Not long ago, a student returned to postnatal yoga after having giving birth to her first child. I love seeing the mothers returning with their yummy new babies and hearing about the birth experience. This one mother, upon telling me her birth story, laughed slightly and said, “I was the poster child for the ‘cascade of interventions'”. I paused and asked why. The story unfolded something like this. It was a few days before her due date and she suspected that her water had broken. She called her doctor and was instructed to come into the hospital to be checked since her doctor was on call there at the time. It turns out that yes, her membranes did rupture. It was a slow leak, not a big gush. The mother wasn’t feeling contractions yet, just mild cramping. So her doctor admitted her and started her on a small amount of pitocin, artificial oxytocin. Slowly after increasing the dosage over a 12 hour period, the student grew tired and very uncomfortable coping with the waves of strong contractions and opted for an epidural. This allowed her to rest and relax for a bit. Labor continued to move slowly and after another 8 hours her cervix stubbornly stayed at 7cm. The doctor declared she was a “failure to progress” and delivered her baby via cesarean. The student seemed somewhat disappointed but resigned that there was nothing that could have changed the path she went down and this was best for her and her baby.
After a birth, especially one that may have some disappointments, I never tell a student what she may have done differently or even options she may have explored. I find that is not helpful and can often lead to depression or self anger. The purpose of this article is for you, the reader, to gain some tools and insight about options and decision you may face should you find yourself in a similiar situation. The birth story my student shared, is not unlike many I have heard in the past. Many carrying the same sense of slight disappointment that things did not unfurl in a different way.
There are many ways in which ruptured membranes before the onset of labor at term (meaning not before 37 weeks) is handled. Some care providers will start induction soon after PROM (premature rupture of the membranes) which is called “active management” while others will wait and see if labor starts on it’s own, which is called “expectant management”. It would be a good idea to understand what to expect with the care provider you chose in terms of management of labor. Find out if there is any flexibility in management of care if PROM occurs.
A few things to keep in mind
The first thing to remember when discussing PROM, is only 8-10% of women experience their water breaking before the start of labor. But should that happen to you, look at the color and notice if there is a strong odor. Ideally, the amniotic fluid should be clear and slightly yellowish. If there is a strong smell and the fluid is greenish/blackish that is meconium, the baby’s first bowel movement, which could be a sign of fetal distress. Should this be the case, you will likely be advised to head to the hospital. Also, if you are unsure if your water actually broke, your care provider can test the fluid to confirm by nitrazine paper test.
If all is clear and your care provider is comfortable with you staying at home longer, just remember, NOTHING GOES INSIDE THE VAGINA! Every time something enters the vaginal canal, there is a higher chance of introducing bacteria which can cause infection. The risk of infection is what often prompts care providers to more aggressively manage care. This same concept should be carried throughout the whole labor. The mother is at higher risk of interuterine infection with prolonged period from rupture until birth, so MINIMIZE VAGINAL EXAMS to decrease introduction of bacteria.
What would happen if you do not immediately get induced?
Rebecca Dekker of Evidence Based Birth concluded in her article, What is the Evidence for Inducing Labor if Your Water Breaks at Term
•If women with PROM are not induced, around 45% will go into labor within 12 hours (Shalev et al., 1995; Zlatnik, 1992).
•Between 77% and 95% will go into labor within 24 hours of their water breaking (Conway et al., 1984; Pintucci et al., 2014; Zlatnik, 1992).
•In another large study, researchers assigned some women to wait for up to 72 hours for labor to begin after their water broke. Out of these women, 83% went into labor on their own and had a normal vaginal birth (Shalev et al., 1995).
Management varies depending on the status of the baby and mother. If the baby appears compromised, or if the mother shows signs of infection which is often indicated by the presence of maternal fever, then induction is imminent. Another concern is compression of the umbilical cord. Think of the amniotic sac as a big water balloon with the baby, placenta, amniotic fluid and umbilical cord all inside the water balloon. Once the membranes rupture, the buoyant container of the amniotic sac is lost and there is increased risk of the cord being compressed between the baby’s presenting part and the cervical opening. Should your water rupture at home, you will likely be asked the color and odor, as well as if you are feeling the baby move.
Is there a relationship between vaginal exams and PROM?
This is the topic that really sparked this article. The student who had what she called “the cascade of interventions” actually had interventions start before she was even in labor. Her care provider was performing weekly vaginal exams starting at week 37. This practice has always been a pet peeve of mine. It either shows some cervical change that can get the mother overly excited and still wait for days or weeks for something to happen. Or on the flip side, a mother hovering around her due date may feel completely deflated to learn her cervix is still pretty closed. I asked my own OB about this. Here is what Dr. Harry Lee said,
“I don’t routinely do a vaginal exam until 40 weeks if there are no signs of labor. Most patients want to know when they will go into labor and the exam gives no such information. And it’s uncomfortable. I was taught to do them routinely starting at 36 weeks but stopped a long time ago. I got tired of shrugging my shoulders when patients asked what their exam meant.”
So besides vaginal exams providing little information as to when labor will start or how the results of the exam will change how the care providers manages labor, there can be other consequences. Now, the data on this shows a mixed result. I was curious if there was a relationship between pre-labor vaginal exams and premature rupture of the membranes.
Through my research, I discovered there have been two major studies often sited on this topic, one lead by Lenihan and one lead by McDuffie. Both these studies compared the outcome of PROM associated with routine vaginal exams starting at 37 weeks before the onset of labor. Amazingly, the two studies came out with completely conflicting results. The results from the McDuffie study explain,
“The overall prelabor rupture of membranes rate was not significantly higher in the membrane sweep group (12% compared with 7%) (P=.19); however, patients with a cervix more than 1 cm dilated at time of membrane sweeping were more likely to have prelabor rupture of membranes if they were in the membrane sweep group (9.1% compared with 0%; relative risk 1.10, 95% confidence interval 1.03-1.18).”
Here is the conclusion from the Lenihan
“A total of 349 patients were studied. In 175 patients in whom no pelvic examinations were done until term or past term, the incidence of PROM was found to be 6%. In the 174 patients in whom pelvic examinations were done weekly starting at 37 weeks’ gestation, the incidence was 18%, which was a significant increase (P = .001). The primary cesarean section rate was comparable in both groups with PROM; however, the overall primary cesarean section rate when PROM occurred was found to be twice that of the remaining population. This, however, did not achieve statistical significance. The study suggests that pelvic examinations before term may be a significant contributing factor to the incidence of PROM.”
Even with the differing conclusion, “McDuffie and associates9 were unable to explain precisely why their results differed so markedly from those of Lenihan.8 However, in view of the multiple experiments cited previously that confirmed the effect of bacteria and bacterial proteases on membrane integrity, antenatal cervical examinations should not be performed as a matter of routine from 37 weeks until onset of labor. Rather, their use should be restricted to situations in which the results of the examination clearly will influence clinical management.
All this information and tales from past students is merely a jumping off point for the pregnant mother to exam what she wants for her own birth. She can weigh the risk versus the benefits of routine vaginal exams and decide what is within her comfort zone. This discussion with her care provider can become an opportunity to look at evidence based practices and use that as a foundation for the care the mother wants to receive.