Premature Rupture of Membranes at Term

What do you do if you are term (defined as more than 37 weeks) and your water breaks before your labor starts?  There are two options, induction or expectant management. Rebecca Dekker, PhD, RN, APRN, and her colleagues offer a comprehensive review of the available research in: What is the Evidence for Inducing Labor if Your Water Breaks at Term.

I would encourage you to read the article.  It represents an incredible amount of research and is fascinating, if somewhat frustrating due to the inconsistencies from one study to the other and changing practices over time, particularly related to GBS testing and our current understanding of the correlation of  increased risk of infection with the increased number of vaginal exams.  Dekker concluded that there is evidence for both induction and expectant management as long as mother and baby are doing well and meet certain criteria.  I have copied a quote from the end of her article below. After my first reading, I went back and identified actionable ideas for pregnant women to lessen the chance of PROM and subsequent infection.  Here is Dekker’s conclusion followed by my summary.

"The American College of Nurse Midwives states that women with PROM at term should be informed about the risks and benefits of expectant management versus induction, and that if women meet certain criteria they should be supported in choosing expectant management as a safe option.

The criteria in the ACNM position statement include:

  • A term, uncomplicated, pregnancy with only one fetus and with clear amniotic fluid
  • No infections including Group B Strep
  • No fever
  • Normal fetal heart rate
  • No vaginal exam at baseline, and then vaginal exams are to be kept to a minimum during active labor

What’s the bottom line?

  • Having labor induced with oxytocin may lower a mother’s chances of experiencing infection, but does not have an effect on the C-section rate or on newborn infections
  • One of the single most important ways to prevent infection after your water breaks is to avoid vaginal exams as much as possible during labor
  • As long as both mother and baby are doing well and meet certain criteria, waiting for up to 2-3 days for labor to begin on its own is an evidence-based option. At the same time, induction is also an evidence-based option
  • In today’s era with access to antibiotics if needed, the “24-hour clock” for giving birth is no longer based on evidence"

Here is my summary from Dekker’s term-PROM (premature rupture of membrane’s) article.

Regarding personal decisions in pregnancy and labor.

  1. Don’t get vaginal exams in the last weeks of pregnancy.  They are usually of no benefit and may increase risk of PROM.  Unless you are facing an imminent induction and you need to know your Bishop Score, an assessment of cervical ripeness, the knowledge that you are 2 centimeters dilated at 39 weeks is not going to make any difference and it will not be predictive of the start of labor.
  2. Stripping membranes is sometimes done in an effort to start labor.  It also increases risk of PROM.
  3. Get treatment for suspected vaginal infections during pregnancy.  Women with yeast infections had higher incidence of PROM.
  4. Take Omega-3 fatty acids during pregnancy to reduce inflammation.
  5. Figure out ways to encourage healthy lactobacillus bacteria in the vagina. Talk to a nutritionist or naturopath about taking a probiotic and eating naturally fermented foods like sauerkraut and pickles.
  6. Figure out ways to discourage GBS in the body (gut and vagina and urinary tract) during pregnancy.  Again, guidance from a nutritionist or naturopath can improve your gut health.
  7. DO NOT get a “baseline” vaginal exam if you have PROM and labor has not started.
  8. Don’t get routine vaginal exams in labor to see if you are making progress.
  9. Only get a vaginal exam when YOU feel you definitely need more information to make a major decision like getting an epidural.
  10. Women should be given a choice of expectant management, including expectant management waiting at home.
  11. Using a sterile speculum does not result in increased bacteria on the cervix.  Vaginal exams do result in increased bacteria on the cervix.

 

Regarding the studies reviewed by Rebecca Dekker and her colleagues, I conclude the following:

1. The studies are difficult to interpret.
2. Most studies were done before current GBS testing and protocols were in place, so rates of infection are higher.
3. The one study reported in 2014 does have current GBS testing and protocols, but the c-section rates in the induction group may be skewed higher because inductions were only done on term PROM women who were experiencing complications such as high blood pressure, fever, fast heart rate.
4. In the TermPROM study from 1996 about 40% of women had a vaginal exam upon entry which may have increased the risk of infection in expectant management groups where women took longer to start labor on their own vs. women who were induced right away.  This may also have resulted in higher infant infections and longer NICU times.