Ornament

The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Ornament

Prelabor or Prolonged Rupture of Membranes - PROM

Why women shouldn't fear home birth
by Mayim Bialik, Ph.D.
This short essay is humorous, honest, insightful and inspiring.

Subsections on this page:



How to Tell if Membranes are Ruptured



This section is for non-professionals, birthing women who aren't getting the information they need from their own care providers about how to tell when their membranes are truly ruptured.  This information isn't to help you make your own diagnosis, but rather to provide a basis for an intelligent discussion with your care provider.

In my practice, I find that women often mis-diagnose their own rupture of membranes.  This can be because:

  1. There are two layers to the amniotic membranes.  The outer bag can rupture and release the small amount of fluid that is accumulated between the layers.  The inner bag is still intact, and it's the inner bag that really counts, in terms of keeping the baby's space protected from germs.
  2. Babies have very long fingernails at term; they don't have any video games inside there (yet!), so they spend a lot of time fiddling with their hands, practicing sucking on their thumbs or fingers, or playing with their noses and ears, or with the umbilical cord.  Those long fingernails can easily cause a little tear in the amniotic sac, releasing a small amount of fluid. However, the amniotic membranes are kind of like Saran Wrap, and as the fluid is released, the amniotic sac sometimes doubles over on itself around the tear, and the membranes effectively re-seal the leak.  This kind of a "high leak" or "hind leak" presents almost no additional risk to the baby, since germs are very unlikely to get through the cervix and move against the outflow of fluid to find the tiny tear in the membranes.
  3. As women get closer to birth, their bodies increase the blood flow to the pelvic floor, which can dramatically increase the discharge of clear vaginal fluids.  Especially for women who have increased their body's ability to discharge fluid through female ejaculation, they can produce quite a lot of fluid that is not actually amniotic fluid, although it looks similar and actually smells the same!  I had a client once who got up in the middle of the night to go to the bathroom and experienced a discharge of fluid that left a puddle on the floor that was several feet in diameter.  When she went into labor, she had a bulging bag of waters that was under so much pressure that it was obviously intact and had never ruptured.
A true rupture of membranes is either: Especially with a first baby, it is unlikely that your membranes will rupture before your labor is well established and the cervix is really opening.  As long as the cervix is closed, it provides support to the membranes, so the pressure of the contractions isn't likely to rupture them directly over the cervix.  With a subsequent baby, a true rupture of membranes behind an opening cervix is very likely to lead to true labor within short order.

If you are drinking plenty of fluids and you are upright, and the gush/flow/trickle of fluid has stopped, then your membranes are probably not ruptured!

Care providers put faith in speculum examination of the cervix.  They believe that if the nitrazine paper tests positive, then membranes must be ruptured.  There is no accounting for any of the possibilities above, any of which could produce a false negative for ruptured membranes, since all they are doing is checking the pH of the fluid in the vagina.  (And, yes, vaginal secretions can give a false positive for nitrazine testing.)

So, if you would prefer not to be induced for a false diagnosis of ruptured membranes, it might make sense to drink a lot of fluid to increase amniotic fluid before going to your care provider and demanding an ultrasound to assess amniotic fluid levels.  If your amniotic fluid levels are normal, then it's not likely that your membranes are truly ruptured!

For hospital-based care providers who are looking for any reason to induce, there is no reason to question a woman's self-diagnosis of rupture of membranes.  If you're induced for a diagnosis of prelabor rupture of membranes or prolonged rupture of membranes, you'll know it was a false diagnosis if you are later found to have a bulging bag, or they rupture membranes at some point in labor, or you experience a significant gush of fluid later in labor, since this kind of gush usually means that an intact sac has ruptured under pressure.  (It is remotely possible that the baby's head could act as a cork for the fluid, but it's really not likely to be a very effective cork for very long, as fluid can easily flow around it under pressure.)


AmnioTest™ is designed to assist in the detection of rupture of the fetal membrane. It would be nice if they were available in single units, as many midwifery practices are low volume.  I don't think this can distinguish between a rupture of just the outer bag and a rupture of both bags, so it's actually not that useful in my practice.  I saw their advertisement in The Canadian Journal of Midwifery Research and Practice (CJMRP).


A normal AFI even in the presence of a self-reported amniotic fluid leak is generally considered to rule out SROM. Nitrazine and ferning can both be false positive. Obviously if there is gross leakage and pooling with a sterile spec. exam you have another story.


In the absence of absolutely clear evidence of rupture (liquor draining freely)  I assume that it is just increasing mucus discharge.  I think we over diagnose ruptured membranes, and as long as fingers and other things are kept out of vaginas it doesn't really matter too much if you do have a slight leak.  If you were preterm with this set of symptoms we'd be waiting and watching rather than pushing to induce/augment things.
I have absolutely NO evidence for what I'm about to say but...I think that sometimes there is increasing pressure on the membranes late in pregnancy and this causes a "porosity" that allows small amounts of fluid to leak without an actual rupture of membranes, possibly sometimes fluid from between the amnion and the chorion leaks through the chorion, with the amnion maintaining a barrier.  This would explain the scenario I had earlier this year where the Mum "leaked" yellow (old mec) stained mucusy/fluid for a day or two, then started to labour, had a "gush" of pale yellow fluid that continued to leak, started pushing spontaneously but wasn't making any progress so VE'd, bulging membranes in front of head, artificial rupture of membranes at Mum's request (she felt that was what was holding things up), more pale yellow fluid drained, eventually exhausted Mother still with little progress in second stage, called for assistance, baby delivered with help from ventouse, layer of membranes intact at birth and ruptured by delivering doctor.  Count 'em 3 or possibly 4 ruptures of membranes!



Nitrazine Fallibility - False Positives



False positive may be from blood, semen, alkaline antiseptics and sometimes alkaline urine. Vaginal infections may also raise the vaginal pH causing a false positive. Just R/O the first four by asking about them and do a wet mount or culture to R/O the infection.


I once, just out of curiosity, pressed nitrazine into my own (nonpregnant) very sweaty summer underwear and got a positive nitrazine test!



Vaginal Fluid Releases



I think that some women will have a watery vaginal discharge that is essentially "female ejaculate".  I had a client who swore that she got up in the middle of the night and left a puddle on the floor; she said it was about a cup of fluid. No labor until the next morning.  At 7 cm she had a bulging bag under so much pressure it's hard to imagine there was a leak anywhere, even behind the baby.


I wonder more and more about this.  Does anyone know what "female ejaculate" is meant to actually BE?  It is so common for women to report a gush of fluid prior to the onset of labour with no evidence of SROM, and so patronising to assume they're all wetting themselves.  This is probably way TMI but I had cervical cauterisation last year and for about a month afterwards I had so much completely clear, liquidy discharge - if I were pregnant there would have been no way to convince me it was not ruptured membranes.  I can only assume it was coming from my cervix itself.  Could it be cervical response to trauma?  In my case to the procedure but in very pregnant women to beginning to efface and dilate?
I wish science knew more about women's bodies!


I have had this event a few times lately... a gush they call it and then nothing. More than what i would consider peeing on themselves but less than waters gushing.  A couple of times we waited and nothing else happened and they didn't go into labor for another week or so... or they said there water broke but when i checked baby is high and there is a definite bag of waters...


Well I know, from teaching Fertility Awareness classes, that women who have been on BCP (birth control pills) and go off, can have lots of watery, slippery, clear cervical fluid for up to several months. It is thought to be caused by excess synthetic estrogen being released from fatty tissue. Perhaps there is a big estrogen surge just before labor that causes profuse cervical fluid? It would make sense that it would clean the vagina by flushing it out a bit.  [Ed: I wonder if this is related to the increase in amniotic fluid that we see a couple of weeks before natural onset of labor?]


Just had one of those weird gushes then nothing then labor in two day.

She woke up from sound sleep with soaked shorts, like 8 inch across wetness, thought one of her kids was in bed and peed on her at first. She has no bladder trouble and is sure she did not pee... Nothing more happened all day, so at 12 hours, I did an sterile spec exam and saw no fluid pooling, could not get fluid from cervix with cough or pushing on uterus, not even enough to nitrazine anything. I ended up stripping her membranes (lightly) and she had a bag well intact that i could feel. Labored in two days, the bag broke when the head was on the perineum.

I also wonder about female ejaculate in general, apart from labor....I have never been able to find an anatomy text book that validates its existence, or explains its orgin. It's like it doesn't even exist in the scientific realm, only in the bedroom!


My OB text reports that a "watery vaginal discharge is also a common presenting symptom in patients with premature cervical dilation (incompetent cervix) even in the absence of ROM.



We have a grandmultip with possible SROM.  Reports possible SROM: notice fluid where the body pillow had been between her legs, then the next day while walking lost an estimated 1 cup of fluid, then 2-3 times more with walking, felt more fluid release.  Had her lay down 1 hour before testing no pooling, tested Ph and for ferning, all neg. She reported soaking 3 pads during the day. Smelled pads, which had some weight to it, and it did not have that amniotic fluid smell and also no urine smell. Last night she reported losing another 1/4 cup of fluid with movement. Going to assess and see if there is ferning again this morning. Having her take hygienic precautions and up her immune system with Vit. C and garlic.


I assume it did not smell fishy, as Bacterial Vaginosis and Trichomonas can both give a lot of discharge, but have the fishy smell.  I think I would do a wet prep when you do the fern test.


I agree on the wet prep - one secret trick i learned from another midwife is to pool them half hour, then put the speculum in, ask her to cough hard, watching the cervix. If you see a spurt of fluid from the cervical os, she is SROM. Fern the pool in the posterior vagina.


This may sound a little wacky, but I did have a similar situation years ago, --sudden onset of leaking lots of clear fluid, only there was also pooling of copious clear fluid which did not fern, no matter how many times I tried.  I mean, this REALLY looked like amniotic fluid.  We ended up ultrasounding her, she had normal fluid levels, never ferned, and was sent home. (eventually came in in labor and had a baby, but not for a couple of weeks).  My theory was that there are lots of glands in the vagina/cervix that create discharge--I just guess it got really watery there for a bit.  But could never prove that--just a guess.


that would make sense if we remember women can ejaculate fluid and often quite a bit. Maybe its a release?


I think you are right.


Don't forget that sexual activity can cause fluid releases even many hours later.  Ejaculate and her own additions can get caught up in the vaginal folds for quite a while ..... If tested it can fool you too, because it has sort of a similar scent to AF, can fern, and can be alkaline on a nitrazine paper.


Once everything else is ruled out we tell them it is hydrorrhea and can be very normal.  They like the big word and relax.

I've started making these books available to my clients in my lending library:

Female Ejaculation and the G-spot by Deborah Sundahl - the whole book

A New View of a Woman's Body  by Federation of Feminist Women's Health Center, p. 54

Transcendent Sex: When Lovemaking Opens the Veil by Jenny Wade

"Female Ejaculation & the G-Spot"
Deborah Sundahl; Paperback; $10.85

I added a new question to my new client intake form:

"Would you like information about becoming more comfortable with your sexuality in ways that can make labor and birth easier for you?  This includes increasing your sexual responsiveness or ability to let go and experience orgasm with abandon, which sometimes results in female ejaculation."

All 3 women who've had this form have answered "Yes" to this question, so I've had to order more books for my lending library.  I was surprised at this level of response but am heartened by it.

One of the things that has struck me about female ejaculation is that the "how to" books talk about a slight bearing down. This is such a novel recommendation for general sexuality, but it's ever so helpful during labor.

Sometimes I see women who respond to the urge to push by tightening up, often from the fear of passing stool, or maybe from their years of learning to respond to an impending orgasm by tightening up to prevent any apparent loss of urine, even if it's really ejaculate.

I don't know how they do it, but some women seem to be able to push the baby through the Kegel muscles without allowing the passage of any stool.  I had a client who did this once and then had massive diarrhea after the placenta was out.  I don't know how she did it!

I think this may be an issue that's related to tearing; if women aren't able to allow the Kegel muscles to relax to allow for passage of the baby even if it also means the passage of some stool, then tearing is more likely.

My hope for all women is that they can learn to let go in their sexuality.  For some women, this will result in ejaculation with orgasm, which is apparently quite pleasurable.  And I can hope that for all women, it will make birthing easier.



Resources



It's essential for everyone to understand that the acronym PROM is loosely used for all of:

Preterm Rupture of Membranes
Prelabor Rupture of Membranes
Prolonged Rupture of Membranes

and then you can also have Preterm Prelabor Rupture of Membranes, which is usually called PPROM.  I like that it is sometimes written pPROM, with the little "p" being for "preterm", I guess because preemies are smaller.

The concerns and appropriate treatments are very different for each of these situations.


Dear all –
As you probably know, in a recently clinical bulletin, ACOG recommended immediate induction for women at term with prelabor rupture of membranes.  This recommendation is not based on good evidence.  We (the CNMs at San Francisco General Hospital) reviewed the evidence, in detail, at a meeting, and decided to continue to offer women the option of expectant management for up to four days.  Since the ACOG bulletin rates their recommendation for induction on as based on Level A evidence, I anticipate that many midwives who do expectant management will be called on to defend their practice.  Should that event arise, attached is my powerpoint presentation with an analysis of the evidence, and a summary of the decisions made by the CNMs at SFGH.  I hope this material will make it easier for you to practice a model of midwifery that seeks to preserve women’s options and guard normalcy of childbirth.

Cynthia Belew, CNM

Term PROM Management – June 2007


Fetal membrane healing after spontaneous and iatrogenic membrane rupture: a review of current evidence.
Devlieger R, Millar LK, Bryant-Greenwood G, Lewi L, Deprest JA.
Am J Obstet Gynecol. 2006 Dec;195(6):1512-20.

In view of the important protective role of the fetal membranes, wound sealing, tissue regeneration, or wound healing could be life saving in cases of preterm premature rupture of the membranes. Although many investigators are studying the causes of preterm premature rupture of membranes, the emphasis has not been on the wound healing capacity of the fetal membranes. In this review, the relevant literature on the pathophysiologic condition that leads to preterm premature rupture of membranes will be summarized to emphasize a continuum of events between rupture and repair. We will present the current knowledge on fetal membrane wound healing and discuss the clinical implications of these findings. We will critically discuss recent experimental interventions in women to seal or heal the fetal membranes after preterm premature rupture of membranes.



Antibiotic prophylaxis in premature rupture of membranes at term: a randomized controlled trial.

Passos F, Cardoso K, Coelho AM, Graça A, Clode N, Mendes da Graça L.
Obstet Gynecol. 2012 Nov;120(5):1045-51. doi: http:
RESULTS: A total of 161 patients were evaluated, 78 in the antibiotic group and 83 in the control group. Maternal infection was significantly lower when antibiotics were administered (2.6% compared with 13.2%; relative risk 0.89, 95% confidence interval 0.81-0.98; P=.013). All cases of maternal infection occurred in women with more than 12 hours of PROM. Newborns of mothers receiving antibiotics had fewer infections (3.8%) compared with those in the control group (6.0%), but the difference was not statistically significant (P=.375).
CONCLUSION: Prophylactic use of antibiotics in PROM at term significantly reduced the risk of maternal infection in our population.



Induction shows benefits after term PROM

25 January 2006
Cochrane Database of Systematic Reviews 2006; 1: Not yet available online

Labor induction has some benefits in the management of women who experience premature rupture of membranes at term, Cochrane reviewers report.

A systematic review of data from 12 studies on nearly 7000 women who had premature rupture of the membranes at 37 or more weeks' gestation has found a lower risk of maternal infection and neonatal intensive care for women who were induced than for those who underwent spontaneous labor.

On average, one case of chorioamnionitis would be avoided for every 50 women undergoing induced labor, and one less newborn would be admitted to intensive care for every 20 induced deliveries, Philippa Middleton (University of Adelaide, Australia) and colleagues calculated.

Newborn infection rates and the incidence of cesarean and assisted vaginal deliveries did not, however, differ between the two groups.

Previously, premature rupture of membranes has been associated with complications such as infection and compression of the umbilical cord. When it occurs at full-term, labor usually begins spontaneously within 24 hours but can be delayed for up to a week.

"Since planned and expectant management may not be very different, women need to have appropriate information to make informed choices," the reviewers conclude.


Here's a great set of slides about PROM from perinatologist.com


Amnicators® - Amniotic fluid indicator swabs - are a rapid, simple way to test for ruptured amniotic membranes.  They're kind of like nitrazine paper on a stick.  They're carried in the United States by Cascade HealthCare Products.


Managing PROM patients at term - Induction, Expectant Management Equally Safe - "The cumulative data in the medical literature show that immediate labor induction will not increase the risk for C-section in nulliparous women with premature rupture of membranes (PROM). In addition, the onset of labor within 24 hours of membrane rupture is not associated with increased risk of neonatal infection if the woman is not already infected with group B streptococcus . . . " per Dr. Stephanie E. Mann


Antibiotics for prelabour rupture of membranes at or near term (Cochrane Review)


When Does the Bag of Waters Break? - Posted 11/22/2004 [An ACNM handout on Medscape - Medscape registration is free]

This is a helpful handout, but I had a few problems with it.  It states, "Usually the bag of waters breaks just before you go into labor or during the early part of labor. It happens most often when you are in bed sleeping."  This is totally contradictory to my experience, which is that waters RARELY break before 4-5 cm with a first baby and 7 cm with a subsequent baby.  The handout ignores the possibility of just the outer bag breaking with a small amount of fluid, and it ignores the mechanisms which cause breaking of the waters, i.e. baby poking a hole with a fingernail, pressure building up inside with strong contractions and reduced support from the cervix as it opens and the one we worry about . . . an infectious process weakening the membranes.  I think most of those middle-of-the-night minor gushes or trickles followed by dryness are simply exuberant birth hormones causing extra discharge.



pPROM - Preterm Prelabor Rupture of Membranes



Antibiotics for preterm rupture of membranes. [Update of: Cochrane Database Syst Rev. 2001;(4):CD001058.]
Kenyon S, Boulvain M, Neilson J.
Cochrane Database Syst Rev. 2003;(2):CD001058.

REVIEWER'S CONCLUSIONS: Antibiotic administration following pROM is associated with a delay in delivery and a reduction in major markers of neonatal morbidity. These data support the routine use of antibiotics in pPROM. The choice as to which antibiotic would be preferred is less clear as, by necessity, fewer data are available. Co-amoxiclav should be avoided in women at risk of preterm delivery because of the increased risk of neonatal necrotising enterocolitis. From the available evidence, erythromycin would seem a better choice.



Abstracts



Induction shows benefits after term PROM

On average, one case of chorioamnionitis would be avoided for every 50 women undergoing induced labor, and one less newborn would be admitted to intensive care for every 20 induced deliveries, Philippa Middleton (University of Adelaide, Australia) and colleagues calculated.
Newborn infection rates and the incidence of cesarean and assisted vaginal deliveries did not, however, differ between the two groups.
"Since planned and expectant management may not be very different, women need to have appropriate information to make informed choices," the reviewers conclude.

Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more).
Dare M, Middleton P, Crowther C, Flenady V, Varatharaju B.
Cochrane Database Syst Rev. 2006 Jan 25;(1):CD005302.

AUTHORS' CONCLUSIONS: Planned management (with methods such as oxytocin or prostaglandin) reduces the risk of some maternal infectious morbidity without increasing caesarean sections and operative vaginal births. Fewer infants went to neonatal intensive care under planned management although no differences were seen in neonatal infection rates. Since planned and expectant management may not be very different, women need to have appropriate information to make informed choices. [This is puzzling.  Does this mean that babies born to mothers who receive antibiotics are being kept with their mothers while babies born to mothers who did not receive antiobiotics are being sent to the NICU, even though there is no difference in infection rates?!?  This should be an alert to the neonatologists and pediatricians that they need to change their recomendations, not that the mothers need to change their choices!]


Is a speculum examination sufficient for excluding the diagnosis of ruptured fetal membranes?
Ladfors L, Mattsson LA, Eriksson M, Fall O
Acta Obstet Gynecol Scand 1997 Sep;76(8):739-742
Over 10% of negative results were false negatives, yet true positives treated as negatives suffered no ill effects.  "The value of biochemical methods in the management of women not in labor with rupture of the membranes after thirty-four weeks of gestation could be questioned."

Warm tub bath during labor. A study of 1385 women with prelabor rupture of the membranes after 34 weeks of gestation.
Eriksson M, Ladfors L, Mattsson LA, Fall O
Acta Obstet Gynecol Scand 1996 Aug;75(7):642-644
A tub bath did not increase the risk of maternal or neonatal infection after premature rupture of the membranes and prolonged latency.

A randomised trial of two expectant managements of prelabour rupture of the membranes at 34 to 42 weeks.
Ladfors L, Mattsson LA, Eriksson M, Fall O
Br J Obstet Gynaecol 1996 Aug;103(8):755-762
A higher rate of spontaneous deliveries was found among nulliparous women with prolonged latency as compared with brief latency prior to induction. A protocol of no digital examination before labour was associated with infrequent maternal and fetal morbidity, regardless of latency.

Management of prelabour rupture of the membranes at or near term:
Prelabour rupture of the membranes at or near term - Clinical and epidemiologicl studies by Lars Ladfors, Department of Obstetrics and Gynaecology, Sahlgrenska University Hospital, Goteborg, Sweden.  1998

This paper is in Acrobat format, which can be difficult to access, so here are the Results:
There were no differences in the frequency of neonatal or maternal infections if the mother were randomised to early or late induction.  No differences were found in the frequency of caesarean sections between the randomised groups.  In nulliparous women ventouse extraction was more often used in the "early induction group" compared to the "late induction group", 14% and 7% respectively (p<0.05). There was no difference in the incidence of neonatal infections between the groups.  Clinical neonatal sepsis was associated with time from PROM to delivery over 32 hours, caesarean section, parous women and gestational age between 34 and 36 weeks.  The false negative rate of a speculum examination of the diagnosis of rupture of the membranes in women without amniotic fluid visible at a speculum examination was 12%.  This study did not show any disadvantages for mother and infants if the women were sent home after a false negative speculum examination.  The prevalence of PROM after 34 weeks of gestation in an urban Swedish population was 12.9%.  In the multiple stepwise regression analysis risk factors for PROM were age at delivery >= 35 years, primiparity, premature contractions, PROM in a previous pregnancy and bleeding in the first trimester.


When Research is Flawed: Should Labor Be Induced Immediately with Term Prelabor Rupture of Membranes? by Henci Goer

Induction of Labor Compared with Expectant Management for Prelabor Rupture of the Membranes at Term.
Hannah ME, Ohlsson A, et al. (N Engl J Med - 1996 Apr 18)

Whenever the study outcome looks weird, it pays to go back and look at the particulars.  Often you'll find some glaringly obvious thing that you can't believe they didn't take into consideration.  Like that goofy study in Canada a couple years ago on inducing vs waiting for labor with PROM.  Even though the study protocol called for no vag. exams if they were going to wait, about a third of those women were digitally examined.  Yet there was no comment on this in relation to possible increase in infection, nor was there a separate analysis of those subsets of pts in the waiting for spontaneous labor group who were and were not examined.  Very odd, I thought, because it could have been one of the most significant contributions of the study.  But maybe that would have meant coming up with a different conclusion than they wanted to come up with.


Apparently Dr. Hannah continues to provide research that obscures rather than illuminates the truth:

Prelabor rupture of the membranes at term: expectant management at home or in hospital?
Hannah ME, Hodnett ED, Willan A, Foster GA, Di Cecco R, Helewa M
Obstet Gynecol 2000 Oct;96(4):533-8

"Conclusion: Expectant management at home, rather than in a hospital, might increase the likelihood of some adverse outcomes. "

Dr. Hannah is an odd scientist if she can simply accept this conclusion without commenting on the mechanism.  In general, morbidity from infection is significantly higher in the hospital - what would cause PROM to be an exception to this rule?  Were women in the hospital more likely to self-select out of "expectant management" and into pitocin induction out of boredom?  Were women in the hospital more likely to be resting, which is generally helpful in reducing infection rates?  If this is the case, then the lesson to be learned is that women with PROM should consider themselves in labor and be resting, rather than continuing with normal daily activities.


Of note, even though there was no *significant* difference in infection rates, there were a couple of bad outcomes in the expectant management group.  HOWEVER the protocol of no vag exams if expectant management was planned was  broken a fair proportion of the time.  The most interesting thing to me about the whole study was that no information was given on whether or not the bad outcomes were in women who had had vaginal exams while waiting, and there was no comparison of those who did and those who didn't.  There is plenty of research to indicate that vag exams and expectant management do not go together and will result in increased infection.  So why was this not looked at?  My only guess is that this woman has an agenda and really did not want to know.  And as the others have said, the big question in the current study also is, were vag exams done?  If so, then you will expect increased rates of infection, period.


I haven't had a chance to read the full article yet - does she propose any mechanism to explain an increased rate of infection at home?  In general, infection rates are significantly lower at home - what could possibly cause them to be higher with PROM? The only thing that occurred to me was that women at home are more likely to be "out and about", using public restrooms, possibly having intercourse, and generally not resting as much as women in the hospital.  This last point would be the one I'd consider worth pursuing since many people consider expectant management to include going on with normal daily activities. Perhaps the best expectant management would include reduced activity.

If she doesn't explicitly propose a mechanism and further study to identify cause and effect, I'd agree that her agenda is showing.


Controlled comparison of induction versus expectant care for prelabor rupture of the membranes at term.
Ottervanger HP, Keirse MJ, Smit W, Holm JP.
 J Perinat Med. 1996;24(3):237-42.

"The active policy of oxytocin induction exposed the mother to a higher risk of operative delivery and a less comfortable labor than the 48 hours expectant care option."






Risk of Infection During Labor Not Influenced by Number of Cervical Exams [Medscape, 6/15/2012] - It turns out that we thought more cervical exams increased the risk of infection because they hadn't controlled for time.  It appears that it's the length of time more than the number of cervical exams that increases the risk of infection.

OLD INFORMATION - Cervical Exams Increase Risk of Infection

A comparison of early and delayed induction of labor with spontaneous rupture of membranes at term.
Wagner MV, Chin VP, Peters CJ, Drexler B, Newman LA
Obstet Gynecol 1989 Jul;74(1):93-7

This is an interesting study, especially for the conclusions it reaches.  As far as I can tell, the most useful results are that induction of labor for PROM doesn't increase cesarean, and that digital cervical exams clearly increase the risk of infection.  Other than that, it ignores the issues of whether induction increases need for analgesia/anesthesia or operative delivery.  And the conclusion ignores the results regarding increased risk of infection from digital cervical exams.

Management of premature rupture of membranes: the risk of vaginal examination to the infant.
Schutte MF, Treffers PE, Kloosterman GJ, Soepatmi S
Am J Obstet Gynecol 1983 Jun 15;146(4):395-400

Presented are the results over a 4-year period of the conservative management of cases of premature rupture of the membranes. Perinatal mortality in infants delivered more than 24 hours after rupture of the membranes is not higher than that in infants delivered within 24 hours of rupture of the membranes, if these results are based on pregnancies of comparable gestational age. Two independent factors influence the risk of infection: the duration of gestation, and the interval between vaginal examination and delivery. If corrections are made for these two factors, there appears to be no clear correlation between the incidence of infection and the period of time the membranes have been ruptured. Conservative management is justified if vaginal examination is avoided until delivery within 24 hours is expected to occur.

Although I know, that infections, for eg. UT infection could cause PROM, I was always puzzled with the cause. Why it would cause a rupture, if there is no local infection at the membrane?

Now I found a study, explaining, that they found two different type of stuff made by the membrane itself. One is for actually destroying the membrane, the other is for controlling the first's activity, and counteracting it until late in labor. They found, that during an infection, the balance is disturbed and the second didn't controll the destroying stuff's activity so well. - so my question was answered. The study was:

Expression of a progelatinase activator (MT1-MMP) in human fetal membranes.
Fortunato SJ, Menon R, Lombardi SJ
Am J Reprod Immunol 1998 May;39(5):316-22



Prevention



Vitamin C supplementation to prevent premature rupture of the chorioamniotic membranes: a randomized trial.
Casanueva E, Ripoll C, Tolentino M, Morales RM, Pfeffer F, Vilchis P, Vadillo-Ortega F.
Am J Clin Nutr. 2005 Apr;81(4):859-63.

CONCLUSION: Daily supplementation with 100 mg vitamin C after 20 wk of gestation effectively lessens the incidence of PROM.


1/24/02 - Lack of Vitamin C May Trigger Fetal Membrane Break
 NEW YORK (Reuters Health) - Women who get little vitamin C both before and during their pregnancies have an increased risk of suffering a ruptured membrane and subsequently delivering prematurely, according to research presented this week at the Society for Maternal-Fetal Medicine's annual meeting in New Orleans, Louisiana.


Antioxidants 'no defense against PPROM' - 6/15/05 - "We found no evidence that antioxidant nutrients are protective against PPROM," writes the team. "Rather, high levels of lutein were associated with an increased risk."

Antioxidants and preterm prelabour rupture of the membranes.
Mathews F, Neil A.
BJOG. 2005 May;112(5):588-94.

CONCLUSION: We found no evidence that antioxidant nutrients are protective against PPROM. Rather, high levels of lutein were associated with an increased risk.


I have heard that Zinc supplementation can strengthen the membranes. I think this is from Michel Odent's info. I have started recommending it to women with history of PROM and so far no repeaters. Don't know if it that their health and nutrition in general is improved by being under the care of midwives or if the zinc is helping.



High Leak or Rupture Over Cervix?



Obviously, the risk of infection will be higher when there is a large opening in the amniotic sac directly over the cervix, and the risk of infection will be almost negligible when the fluid is leaking from a high leak in the hindwaters.  Bacteria would have to be awfully clever to find their way against a tide of outflowing fluid to find a small opening high in the amniotic sac.

Some ways to tell that the fluid is coming from a high leak in the hindwaters:


Some women just seem to start producing large amounts of clear vaginal lubrication as they get close to term.  Does anyone know if this tests positive with nitrazine paper?


Does anyone have any advice/tricks for telling if someone's waters have gone, i.e. hindwater leak rather than a huge gush apart from doing a
speculum? The client in question is reporting continual wet knickers or pads and is convinced it isn't urine.  It sounds like heavy liquidy vaginal discharge to me but could be a hindwater leak.


If she hasn't had any bloody "show", she may just continue being wet and keep the baby in longer.  Usually with this early wetness business, I find that there is a later, true release of the membranes.


Personally, I think this is a "toning up" of the urethral sponge, i.e. "the G spot" or "the G crest".  And, yes, I almost always see a true release of fluid later on in the labor - often right before pushing starts.



When is Labor Likely to Start?



Women with a possibility of ruptured membranes should be taking their temperature every 4 hours to monitor for infection.  It happens that temperature changes may offer a clue as to how soon labor will start.

Some relevant research



Preventing Infection



Oregon grape in labor (or in non labor) for PROM and limited or (preferably) no vaginal exams has yielded fine results even with two or three days time between ROM and birth.


I can agree with you that I've never had an infection in the women who use vit C; but never in those who don't use vit C either.

In fact, I've never seen an infection. (this goes back to '73). I know of one or two in our region over the years; in each case multiple VEs were done in the mis-assumption labor was beginning, or in an attempt to stimulate labor.

I don't think our region has seen any since we adopted the "Nothing in the vagina" protocols in the mid 80s.



Vaginal or Speculum Exams of the Cervix



I've been wrong on more than one occasion in thinking that a wet bed or chair is a sure sign of ROM.  Some women become incontinent as that head gets lower and lower, especially with posterior babes.


Oh, yes.  Learned this one early on--an RN friend of mine dipped nitrazine paper in a cath UA specimen and watched it turn very blue.
Many things are nitrazine + (KY jelly, cervical mucus, alkaline urine).  Are sperm nitrazine + ?

If you're going to diagnose ROM, you've got to do a sterile speculum exam!


Oddly, sometimes true PROM yields a negative fern test, even with positive nitrazine!  A perinatalogist once told me that sometimes amniotic fluid just doesn't fern, especially if it's much before term.


Several times I've had a neg fern after letting the slide dry for what I thought was a long time.  But I kept the slide because I saw pooling.  Sure enough after a good 20-30 minutes - the forest of ferns appears.


I don't understand this. Someone please explain why one feels it necessary to check with a speculum and how that is different than a "sterile" gloved finger? If one believes no VE if at all possible, why does one assume a "sterile" speculum is any safer than a "sterile" gloved finger? I've heard this response a lot over the years. If I plan no VE, then that means nothing in the vagina. I have never chosen to do an exam to confirm ROM. If we can't tell by a few other means, then they probably are not broken or they have resealed. We look on the pad, we smell, we try to get the woman to squeeze some into a clear glass jar. Very often it's urine when they were sure it was amniotic fluid.


I have wondered more than once at this rationale: to aid in diagnosing questionable ROM (usually prelabor) it is OK and even recommended to do a sterile speculum exam but it is totally taboo to do a sterile digital exam.

WHY????


A digital exam, by its very nature, takes the examining finger and puts it into the cervix (or onto the cervix if it is closed). A speculum exam should not introduce bacteria into a partially dilated cervix.

It has nothing to do with whether the glove or speculum is sterile...the point is whether or not vagina bacteria are pushed up into the cervix.


There is a vast difference between speculum exam and digital exam. The speculum does not even touch the cervix. It merely opens the vagina enough to see the cervix, sample fluid from the vaginal vault (if necessary) to check for ferning.

During a digital/vaginal exam, the examining finger goes into the cervix, presumably into/through the internal os if it is a properly done exam. This pushes all the vaginal bacteria up into the cervix, through the internal os, and into the uterus.

It is not always possible to tell, from the outside only, if someone is ruptured. Why is it necessary? +GBS, +HSV, etc.


Well, here's my take on this: with a sterile speculum you can visualize the cervix, take a culture, look for fluid, and obtain a swab to look for ferning on a slide, and obtaining a swab to look for Bact Vag. GBS swabs do not touch the cervix, but rather the vaginal pool and rectum. You are not actually touching the cervix, loosening up the bacteria. If you can't see head/hair, obviously she'd not that far dilated, then you do not need to do more. If she's contracting, and you are concerned about labor, obviously an exam is appropriate. Suppose you have someone preterm who probably has ROM. In that case, would you also check them? Usually with them we wait until labor starts, or give something to mature the baby's lungs before encouraging labor.

For me the only true signs of amniotic fluid is: seeing it and + fern. Even nitrazine is not that accurate. NO CERVICAL EXAMS !! To choose not to do a speculum exam would also be reasonable, if you feel comfortable documenting things that way. I too feel that someone with a true rupture will continue to leak, and it will become very obvious. 


I know many midwives feel there is a definite difference between a SSE and a SVE; that SSE is perfectly acceptable.  However, I have always been able to gather enough information through discussion with and observation of the woman that we can determine ROM with nothing entering her vagina. I don't see that visualizing the cx gives me enough information to warrant the potential risk.  If there is ROM, anything entering her and pushing upwards pushes up any potential bacteria higher than it might have gone anyway.  Yes, a SVE is more manipulative, so perhaps has MORE potential to increases sepsis risk, but I still think a SSE carries some risk as well.   Of course, this protocol changes with quiestionable FHT.


Its my understanding that the "clock" starts ticking from the minute anything is introduced into the vagina, not necessarily only the cervix. Read some research on this a few years ago and haven't seen anything different since. Is there something else out now which confirms that the SSE is not implicated in infection?


Standard in this region is to avoid all vaginal exams until ESTABLISHED LABOR in PROM cases; and infections are unheard of.



Antiseptic Digital Exam



It is a regular digital exam. The deal is, you bring a big soup pot filled with water to a boil with a lid on. You add to the water about a cap full of liquid Lysol...no kidding...the stuff people clean their toilets with. Let it cool enough to touch it. Then you don a sterile glove using sterile technique and dip and rotate your hand in this hot smelly stuff. It feels very weird when you do this...all hot and tingly.

You may also wash the external genitalia with it. I doubt there has ever been an RTC on it. But Dr. White is of the notion that Lysol (which he claims is more beneficial than betadine) will kill any bug it meets on contact. Anecdotally, I have not had any infections post exam with PROM or PPROM using. My biggest concern when he suggested it to me (at my own birth!) was irritating that very tender and sensitive place. He assured me that he had been doing this for 40 years and never had a complaint or a resultant infection. I am the most sensitive skinned creature. I once broke out in a horrid rash just from being touched by an EMT with a latex glove on..I get blisters from washing the dishes etc. But it didn't hurt me and it hasn't bothered anyone else I have used it on.

As to whether or not it works or is scientifically sound..I dunno....but..on the outside chance it does, and since it is pretty benign, I will likely continue to use it for the occasional PROM who has good call for an exam.



Bathing with PROM



Warm tub bath during labor. A study of 1385 women with prelabor rupture of the membranes after 34 weeks of gestation.
Eriksson M, Ladfors L, Mattsson LA, Fall O
Acta Obstet Gynecol Scand 1996 Aug;75(7):642-644
A tub bath did not increase the risk of maternal or neonatal infection after premature rupture of the membranes and prolonged latency.

Is there an association between water baths during labor and the development of chorioamnionitis or endometritis?
Robertson PA, Huang LJ, Croughan-Minihane MS, Kilpatrick SJ
Am J Obstet Gynecol 1998 Jun;178(6):1215-21
Water baths during labor are not associated with chorioamnionitis or endometritis.


Even in non-pregnant women, it seems quite common for some water to enter the vagina whilst in a bath, ( this is an informal straw poll amongst friends and acquaintances, and not in the least scientific !) so on those grounds alone I would be wary of bathing with ruptured membranes.


I am glad you admitted to the non scientific nature of your evidence, because it has been scientifically "proven" that the vagina is not a straw, and while some water does enter the vagina during a bath (which I personally can attest to), it does not travel beyond the lower portion, therefore is not a risk factor for uterine and neonatal infection. There is no current evidence that tub bathing after rupture of membranes increases infection risk.

A study was done on women in labor, who agreed to get in a tub of dyed water (indigo blue? a "neutral" substance often used as a medical marker) with a tampon in their vaginas. After a period of time (an hour?) the tampons were removed and showed no penetration of the dyed water. While water may enter the vagina, it does not get propelled further up in the vagina, nor approach the cervix and uterus.

I would even argue that time spent in water decreases infection. As a big proponent of water-labor and water-birth, I explain the worldwide evidence that water-births show a lower rate of maternal and neonatal infections by the mechanisms of dilution and pathocide (if that is a word).

For example, HIV dies almost instantly on contact with water.

Where would I rather conduct a birth (where I know no matter how careful I am some amount of blood and body-fluid contact is inevitable (not during every birth, but someday, somehow)-- in air or in water? Water -every time.

Other problematic pathogens -- E. coli..... b. strep.... hepatitis.... if they are present in the woman's body and pass into the water, they will be dramatically diluted by the waterbath. Does this reduce their virulence? I suppose so, and the results of waterbirths bears this out, with fewer infections noted.

Does the small amount of water that enters the lower vagina have a cleansing effect? Possibly.

Does the waterbath cleanse the anal area, reducing possibility of infection by E. coli and yeast? Possibly.

I am not promoting this as the last word on water and infections, this is my conjecture based on the literature that exists currently, a rudimentary understanding of the infectious process, and my own experience.

Is it also possible that water is actually a medium for bacterial spread and growth? Possible....but contradicted by the available evidence.

Perhaps some of our learned lab colleagues can weigh in on their knowledge of the effect of tap water on common pathogens. I know that E. coli lives in water, but what about GBS?


References:

Seigel. P. Does water enter the vagina during labor? OBGYN 1960;15 660-661

[Bath after rupture of membranes].
[Article in Swedish]
Waldenstrom U, Nilsson CA
Jordemodern 1992 Sep;105(9):311-2

Waldenstrom U. Nilsson CA. Warm tub bath after spontaneous rupture of membranes. Birth 1992:19(2):57-63

And The Guide to Effective Care.....(as always)


I don't forbid baths.


I do--or at least, I tell them the latest research says it's ok, but I prefer they don't bathe. Of course, it's superstition, and I don't mind if they are only going to be ruptured for a day or two before delivery, but if they are going to be ruptured several days, it's one thing that makes me feel better. READ THAT LAST PART CAREFULLY. It MAKES ME FEEL BETTER that they don't take tub baths, and it's a simple thing to do to make me happy. The only two incidences of pp sepsis I have ever encountered were women who spent considerable time in the tub with ruptured membranes. But please note this--both women were transported eventually to deliver, so the infections could have occurred from the hospital. Since then, I ask them not to tub bathe, but I don't forbid them if they really want to.


One of the things I think about with ROM, bathing and the risk of infection is that when a non-pregnant women baths her vaginal muscles are firm, her cervix sits high and usually posterior to the vaginal opening, her vagina is dry and her uterus is as closed as it gets. When a woman is pregnant with ROM, her vagina is soft, wet and the cervix is usually low and anterior and most likely open...that seems like a situation that would encourage the passage of any bacteria present directly to the uterus.


the research done with cotton swatches and women in baths (showing that no water enters the upper vagina) WAS DONE ON POSTPARTUM WOMEN -- ranging from one to five days postpartum I think. Believe me, a postpartum vagina is as patulous as it gets!


Does bath water enter the vagina? [full text]
SIEGEL P.
Obstet Gynecol. 1960 May;15:660-1.

The original study in was done in 1959 and published in the Journal of OB/GYN in 1960 Siegel, P. Does bath water enter the vagina? Obstetrics & Gynecology, 15, 660-1.  There were 10 women- in the study- 5 in the last 2 wks of pregnancy and 5 in the first 3 days PP. Many of the participants were of high parity-para 8-10

It involved women, some pregnant, but not in labor, most, however were not pregnant.  All of the women were asked to bathe for 20 minutes in a normal bath, after sterile tampons had been inserted into their vaginas.  Iodine was placed in the bath water so that it could be seen on the starched tampons, if the bath water entered.  Upon exiting the bath the tampons were removed by sterile procedure and examined closely.  Not one single tampon showed any trace of iodine.  The authors concluded, back in 1959, that the "myth of water randomly traveling into the vagina can be put to bed."



Trickle PROM



Here's another question for you: when do you consider PROM true PROM? What if you have suspicious trickles, and can't document fern, or see fluid? How many of you have experienced a gross rupture of fluid, and then when active labor hits, there is a very nice, intact bag there? I've experienced it more times than not, and after spending time getting someone into labor find this is an interesting dilemma. When do you decide to intervene???



Protocols



Induced-Labor Necessity Notion Draws Challenge followed by Critique


How long do you let your ladies go after ROM?


Assuming no history GBS, clear fluid, negative GBS culture at time of rupture, and reassuring fetal surveillance, we wait until they go into labor.


We do nothing to confirm ROM but check by close questioning of the mom, signs of wet bed, chair, shoes, etc., visualized vernix or mec.  Don't do nitrazine, sterile spec, vag exam.  I feel I can be just as accurate as any other confirmation method.  If the mom isn't *sure* it was her BOW, it usually isn't, IMHO.

My personal protocol is transport and abx by 24 hrs after the first vag exam, and we don't do them till well-established active labor, so most moms don't get abx treatment.  We are working with women who are responsible, mostly clean in body and home, healthy, term.


I don't put anything in the vagina, supposedly-sterile or not, unless FHR deem otherwise, and I would give mom the same instructions.. Then I wait.  I usually opt to begin sepsis prophylaxis after 24-36 hours (vit C, echinacea, garlic) just to give us that extra comfort cushion.  After 36-48 hours, I do discuss with them standard medical protocol, discussing methods of home induction, such as castor oil, leaving them the option to encourage labor or not (unless I have reason to promote labor otherwise).


More times than I like to think about, families have seen their homebirth plans go awry when waters are broken for a prolonged period of time and
an infections sets in.  Then we end up at the hospital for antibiotics and pitocin, and labor may be dysfunctional if the uterine tissue is infected and can't function effectively.  This could even cause a c-section when the mom could otherwise have had a nice homebirth.  And the baby very often ends up with IV antibiotics for 6 days after the birth, which can be a nightmare for the family and a huge expense.  I encourage herbs to get labor going within four hours of broken waters.


  1. do not do any kind of vaginal exam.
  2. regular temp.
  3. regularly check fetal heart.
if there is no sign of infection, i would be prepared to wait anything up to a week - see Effective care. 

The LM licensing board limits us by law to 72 hours "without signs of labor". Unlicensed midwives (though not required to) usually follow this same time-line. We do commonly make a distinction between "leaking membranes" -- thought to be a hindleak -- and "full rupture".

One distinction, though We DO NO VAGINAL EXAMS until labor is in full progress; perhaps not even until second stage looks close. Have never heard of a uterine infection in anyone following the "nothing in the vagina" routine.


Whenever we choose conservative management with PROM, the first rule is "Don't check her!" We sometimes look with an amnioscope if we're not sure, or a simple check with a sterile speculum and amniocator. We also keep them checking temperature p.o. and p.r. plus NST's and BPP's while hospitalizing them.

Of course since the Canadian report our center has become very pro-inducing labor with PROM, but there are the few brave souls who say "Thanks , but no thanks" and of course the preterm ruptures as opposed to the prelabor raptures. What I always questioned about Hannah's study, and it was a big multi-center one, is that one of the significant findings was that the women were actually happier with induction of labor for PROM. If this was in England where they would be managed at home as opposed to being hospitalized in a High risk unit, I wonder if the would have felt the same.


I don't have the info on the Hannah PROM study web site, but did read the study (in the NEJM, I think) shortly after it came out. One thing that stuck out like a sore thumb to me was that even though the study protocol called for NO digital vag exams, about 1/3 of both the induction and the expectant groups had exams. Thought it was very interesting/odd that there was no comment on this, or analysis of those who did and didn't have exams, since the difference in infection rates has definitely been significant in other studies.

PS I forgot to suggest that you call Martha Harvey at Bassett Health Care in Cooperstown, NY, (607)547-3170, for protocols for expectant management of term PROM. She gave a presentation at the ACNM Convention a few years ago, has a very complete reference list, and they have been doing this (waiting rather than inducing, unless there are indications) for years.


We have a pretty weird practice for a group of obs and cnms in that we strive actively to avoid inductions unless medically indicated.

Women often want to be induced (PROM, post dates, etc.), would like ultrasounds every week, etc. We base our clinical activities on what we feel is best...not necessarily what makes women most happy!

Our moms with PROM are not hospitalized (nosocomial infections etc.), but are kept home with daily NSTs, temps etc. until they go into labor.


Make homevisit. See her. Check vitals. Listen to baby. Observe and listen to mom to see if she seems ready to give birth. If there seems to be some holdback, explore it and/or encourage her to do so depending on situation. Tell her to have a look at the handout I gave her titled WHEN YOUR WATER BREAKS BEFORE LABOR. It states:

  1. Drink plenty of fluids, minimum: 8oz 8x day
  2. Allow nothing in vagina, no fingers, no tampons, no oral-genital contact, no penis, nothing whatsoever!
  3. Wear something loose-fitting with no panties.
  4. If you are leaking and need something for sitting, use clean towels fresh out of a hot dryer.
  5. Take your temperature every 3 hours while you are awake.
  6. Take 250mg Vit.C every 3 hours while you are awake.
  7. No baths. Shower as much as you like.
  8. Eat foods that are unconstipating and easy to digest.
  9. Be meticulous about toileting.
If she calls at 11pm or 3am I will tell her to sleep and do visit/handout review in the morning. If Mom and babe check out okay after 12 hrs of ROM and labor hasn't started...

wait....talk to another midwife about possible hold-ups, talk to mom about risks/possible hold-ups, encourage mom to get labor going.

It's hard to make a formula with time limits and what to do in meantime as each situation is unique.

For example: Is this her first homebirth? Does she want to be in the hospital? Does she need some attention from me? from her mate? Is her mother-in-law there but due to leave tomorrow? Is her dearest friend arriving in 2 days? Is she nervous about birthing this baby with her older children present? Is she a midwife with a busy practice, 3 kids and a husband who spends his time drinking beer with the boys?

I'd surely call my back-up OB/GYN and consult before transporting or setting a time limit.


[from ob-gyn-l]


Is any one else bothered by the "new standard" wording from the FDA or is it just my medical legal paranoia coming through???


Well, it would be bothersome that our Government, in its vast and magnanimous paternity, directly contradicts its own recommendations....


PROM Fluids Tested to Assess Lung Maturity


If we have a patient with PROM and no labor, we do a beta strep, begin antibiotics at 18-24 hrs (depending on which resident read which article this week) and have had people be firm about not wanting pit who have waited over 2 days. By then, many people want to be induced. If there is no sign of infection and the baby is fine, what is the rationale in your place of practice to giving her pit after only 12 hours. I realize that I am lucky to have a place this relaxed about it, but we don't have a raging endometritis rate or a lot of infected kids. And most of the women go into labor by themselves eventually.


I also remember one crucial piece of how we manage PROM. After 1 sterile speculum exam to confirm rupture (and that is usually when the beta strep culture is taken), there are NO DIGITAL EXAMS done. The cervix is visualized to the best of the examiner's ability and then she is left alone.


I have seen a few PROM on the last couple of days and I have a doubt about its management. How much should we consider the amniotic fluid index (AFI) in these patients. Lets say, NST, Biophysical Profile and Doppler are normal, except by the AFI, which is zero.


Management would depend on the gestational age. If the patient is at 34 weeks or greater (some would say 32 weeks or greater), I strongly consider induction of labor with possible prophylactic amnioinfusion. If less than 37 weeks, or if prolonged ROM (say greater than 18 hours) I usually prescribe antibiotics.

If she is really preterm I usually prescribe antenatal steroids (controversial) and antibiotics, and do not offer tocolysis if labor ensues. I would hospitalize the patient with continuous fetal monitoring since she is at risk for variable decelerations with possible hypoxemia. Furthermore, I always worry about chorioamnionitis in these cases, and would observe her closely with abdominal exams, temperatures, and fetal monitoring. In preterm situations if I can perform an amniocentesis (pretty tough with an AFI of zero!) then I will do so to help rule out infection, and to check for pulmonary maturity if over 32 weeks or so gestational age. Finally, if extremely preterm (essentially nonviable) then I counsel on the risks of continuing the pregnancy versus expectant management, and if the patient desires, will induce labor for the indication of extreme prematurity with PPROM. If she wants expectant management, I will usually offer to discharge her home with regular vital signs, and subsequent hospitalization when a reasonable viability is reached.

This pretty much covers the scheme where I practice, although, of course, there are variations depending on the clinical situation.


PROM is such a tricky issue.  There's a lot of conflicting research on the subject:

Some research shows clear advantages to induction and/or antibiotics, while other research shows no difference in outcomes.  (And I have often wondered why hospitals were so eager to induce women who are already receiving antibiotics. Do they think the antibiotics work or don't they?  If they work, why are they so eager to get that baby out?  I know, they need the room!)

Unfortunately, there is no research comparing overall outcomes for homebirth clients who choose to receive expectant management vs. homebirth clients who choose to transport to the hospital for antibiotics and induction.

Some things to keep in mind for homebirth midwives trying to make use of the research:

Many studies are done in large urban hospitals where overall health is going to be worse and rates of infection are likely to be higher.  A more promiscuous population is also more likely to have recent GBS infections where mom and baby don't have the immunity conferred by a long-standing carrier status. Remember - only 2 out of a thousand babies becomes infected with GBS; these are going to be the 2 who are most compromised by prematurity, poor maternal health and obvious infection. How do these study results apply to a homebirth practice with healthy women in long-standing monogamous relationships?

Yes, it is likely that for any laboring woman (with or without PROM), the administration of antibiotics will reduce the short-term infection rate.  (Dhuh.)  Heh, why don't we give antibiotics to all laboring women?  Because nothing occurs in a vacuum.  We know from generalized GBS research that administration of antibiotics during labor increases the risk of short-term adverse effects for mom and baby and longer-term postpartum infection from antibiotic-resistant bacteria.  This applies with or without PROM, and it can have disastrous results for the baby, i.e. kill the baby.

Then, you have to add in all the other factors that come into play anytime you change the place of birth from out-of-hospital to in-hospital.  The overall hospital infection rate is 4 times higher than at home.  It's very hard in many hospitals to keep the baby with the mom continuously; this is going to interefere with the establishment of a healthy breastfeeding relationship, which is especially a problem for first-time moms, who seem to be plagued with PROM more than others, for lots of reasons. Babies who don't breastfeed are 10 times more likely to end up requiring hospitalization during the first year of life for respiratory or intestinal infections, and some of them will die.  If even 5% of moms transported for PROM end up not breastfeeding because of being in the hospital, that is significant.

So, even though transport for PROM may reduce the short-term infection rate, what are the long-term effects on that baby? We don't know.

In general, I tell moms that I am comfortable with truly expectant management, avoiding vag exams while watching for signs of infection or fetal distress.  I believe that the research supports this as a responsible approach if you're only looking at the well-being of this mom and baby.  (It's a whole 'nother ball game if you're looking at the long-term effects on homebirth of having a single homeborn baby die from GBS infection after PROM.  How does it affect the legal and political climate in that area?  How does it affect the midwifery community if the midwife involved is forced to stop practicing out of legal issues or simply disgust at the myopic way medicine looks at all these issues. These are not unimportant issues, but I think it's important to remember that they are not issues that help you assess the risk/benefit to this mom and baby.  I fully understand and respect that different midwives will use different criteria to decide whether they feel comfortable staying home with a particular circumstance.  The loss of malpractice insurance may shift this for some midwives, too.)

I look at each case individually.  I take into consideration that for some first-time moms, PROM is their way of getting into the hospital (for pharmaceutical pain relief, general anxiety, whatever) while saving face.  (No, there are no RCTs on this subject!)  These women "need" to be in the hospital.

There will be cases where PROM is caused by an infection; you have to be open to seeing the signs of infection in the mom and baby and react appropriately with a STRONG recommendation for transport for antibiotics and possible induction.

Then there are other cases where baby poked a hole in the sac, or where a momentarily odd head position allowed a toning contraction to break the bag.  These women do not have infections, and they don't need to be in the hospital.

How do you tell the difference?  As other midwives have pointed out, you OFFER transport for antibiotics and induction.  If they jump at the chance, well, there's your answer.  If they want to talk more about their options, you lay out the rules:  nothing in the vagina, meticulous toileting, regular temp. checks, supplements to prevent infection and maybe herbs to get labor going if you think it's a good idea.  If they respond with a nicely responsible and enthusiastic attitude, then you start charting like crazy.  You write out a little informed consent right there in your chart re:  "Recommended transport to hospital for antibiotics and induction for PROM; client declined in favor of expectant management." Then you have them sign something like: "My midwife recommended transport to the hospital for antibiotics and induction for PROM.  I have declined in favor of expectant management.  I will monitor my temperature and discharge for signs of infection and accept the responsibility for making the decision to stay at home.  I understand that this increases the risk of infection, which, although small, may cause death or brain damage for my baby or serious infection for myself."  [If anyone has a more thorough informed consent for expectant management for PROM, I'd love to see it!  Thanks.]

I try very hard to put responsibility back on the family. Although I might feel comfortable about staying home, this is NOT MY BABY!  I am NOT THE PARENT!  I cannot be responsible for making this decision when it could possibly have life and death consequences for this baby - EITHER WAY!  Hospital-based practitioners are "willing" (they don't really have a choice; they are "de facto" assigned responsibility) to accept responsibility because they aggressively pursue the most conservative treatment available.  Note that conservative has come to mean "legal risk reduction", rather than "medical risk reduction".)

There are so many areas in medicine where there is a blindness to the reality that interventions can themselves cause problems, and this applies to routine antibiotics/induction for PROM. Nobody ever looks at a bad outcome and says, "Gosh, if we hadn't induced and/or given antibiotics for PROM, this would never have happened."

I see my role as assessing each individual situation and educating the family about what their options are, what the standard of care in the area is, what the research tells us, and how this applies to them.

If the family is not willing to take responsibility, then they need to be in the hospital.  Even though I haven't been doing this as long as some of the other midwives, I have learned that it is not healthy for me to care about having a homebirth more than the family does, even though I may know more about what a hospital birth really looks like and the long-term effects on all aspects of health.

So, when it comes right down to it, I support the family's choice if it feels comfortable for me and they are willing to take responsibility.  (I understand that the family's willingness to take responsibility in the moment doesn't necessarily mean that they'll still be willing to take responsibility for a bad outcome.  It's important to listen to your instincts about how safe it is FOR YOU to go out on a limb for these clients, even if you believe it is clinically safe.)

These are tough issues.


But again to put it into perspective -- the baby MOST likely to die (or to be born extremely ill with strep) - is born already sick either with intact membranes or membranes which rupture right near birth.... not after PROLONGED Rupture of Membranes!

in other words --- the baby most likely to be the sickest is the one who would not be helped by hospital birth because he would not be covered under most GBS protocols (or the abx wouldn't have time to work).

I am honestly thinking that there is no real way to eliminate strep in babies -- those couple babies in a thousand who get sick --- except possibly to give EVERY mom a shot of penn when she's about 35 weeks pregnant. And nobody is gonna sit still for the expense of that (or for the risk of anaphylactic reaction). But I do think it would get rid of strep!

Just how serious are we getting rid of this rare disease? Not serious enough I think to take this extreme (but effective) step.

The "strep issue" is truly a condition created and ruled by the malpractice attorneys, not by researchers or by practitioners!


One of the nice things, at this point in my life, is my own stats.  I depend on them and am often left very confused by stats which come from other places.  What also helps me, is the stats of other area midwives, which usually correlate with mine.  Together we all have well over 10,000 births.  Though one lady, and her babe, died from infection with PROM, no other deaths of either mom or babe. With the one woman, she did not present herself to the midwifes center until the 3rd day of PROM.  Baby died, in utero, within hours of being at the center and was transferred into hospital where babe was delivered in the morning and the woman died that evening.

My belief is that with proper hygiene instruction and careful watching, any woman with PROM is safe.  And...most PROMs will spontaneously deliver within 52-72 hours from SROM.  Induction at that time will produce better results.

As for the GBS+, well, there I have no stats.  Most of my ladies are not tested for such and so I cannot give much comment there except to say that the babes have not had any problems. 


I personally have seen some very sick babies born to mums with PROM - and the babies I have seen die from GBS were also PROM - your comment about babes who die with no history of PROM interests me as it is not something I have come across in clinical practice - do you have some literature I could peruse on the subject ?


Look at the mortality and severe morbidity stats for GBS sepsis. They are clustered almost entirely within one group --- the 34 to 36 week old rapid labors (not generally with PROM)  -- with a second and much smaller grouping at term with PROM.

This was one of the reasons why there was so much controversy within the CDC about whether to include PROM in the risk data -- the attack rate is very low and thus hard to tease out of the stats..

It is still today even after our almost routine prophylaxis -- the baby most likely to be in the mortality stats for GBS is already sick when he is born -- with most of them being born at that 35 week hump -- and no time for the four hours of abx before birth.

Babies do die of sepsis from other causes than GBS -- but strep seems to have a particular affinity for small babies.



Case Studies of PROM



This pregnancy all going well till last night at 32 wks she has PROM, clear with mild contractions, contractions slowed with use of viburnum. At 7:30 am she was still leaking but very little, 2cm/90%/0station and still having very mild, irregular contractions.

Gave her oral terbutaline at 9:30am which stopped labor. Due to the continual leaking we transported to hospital where they confirmed the ROM, baby doing great, head down, good pockets of fluid around baby, culture, IV penicillin, and celestone to mature the lungs. They plan to continue IV antibiotics for 2 days, repeat the celestone in 24 hrs and then give oral penicillin for one week. As long as there is no infection they will monitor her and baby for signs of infection until 36 weeks and then induce. If any signs of infection they will induce immediately adding more IV antibiotics. Would any of you consider monitoring her at home if things settle down? Any other thoughts?


I have had a number of experiences with PROM. The ones that comes immediately to mind:

A: Not Premature PROM, but ruptured 6 days before any ctx. Took temp. regularly, used Vit. C 1000 TID. On day 6, temp began to rise, but M went into good labour and birthed her baby without further complications.

B: Ruptured at 35 weeks, clear and continual slow leaking for 3 days. Don't remember if any ctx, but leaking stopped, resealed and continued pregnancy for 6 weeks and delivered a healthy baby very nicely.

Several others both premature <35wks with ROM and ctx. No mec. Sent to bed, gave brandy to the point of just feeling "tipsy" which quickly stopped the labour and all these woman continued to term with no infections, antibiotics or complications.

So, I do think it is very possible to monitor at home, keeping an eye on signs of infections, cautioning re: hygiene, etc. and fetal movement. I like to check on them daily and give immune boosters as prophylactic.



Fluids without Rupture



It is possible to have fluid coming out of the vagina that is not from a true rupture of membranes - some possibilities to consider:

The bottom line, of course, is that if the belly is still full of fluid, it almost doesn't matter whether there might have been a tiny rupture that has since sealed over . . . it's very unlikely that bacteria managed to move up against an outflowing of fluid and find the very small hole in the sac before it sealed over.  If you're seeing reassuring heart tones from the baby, and there are no signs of infection in the mom, don't fret about it.

 




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