Edited and updated: May 2013
Most women experience their waters breaking towards the end of labour, and amniotic fluid plays an important role in the labour process. However, a significant minority of women experience their waters breaking before labour begins. The standard approach to this situation is to augment labour by using prostaglandins and/or syntocinon (aka pitocin) to stimulate contractions. 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 augmented rather than wait. I wonder how many of these women would choose a different path if they knew there was no increased 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: planned vs expectant management
A Cochrane review comparing planned (augmented 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 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 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.
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 augment 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: planned vs expectant management
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 (augmentation) 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 augmenting 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.”
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 (Ajslev et al. 2011; Bengmark 2012; Dahlen et al. 2013; Glasgow et al. 2005; Trasande et al. 2012). 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. Some 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:
- Encourage the mother to 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 also like to boost their immune system with nutritional supplements (eg. vitamin C, echinacea, garlic).
- Encourage the mother to be self-aware, connect with her baby and let you know of any changes eg. feeling unwell, 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 mother and baby together skin-to-skin to reduce the chance of infection by allowing the baby to become colonized by his mother’s bacteria (this applies to all births).
- Ensure the mother is aware of signs of infection – in both herself and her baby – and can access support if worried.
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.
Here is a real story of 2 different approaches to pre-labour rupture of membranes and 2 very different outcomes.
You can read this post in French here.