluid coming out…now, had the fluid been clear I probably would have stayed home longer, but I had no idea I was GBS positive so who knows what risk I would have put my son in…I enjoyed reading your article, but I have to comment on you letting your Mag Sulfate Pre-Eclamptic patients ambulate…we give Mag to prevent seizures…why do you administer mag? Because when seizures occur it is then Eclampsia…our Mag Pre-E moms don’t ambulate because the mag makes them too weak and we give it to prevent seizures…I personally wouldn’t want my patient to be weak and fall or have a seizure because I let them walk…please tell me your medical rational behind letting these mothers ambulate…thanks!! :)

    • GBS infection is dangerous – however it is still unlikely to occur even with when you are GBS positive ie. colonised (might do a post on this at some point).
      Re. Mag Sulfate… not sure where I have suggested ambulation, or even mentioned Mag Sulfate. The post is about induction for ‘post dates’ pregnancy ie. a physiological variation, not induction for a medical condition ie. a pathological complication. In Aus we also use Mag Sulfate for pre-eclampsia to prevent seizure. Women requiring this medication are ill and I would not be encouraging ambulation… they usually feel too unwell to mobilise anyway. Please let me know where I have suggested otherwise and I will amend it.

  62. Pedantic Midwife says:

    OK. So, Mrs Pedantic Midwife here….
    I totally agree that the rush to deliver babies following pre-labour rupture of membranes is unnecessary.
    My gripe is with the use of terminology.
    A labour that has not started spontaneously is INDUCED, not Augmented.
    Augmentation is used to stimulate a labour dystocia, i.e. a labour that has started spontaneously but has stalled for some reason.
    Spontaneous rupture of membranes alone is NOT labour and therefore, by definition, cannot be augmented.
    Increasingly the terms induction and augmentation are being used interchangeably. What next? Gravida and Parity? Oh sorry, I forgot. Some people already do that as well….

    • Hi Pedantic Midwife
      I understand your point :) I used the terminology ‘augmentation’ because this is the term used in clinical guidelines and in the clinical area when referring to ‘induction’ for PROM (at least where I have worked). The reason I was given when I questioned it is that rupture of membranes is the body beginning the process of labour ie. something has happened from a physiological perspective. Defining when labour starts is a tricky issue because there is no concrete beginning… only constructed beginnings which then don’t fit individual women’s physiology. I think if a woman’s membranes have ruptured at term, her labour is beginning… changes are occurring. Contractions may not happen for a while, but left alone she will continue her labour within hours or days. By using synthetic oxytocin you are augmenting the process she has begun. Many women labour within hours of ruptured membranes and would consider that their labour ‘started’ when their ‘water’s broke’.
      If we are using text book definitions of ‘labour’ then those women who have irregular contractions and are ‘only’ 3cm dilated and get an ARM are being induced not augmented – although clinically this is considered ‘augmentation’.

  63. stacy hancock says:

    I also asked if there was a risk to the antibiotics they wanted us to have in labor due to testing positive for GBS. My husband is allergic to penicillin. I was told there would be no problem. We went on to have thrush, which was awful enough in itself. But now my son is 4, and I’ve spent the last 2 years trying to learn how to heal his digestive system. He is in fact, allergic to penicillin. I did a lot of things right for him(thankful he was my second born, we breastfed 17mos) so things are not maybe as advanced as they could be, but it’s still been a very difficult journey. He didn’t sleep through the night without pain until he was 3 1/2. I would love to read the studies specifically on that.
    I’d like to vent for a second about the absolute idiocy behind the current protocol to check a woman’s dilation REPEATEDLY and to artificially break her waters when she’s tested positive for GBS. Common sense says both would only further the risk of possible infection(they broke my water, too). Wish I’d have followed that instinct to say no to the antibiotics, but was told it was that or he had to get them after birth. I hate how they make it sound like you have no options, no right to really decide for yourself or your children.

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  65. Sophie Booth says:

    My waters had a slight leak so didnt know when it started, they did break waters properly to get labour going, didnt give me any antibiotics and when baby was born she did have an infection!! a respiritory infection, had to stay in hospital for a week whilst she was treated with IV antibiotics which wasnt nice

  66. anastasiacampos says:

    Hi there,

    I’m thankful for your post. I’m currently 38 weeks, 72 hours after PROM and have been thinking and reading for a majority of those hours. We are committed to staying home and waiting for our daughter, unless there are signs of infection. Do you have any further resources on going beyond 96 hours? In my reading, it all stops there.

    Blessings,
    Ana

    • I’m sorry I don’t… perhaps a reader will pop in with their experience. I’m hoping you have your baby in your arms now. Let us know what happens.

      • anastasia says:

        Rachel,

        Thanks for your kind words. There seems to be a cliff at 96 hours – the data stops short, though stories like Emma’s and others show that many women have birthed safely at home beyond that point. There are stories on Facebook and baby boards and plenty of stories from midwives. Here are two resources I found that affirm expectant management beyond 4 days as a safe and conservative approach:

        Ina May’s perspective:

        Gloria Lemay’s perspective:

        http://wisewomanwayofbirth.com/membrane-release-before-birth-sensations-begin-what-to-do/

        Linked in Gloria Lemay’s post is a video of a family’s HBA3C 10 days past ROM:

        http://www.onetruemedia.com/otm_site/view_shared?p=2a4e81fbf0f66accb8afce

        Since posting my question, my situation has taken an interesting turn. My midwife and I have concluded that the waters I released were highly unlikely to be a true rupture. This based on several factors: relatively early (37+4), amount of fluid (about 1/4 C), no birthing waves after 4 days, no birthing waves after 4 oz. castor oil (taken about 8 hours after release), and most notably, no continual leakage whatsoever. Not when shifting positions, exercising or lots of movement from my little girl.

        During part of my midwife’s training, she worked with a religious population that rarely transfers for anything other than life-threatening scenarios. She called the midwife who she trained under and explained the scenario. The midwife listened to the details and said, without a second thought, “it wasn’t a true rupture”. She has seen it time and again in her practice where although there is a fluid release, the true sac releases later or during the birth. She said with confidence that based on her experience, there is a high likelihood that the outer bag only has released. She also has seen true rupture as well, and nothing noteworthy came of it other than a beautiful baby.

        I’m keeping up with the recommended hygiene protocol and continuing to watch for signs of infection. I found this researcher’s work, which states that “Definite Differential diagnosis is only possible if leaking stops (False ROM) or if meconium is present (True ROM).”

        http://www.webmedcentral.com/article_view/1355

        It seems to be agreed upon by the medical community, midwifery community and most women’s experience that a rupture of the amnion is almost always followed by a trickle, continual gush or appearance of more fluid. I would love to hear your thoughts on that distinction and what you have observed in your practice.

        Best,
        Ana

        • Thanks for the update and resources. Yes, a ‘true rupture’ would = continued leaking of fluid until baby was born. It sounds like this was not the case for you. Happy birthing… if a few weeks time. Come back and let us know what happens :)

          • anastasia says:

            I just received a comment through my e-mail and realized I never came back with an update. So! My daughter came at 40+3. There was no continual leakage after I woke up in the middle of the night in a circle of water at 37 weeks. I still contend it was not urine — no incontinence before or after that moment, it was odorless — but it’s not impossible!

            During labor, there was no defined moment of water breaking (I had a water birth). My daughter swallowed meconium, and though pink and vigorous at birth, her breathing was very noisy and her respirations were high. She never latched, and threw up meconium/colostrum three times in her first 24 hours (I had begun hand-expressing and spoon feeding). She was behind on calories, and VERY difficult to wake, so we gave her some donor milk, which also came up. At 48 hours we brought her to Phoenix Children’s Hospital. She threw up on the way, and while there.

            She checked in with a temperature of 100.2 and a weight loss of 9 ounces (birth weight was 8.9, hospital checkin was 8.0). They consider 100.4 a fever, and their protocol changes significantly at that point (spinal tap, etc.). After getting an IV, she perked right up and took two ounces of my pumped milk from a bottle. We had an X-ray, blood work, electrolytes, bilirubin. All came back normal, but on the respective lower/higher ranges, on the borders of something perhaps wrong but nothing conclusive. We were admitted and stayed overnight where she began consistently waking for feedings of pumped milk every 2-3 hours and keeping it down.

            We left the hospital, she was okay. And… for the next three months struggled 24/7 to breastfeed. For her first six weeks, she was hardly interested in eating. She would drink the letdown and then drift back to sleep. She struggled big time with a bottle. When awake she was alert and meeting milestones, but eating from breast and bottle both seemed to be a fatiguing work. A tongue tie and torticollis were both diagnosed (tt revised). We had her heart checked out. There were pockets of time where she just seemed downright unwell. But overall she was bright, beautiful, and stumping us all (and we had EXCELLENT help in every department).

            At six weeks a light clicked on and she “joined the party”. She began participating in breastfeeding, but had sucking problems, coordination problems, etc. It took us six more weeks to get nursing on track. Weaning from the pump proved more challenging than expected (it was a stumbling routine of combo pumping/bottle feeding and nursing). I include all of this detail because I honestly don’t know to what extent the “false ROM” had anything or nothing to do with what we experienced. I am curious if any other meconium babies had similar postpartum issues.

            Vivian is now six months old, a chubby breastfed baby, sitting, crawling, and working on two teeth. She is a champion sleeper (sleeps 13 hours straight overnight – don’t hate me!) and is known for being extremely energetic, always kicking her feet, looking around, smiling and laughing. This is all behind us now, but it was emotionally traumatizing at the time and set the initial course of my mothering.

            When I thought my water had broken, I e-mailed Judy Cohain, after reading her work on true and false rupture here: http://www.webmedcentral.com/wmcpdf/Article_WMC001355.pdf. She was a valuable resource and sent me an updated version of her research. There is little to no research on the subject so I have no idea if what we experienced is characteristic or just our unique story.

            This post is longer than I set out to write, but that’s birth stories for you. Thanks for reading.

          • Thanks so much for coming back and updating us. It sounds like you have had quite a challenging start with your baby and I am so pleased things are improving. What was her diagnosis? Swallowing meconium is common (as baby’s swallow amniotic fluid and anything in it) so that may have been a red herring. Noisy breathing is not normal and can be a sign of infection or respiratory problems. Thanks for the link to Judy’s article – I hadn’t come across it before. :)

    • See Emma’s story – just posted ;)

  67. Emma says:

    Hi I just wanted to share my story because it turned out so well despite the pressure of many medical professionals…. I had what I’m guessing was a hind leak a week before my baby arrived- it was less than a cup and it seemed to reseal as there was no further leaking- my home birth midwife came with me to the hospital to do numerous tests the next day to check that it was amniotic fluid, and it was. She researched that in Australia the longest any hospital will let you go is 96hrs but she was worried and checked that I was negative for gbs and asked me to visit the hospital daily to monitor the baby. All the signs with the baby were good and I felt good but she asked me to talk with the dr and kept asking me to give it an end date- to opt for an induction. 6 days later my waters broke for real- I felt like I was weeing myself constantly the whole day, there was no coloring and I still felt good despite some slight tightenings. That night I was up with discomfort in my belly which after discussing with my midwife I thought were bowel related- The next day my midwife insisted we go into hospital where we were bombarded by a range of staff insisting we induce or the baby could be in a septic environment and that every day we left it the risks rose exponentionly. My midwife said either I go into labour naturally that night with antibiotics or I be induced the next morning otherwise she could no longer support me. We both wished we hadn’t mentioned the leak and felt sure that now the waters had really broken it wouldn’t be long. I had an uncomfortable contraction in the hospital bed while they were out of the room and it showed up on the CTG but they didn’t acknowledge it and seemed to be trying to stall for time by asking to monitor the baby for longer- they wanted to start the induction immediately. We felt strongly the baby wasn’t in distress, didn’t need antibiotics and that if I was induced we would definitely become distressed. Just then the only other home birth midwife in the area happened to drop into the hospital and our midwife gladly handed us over… I had a contraction while she was meeting us, she put her hand on my belly and acknowledged I was in labour- she later guessed I would have been at least 3cm dilated. We had barely escaped the hospital, feeling deeply relieved when strong labour began and I birthed naturally at home with my body guiding me in a quick and beautiful 5 hours. Our baby had slightly puffy breathe and slightly low temp- in hospital he would have been whisked away- but our midwife put us to bed with him on my chest and stayed close by for the next 24hrs monitoring him closely and ensuring he got enough colostrum goodness and he is perfect and we are so so grateful! I had a friend go into the same hospital the next day, agree to an induction and end up with an emergency cesaerian- for us being at home allowed us to trust the process and it was magic!

    • Thank you! and great timing… see previous comment :)

    • anastasia says:

      Emma,

      Thank you so much for sharing your story. I am thrilled for you and your family. What an amazing series of events! Congratulations on your baby boy. I am smiling from ear to ear.

      I can really relate to this part of your story: “We felt strongly the baby wasn’t in distress, didn’t need antibiotics and that if I was induced we would definitely become distressed.”

      Like Rachel has wisely said, there are always risks with our decisions. You did what you truly believe is best according to your knowledge, and didn’t allow others to intimidate you into accepting their conclusions out of fear. After all, it is us who live with our decisions, not the institutions/organizations that make recommendations. I applaud your strength mama. I’m strengthened by your story as I plan to welcome my daughter into the world whenever she’s ready.

      Best to you,
      Ana

  68. Lisa Hawes, RN, BSN says:

    What if the cord prolapsed at home? What do u do?

    • This is an obstetric emergency. You get the pressure off the cord (manually and with maternal position) and transfer to hospital ASAP. Cord prolapse is more likely to happen with a ARM and a high head than with a well engaged baby and spontaneous rupture of membranes… if the head is high, the pressure on the membranes is not generally enough to rupture them. Whilst rare, it is a possibility at a homebirth.

  69. Jane says:

    By breaking the water sac, with no apparent reason except time saving, eliminates babies being born in the caul. This is a very special and spiritual aspect of birth. Look up Caulbearers, I am one and all 3 of my daughters I believe were supposed to be caulbearers, but at the time the midwives decided to break it. I knew nothing about the caul at the time, apart from my mother telling me I was one. Since then I have researched this and believe this interference is another cog in the wheel towards a robotic society devoid of spirtuality, and humanity. See Michel Odent’s book “Childbirth and the Future of Homo Sapiens”. Question everything you do to interfere with this process, there is so much we do not know or understand about the nature of birth.

  70. Vicky. says:

    Both my pregnancies I had pre-labour rupture of membrane. First pregnancy no problem, second pregnancy asymptomatic infection and the death of my daughter shortly before she was born (which the infection may or may not have had a part to play though the placenta and umbilical cord were shown to have problems resulting from infection). Even though I know what the research shows, and even though I know I never would have chosen induction, it doesn’t make it easier that I get to be the exception.

    I’d still always point to the Cochrane review in discussions with pregnant friends but it’s hard not to let personal experience colour my views.

    • Personal experience is so much more powerful than numbers. For the woman who is the x% risk – it is 100%. I am sorry that you lost your daughter. Thank you for sharing your personal experience.

    • Melissa says:

      You are so brave to share. I don’t know you, but I love you, and I am so sorry for the loss of your precious baby.

  71. Pingback: A Labor & Delivery Nurse's Journey to Home Birth - Birthing in Conscious Choice

  72. Sinead says:

    This article is just what I needed to read – 40 hrs post PROM – feeling well, baby moving etc – feeling inspired – have some beautiful supportive women to back up any doubts. Off to walk in the splendid sunshine by the sea! Thanks from my heart.

  73. jessicalearl says:

    Hi, great post. I have a little bit of a story to share on the subject of induced/assisted labor.I had my baby 8 weeks ago and looking back there are a couple things I would have changed. I had hoped for the first few months I could do a home birth but I struggled with depression and just wanted it over with so I thought hospital would be easier. This being my first pregnancy I was also scared about all the things doctors say you should be careful of when pregnant. I was afraid of infections or any harm that could come to the baby. I had already researched home births but no matter how much I learned I was still afraid of the worst and needing to go to the hospital anyway. Now that I’ve actually had the baby I’m less afraid and if I get pregnant again I would like to try harder to have a home birth.

    My experience at the hospital was absolutely miserable and I remember thinking “I wish I could just lay in a comfortable bed. My bed.” And I remember hating my doctors. It felt like they didn’t care and ignored when I was feeling pain. I felt like a lot of things were forced on me. Or if not forced I was brushed over and ignored.

    My ob/gyn didn’t really show any care for me and wasn’t available the day I was pregnant. She popped in for a second after the baby was born. I didn’t mind that it wasn’t her delivering the baby. It’s not like she was very informative through out my pregnancy. I remember having her do check ups and tell me I was good and then I would leave. I came back to the clinic a week before my due date and the only available person was a midwife and she talked down to me because I hadn’t seen the doctor in 2 months. Its not like my doctor said it was important that I do and she kept saying everything was good so why should I have made appointments? And I didn’t know that was a thing. As much as I researched I didn’t know it was taboo to not go to every single appointment no matter what. But again, suffering from severe depression and a doctor who didn’t care, it was hard to understand all the things I “should” have been doing. If I do it again, I’d look harder for a doctor/midwife who cares.

    But the absolute worst part was my nurse. Well one of the nurses. When I went into the hospital after my water broke, as everyone told me I should, and was put on pitocin after about 4 hours of only being at 3cm and 80% effaced. The contractions got stronger and it hurt like hell, as many women know. But I was dealing and I felt ok. But then when they had to up the pitocin ( i was at 4cm after 10 hours) and that’s when I really felt the contractions. After 15 hours I felt I couldn’t take it anymore so I asked for the epidural. They said ok and then said they needed to examine me before. They checked and say they my water hadn’t “fully” broken so they said they were going to puncture the sac and then stick the catheter/heart monitor in.Next thing I know there are 4 doctors around my bed telling me the anesthesiologist will be here shortly but in the mean time they are going to puncture the sac and stick the catheter/heart monitor in. They made it sound like I didn’t have much choice in the matter even though I wanted to wait for the epidural. And then I experienced the worst pain ever. I would compare it to getting stabbed repeatedly in the groin area. I screamed, I couldn’t control it, my back arched and grabbed the bed rails and cried. They tried forcing the catheter into my uterus when I was having a contraction. Instead of stopping after I screamed I heard the nurse say “huh, that’s not supposed to hurt.” I can’t really remember the order of events, as I was screaming in agony but apparently my water broke fully and the baby’s heart rate dropped at the same time I was having the catheter inserted. I’ve always been one to try being quiet, even when in pain, so when I was done screaming but still in pain I clenched my teeth and tried to breath. I couldn’t. My body was so tense I was holding my breath. The doctors kept telling me to breath because the baby’s heart rate was going down. They kept moving me trying to get the baby’s heart rate up, and I wanted it all to be over. Every way they moved me hurt. After a minute I was on all fours on the bed with an oxygen mask hyperventilating and crying harder than I ever had before. 10 minutes later the anesthesiologist came in and gave me the epidural, a couple hours later they tried the catheter again and it went in with no problem. Because of this the last 8-10 hours were horrible. I was in less pain but I remember telling my grandma that I was afraid the doctors were going to come in and hurt me again. I was shaking violently for 8 hours, not from pain but purely from fear that the doctors were going to torture me. I kept bagging my husband to make them stop touching me and get me out of there (I was also a little delirious from exhaustion and hunger). I’ve told people who’ve also had to have these go in and told me what the doctors did didn’t make sense. And the nurse that kept telling me things shouldn’t hurt is someone whose name I could remember because I hated her and wanted to let someone know that she made me feel worse about everything that was happening.

    Anyway, sorry for the long story. I had my baby boy after being in labor for 23 hours and if I had to do it again I would have 1)spent more time finding the right doctor/midwife and 2) if i ever decide to do hospital birth, waiting a while after my water breaking to go in. Everything felt pushed and rushed. The enjoyable part of my whole pregnancy was pushing and delivering the baby. It was the only time I felt things were going right and holding him in my arms was the only time I felt it was all worth it.

  74. Geoff says:

    ‘Obstetricians also have great respect for research evidence – certainly more than other forms of knowledge midwives also use (experience, intuition, witchcraft etc.). I’ve found that a ‘good’ research review waved about with a smile works wonders when going against an institutional norm…’

    As a (non-birthing) research fellow in a department of health sciences, when my wife’s membranes ruptured this was one of the first things I looked up. She had heard about this, and seriously did not want to be induced.

    I was acutely aware that my reading of the evidence was non-expert, so sought to clarify it with something like 5 midwives, in addition to either two or three consultant obstetricians. Not one was aware of it; the most curious / positive response I received from an obstetrician was acute questioning and a barrage of acronyms (I had to explain again that I’m a non-expert!), backed up by a reassurance that the 24-hour induction process was definitely for the best, and that in not opting for 24-hour induction we were ‘taking a risk.’ This, despite my repeated requests for clarification re: my understanding of odds ratios, and the relative chances of infection / negative outcomes discussed in the Cochrane review!

    We were consistently told about ‘NICE guidelines,’ and the message that we were ‘taking a risk’ was hammered home by people in NHS costumes so consistently that – despite being notionally aware of the Cochrane review – I began becoming seriously worried myself. My wife, to her eternal credit, stuck by her guns; but I was pretty shocked by the consistency with which we were told something that seemed to be entirely divorced from the evidence base, backed up by nothing more than messages centred on – basically – fear and wrongdoing. (“You are running a risk; the most important thing to us is the child’s welfare; we cannot / will not offer you support unless and until you go into active labour and / or you opt for induction.”)

    • It is frustrating that practice is culture-based rather than evidence-based. This seems to be a particular problem in midwifery/obstetrics. Archie Cochrane awarded the ‘wooden spoon’ to obstetrics (for the least evidence based speciality) in the late 70s… not much has changed unfortunately. I hope it all worked out for your wife/baby and you. Thanks for sharing your experience.

  75. Natalie says:

    I would just like to say that after doing research on the Internet and hypnobirthing I chose to trust my instincts. My waters went fully when I was 38+6. Monday 7pm and my son wasn’t born until Friday 2.30pm. I’m writing this on here as when doing my research there wasn’t anyone who had gone past 72 hours which I did. I’m not saying you should choose this I’m saying trust your instincts and if all is ok with temp, movements and no signs of infections then you can choose to wait. I did and my little boy was perfectly healthy as was I. I ended up in hospital as the doctors scared me a bit into staying there rather than my planed home birth and they said I couldn’t have a water birth so that was my compromise with them although in hindsight I could have had my water birth at home I believe but the doctor scaring me stopped me. In their defence they do see the minority of when it goes wrong or infections so I could see where they were coming from.
    So I went 92 hours from my waters breaking to giving birth with no interventions of any kind.
    Hope this helps with the weighing up and decision making xx

  76. Melissa says:

    Just wondering, after my last baby was born (he is my third — all born at home), I just felt hot. I was hot for several hours, I don’t recall experiencing that before. I didn’t think to be alarmed, so I obviously felt fine other wise, and I didn’t ever even mention it to my midwife (Yay to birthing hormones for keeping me from being concerned about something that was a non issue in me!!) I have since read that it is very common for a mother to have a sustained temperature raise after delivery. I’m just curious about the varacity of that fact, and how healthcare professionals balance that with looking for signs of fever. Thanks!

    • Where did you read that it is common for women to have a sustained temperature after birth? (not having a go – I’m just interested). It is common during and after an epidural… but I haven’t noticed or read anything about it after a physiological birth. Except that the woman’s chest temperature alters depending on baby’s temperature (if he is skin-to-skin).
      I’d be keeping an eye on any temperature after birth, especially after ‘prolonged’ rupture of membranes. With a uterine infection women will often feel fluey and have uterine cramps and pain.

  77. dez says:

    I wish I’d read this article before my oldest was born! My water broke and it was a very hardecision to walk away from induction. I ended up inducing anyway after three days, and my baby was taken to NICU for observation abd antibiotics. Breastfeeding thankfully wasn’t hindered, but bonding was and it took a long time to rectify.

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