Your Water Breaks First - A Date to PROM (Premature Rupture of Membranes) - Turning Data into Choices and Decisions

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All that I have written thus far represents the level and the depth of research I felt necessary to properly educate myself and comprehensively answer the question: Why are most women in the United States induced when their water breaks at term? 

I had no idea that it would get this complicated.

I’m going to try to break it all down into the four most typical scenarios that might present for term PROM.

Remembering that if your water breaks before 37 weeks, you need to call your doctor/midwife, gather your birth team, and head into the hospital as this is PPROM and a medical emergency. 

Ironically, expectant management (waiting) is the “go to” management protocol when this birth complication presents, as the value of allowing a premature baby to remain in utero far outweighs the minute potential of infection.

Scenario A:

Your water breaks at term and your at home assessment (TACO) leaves you concerned, perhaps you exhibit signs that infection and/or meconium staining might be an issue, such as the color and odor of your amniotic fluid, your temperature is high, perhaps you have a sore throat, etc. These are all things that need to get fully checked out by your doctor/midwife. So put in a call to your health care provider and ready yourself and your birth team to leave for the hospital. Once you get all your answers then you will need to make your best decisions armed with the best knowledge possible.

Scenario B:

Your water breaks at term and regardless of your TACO assessments you have tested positive for GBS, call your health care provider and ready yourself to leave for the hospital.

My standard advice is that while the likelihood of neonatal infection is uncommon, if certain criteria are met, a genuine risk does exist, and it can be quite devastating to the health of your newborn, so unless you feel incredibly and strongly otherwise, get treated with prophylactic antibiotics. At some point I will be writing more on this topic so that I don’t have to direct you elsewhere but in the meantime there is an extremely thorough presentation of the facts and evidence on Evidence Based Birth.

The Centers for Disease Control (2010) guidelines for management of GBS+ women say nothing about inducing woman with ruptured membranes at term, which suggests that awaiting spontaneous labor is acceptable provided that antibiotic therapy is initiated.

It seems common sense would dictate that women wait for the first round of antibiotics to be fully administered before making any decisions and even those who prefer not to wait for labor to begin on its own should delay induction until they have the initial round of antibiotics on board.

In any case, regardless of GBS status or decisions around whether or when to induce, to minimize the risk of infection, women should avoid digital exams until labor is well established and their use should be kept at the very minimum during labor.

It is very important to remember that most of the studies as of the 2017 Cochrane review did not take into account the number of digital vaginal exams, nor did they follow current GBS infection protocols.

But for the record, ACOG as of February 2019, has this recommendation regarding management of term PROM and a positive GBS status.

“For women who are GBS positive, however, the administration of antibiotics should not be delayed while awaiting labor. In such cases, many patients, OB-GYN’s, and other health care providers may prefer immediate induction.”

Scenario C:

Your water breaks at term and while nothing seems amiss, you still worry, call your doctor/midwife. Ready yourself to leave as health care providers, especially doctors, always want to check.

If your preference is to wait for your labor to begin on its own then if it is at all possible visit the doctor/midwife’s office rather going to triage station at your hospital. Your healthcare provider will want to monitor the baby and check for a prolapsed cord. Prolapsed cord is extremely rare in term moms even with PROM and remember there is no evidence that term PROM is even a risk factor for prolapse.

Both of these procedures can be performed without a vaginal exam being necessary, politely decline this type of exam and request that non-invasive techniques be utilized instead.

It is easier to get back out of a doctor’s office, hospital staff is likely to convince you to stay, get checked in, and you may have hours ahead of you without contractions being present.

If your preference is for immediate induction, gather your birth team, call your healthcare provider and head to triage at the hospital, you won’t get any argument from your medical team.

Scenario D:

Your water breaks at term, you have strictly assessed all the criteria, and have maintained hygienic protocols, to your best knowledge all is well, you take a deep breath, call your health provider, explain the situation, explain that certainly, your most important objective is a healthy baby, remind them of your previous discussions and your deeply felt desire for a physiological intervention free birth. Stating that you understand their need to assess your condition, assuring them that this will give you peace of mind as well, and then politely request to been seen in their office rather than in hospital.

Both Scenario A and B represent the need for medical intervention and decisions made in these scenarios are best left until you have a full picture of your direct circumstances.

If options regarding non-invasive procedures and vaginal birth remain a possibility and are important to you— then politely state that these less invasive interventions are your preference.

In Scenario C and D there exists the potential of a choice. The two viable options are immediate induction or waiting for labor to begin on its own after term PROM.

I now want to give some guidelines based on my research regarding both of these options.

Regardless of circumstance your doctors will state that they want to see you in labor by X amount of time, most doctors will press strongly for immediate induction and are likely to push that you be seen in triage at the hospital rather than in the office.