In most cases, these membranes rupture during labor or within 24 hours before starting labor. Premature rupture of the membranes PROM is said to occur when the membranes break before the 37th week of pregnancy. Amniotic fluid is the water that surrounds your baby in the womb. Membranes or layers of tissue hold in this fluid. This membrane is called the amniotic sac. Sometimes the membranes break before a woman goes into labor.
When the water breaks early, it is called premature rupture of membranes PROM. Most women will go into labor on their own within 24 hours.
If the water breaks before the 37th week of pregnancy, it is called preterm premature rupture of membranes PPROM. The earlier your water breaks, the more serious it is for you and your baby. The biggest sign to watch for is fluid leaking from the vagina. It may leak slowly, or it may gush out. Some of the fluid is lost when the membranes break.
The membranes may continue to leak. Sometimes when fluid leaks out slowly, women mistake it for urine. If you notice fluid leaking, use a pad to absorb some of it. Look at it and smell it. Amniotic fluid usually has no color and does not smell like urine it has a much sweeter smell. If you think your membranes have ruptured, call your health care provider right away. Prelabor rupture of the membranes is the leaking of amniotic fluid from around the fetus at any time before labor starts.
If labor does not begin within 6 to 12 hours, the risk of infections in the woman and fetus increases. If the pregnancy is less than 32 weeks, women may be given magnesium sulfate to reduce the risk of cerebral palsy.
The flow varies from a trickle to a gush. As soon as the membranes have ruptured, a woman should contact her doctor or midwife. Usually, the fluid-filled membranes containing the fetus rupture during labor. But occasionally in normal pregnancies, the membranes rupture before labor starts—prelabor rupture.
Prelabor rupture of the membranes may occur near the due date at 37 weeks or later, when pregnancy is considered full term or earlier called preterm prelabor rupture if it occurs earlier than 37 weeks. If rupture is preterm, delivery is also likely to be too early preterm Preterm Labor Labor that occurs before 37 weeks of pregnancy is considered preterm.
Babies born prematurely can have serious health problems. The diagnosis of preterm labor is usually obvious. Measures such Intra-amniotic infection Intra-Amniotic Infection Intra-amniotic infection is infection of the tissues around the fetus, such as the fluid that surrounds the fetus amniotic fluid , the placenta, the membranes around the fetus, or a combination Presentation refers to the part of Early detachment of the placenta placental abruption Placental Abruption Placental abruption is the premature detachment of a normally positioned placenta from the wall of the uterus, usually after 20 weeks of pregnancy.
Infection of the uterus can cause a fever, a heavy or foul-smelling vaginal discharge, or abdominal pain. If prelabor rupture results in a preterm delivery, the premature newborn Premature Newborn A premature newborn is a baby delivered before 37 weeks of gestation.
Depending on when they are born, premature newborns have underdeveloped organs, which may not be ready to function outside When there is bleeding in the brain, the brain may not develop normally, causing problems such as cerebral palsy Cerebral Palsy CP Cerebral palsy refers to a group of symptoms that involve difficulty moving and muscle stiffness spasticity.
It results from brain malformations that occur before birth as the brain is developing If the pregnancy is less than 24 weeks when the membranes rupture, the fetus's limbs may be deformed. After the membranes rupture, contractions usually begin within 24 hours when the woman is at term but may not start for 4 days or longer if rupture occurs between 32 and 34 weeks of pregnancy. Using a speculum to spread the walls of the vagina, the doctor or midwife examines the vagina and cervix the lower part of the uterus to confirm that the membranes have ruptured and to estimate how much the cervix has opened dilated.
If prelabor rupture of the membranes is diagnosed and the fetus can survive outside the uterus, the woman is usually admitted to a hospital so that the status of the fetus can be determined. If the pregnancy is less than 34 weeks, usually rest, close monitoring usually in the hospital, antibiotics, and sometimes corticosteroids. Researchers have combined all of the results from randomized trials on this topic into one large study, called a meta-analysis.
In , an updated Cochrane meta-analysis replaced the prior version that was published in The new review contained 23 randomized trials with a total of 8, people giving birth. Ten studies compared expectant management to induction with IV oxytocin, and 12 studies compared expectant management to induction with misoprostol or vaginal prostaglandin E2 Middleton et al. One problem that we noted with this review is that only 2 of the studies contributing participants out of the 8, total screened and treated for Group B Strep.
Five studies gave antibiotics to everyone, regardless of whether or not participants had Group B Strep.
If the reviewers specified the exact level of evidence for each finding, we have noted that in parentheses below. The researchers found that overall, there may be more pros than cons to induction with term PROM. Women who were immediately induced after term PROM had shorter durations from PROM until birth, were less likely to experience maternal infections low-quality evidence , and appeared to have no increase in the risk of Cesarean low-quality evidence. Their babies were less likely to need antibiotics after birth and less likely to be admitted to the NICU, and both mothers and babies had shorter hospital stays.
There were no differences between induction and expectant management groups in the risk of serious maternal infection very-low quality evidence , definite newborn infection very-low quality evidence , or perinatal mortality , a combined measure of stillbirth or newborn death moderate-quality evidence.
Two possible side effects of medical induction are uterine hyperstimulation and uterine tachysystole. In , the American College of Obstetricians and Gynecologists recommended abandoning the term hyperstimulation because it is vague and not defined. Instead, the term uterine tachysystole should be used.
Uterine tachysystole is defined as the uterus contracting too frequently more than 5 contractions in 10 minutes, averaged over a minute window , and can lead to a possible decrease in oxygen to the baby as well as fetal heart rate changes during labor. Four studies in the Cochrane review reported higher rates of hyperstimulation or tachysystole in the induction groups. The largest study that reported this side effect was carried out by Krupa et al.
In this study, there were participants, and half of them were induced with misoprostol [Cytotec]. The researchers found that On the other hand, they found more fetal heart rate decelerations in the expectant management group Because it was such a large study, the Term PROM study results drive most of the findings in any meta-analysis, including the Cochrane review on this topic Dare et al.
Therefore, we will focus on the findings of the Term PROM study in this article, while occasionally mentioning results from other studies. Between the years of , a group of researchers from 72 hospitals enrolled 5, low-risk women from six different countries Canada, United Kingdom, Australia, Israel, Sweden, and Denmark into the Term PROM study.
Women were invited to be in the study if they came to the hospital with PROM. Everyone had a non-stress test before entering the study, and they were not included in the study if they had meconium staining of the amniotic fluid or any signs of infection when they arrived at the hospital.
Everyone was swabbed to check for Group B strep when they entered the study, but in most cases nobody knew the results of the GBS test until after the baby was born.
People with term PROM were randomly assigned to one of four groups:. Those people who were assigned to the waiting groups could wait for labor to begin either at home or in the hospital. They were told to check their temperatures twice per day and were told to report any fever, change in the color or smell of the amniotic fluid, or other problems. In the Term PROM study, there were no differences in Cesarean rates between the induction groups and the waiting for labor groups.
Cesarean rates were low in all four groups When the researchers separated out those people who had given birth before, versus those who were giving birth for the first time, they still found no differences between groups. Among people giving birth for the first time, Cesarean rates were:. About 1 in 4 of people giving birth for the first time had forceps or vacuums used during their births. Among people who had given birth before, only 3. There were no differences between induction and expectant management groups in rates of forceps or vacuum deliveries.
Most other studies that compare the rates of Cesarean section in induction vs. The chorioamnion or membrane is a physical barrier to bacterial invasion during pregnancy, so when the water or membranes break, this means the mother is at higher risk for infection.
Chorioamnionitis means inflammation of the membranes due to infection. For the rest of this article, we will refer to this condition as chorio. There were no differences in rates of chorio between people in the immediate induction with prostaglandins group compared to people in the waiting for labor for up to four days until induction with prostaglandins group. This is a pretty high rate, and could be partially explained by the fact that very few people in the study had antibiotics for Group B Strep—a known risk factor for chorio.
In , researchers published a large study that people with term PROM, and they found that with screening and treatment for GBS, the overall rate of chorio was 1. When we look at the Term PROM study, there are several potential reasons—other than the induction itself—that could help explain why those in the immediate induction with oxytocin group had lower rates of chorio. These reasons include the fact that people in the immediate induction group had fewer vaginal exams, shorter labors, and spent less time in the hospital compared to women in the waiting group.
Similarly, the Cochrane review found that induction is associated with a lower risk of infection in the mother. However it is very important to note that most of the studies in the Cochrane review did not take into account the number of vaginal exams, nor they do not follow current GBS infection protocols.
The number of vaginal exams that someone with PROM has after their water breaks is a very important possibly the most important predictor of whether someone with term PROM will develop chorio.
Compared to those who had fewer than three vaginal exams :. The strong link between the number of vaginal exams and the risk of chorio has been confirmed in many other studies.
For example, in , Ezra et al. The reason vaginal exams can lead to infection is because even though care providers use sterile gloves, their fingers are pushing bacteria from the outside of the vagina up to the cervix as they conduct the exam. In fact, vaginal exams have been shown to nearly double the number of types of bacteria at the cervix Imseis et al. In one small research study, five women had two sterile speculum exams, and their cervixes were swabbed to check for bacteria after each exam.
There was no increase in bacteria on the cervix after the second speculum exam Imseis et al. This is important because those people who were in the waiting groups took longer to give birth than those people who were induced with oxytocin. In other words, those in the waiting groups likely had an increased risk of infection due to the initial vaginal exam Seaward et al.
Not surprisingly, the Term PROM study found that people who are induced give birth more quickly than people who wait for labor to start on its own. Women in the immediate induction with oxytocin group gave birth an average of 17 hours after their water broke, and women in the immediate induction with prostaglandins group gave birth an average of 23 hours after their water broke—compared to an average of 33 hours among those in the waiting groups.
There was no evidence that term PROM increases the risk of cord prolapse. Cord prolapse only occurred two times out of more than 5, people with PROM who were enrolled in the study—once in the induction group and once in the waiting group.
There were no differences in newborn infection rates between any of the groups. The Term PROM researchers carefully defined what an infection would be and even had separate doctors evaluate for newborn infection. Several other studies have looked at risk factors for newborn infection. These risk factors included:. In some studies, mothers whose labor took longer to start after their water broke were more likely to have newborns who were admitted to the NICU, or having a longer stay in the NICU Akyol et al.
It was not clear if this was because care providers were being more cautious with these infants. In the Term PROM study, there were no statistical differences in stillbirths or newborn deaths between the groups. Despite the fact that the study included more than 5, mothers, it was still not a large enough study to tell a statistical difference in deaths.
Because stillbirths and newborn deaths are such a rare event, you would need more than 28, people in a randomized trial to tell a difference in mortality rates between groups. There were two deaths in the expectant management oxytocin group, two deaths in the expectant management prostaglandins group, and zero deaths in the induction groups. The fact that all four of these deaths occurred in the two waiting groups could have been due to chance, or it could have been related to the waiting for labor to begin.
Because the study was not big enough to tell differences in death rates, we will never know the answer to that question. In the Term PROM study, there were no differences between groups in the following newborn health issues:. Fewer babies in the oxytocin induction group 7. This may be because mothers in the waiting group were more likely to have chorio, and it is quite common for babies to receive antibiotics if their mother experienced chorio.
The researchers suggested that these longer NICU stays might have happened because care providers are more worried about infants born to mothers with prolonged rupture of membranes and want to provide more monitoring for them.
In the Term PROM study, mothers in the oxytocin induction group were less likely to say that there was nothing they liked about their treatment 5. In other words, rates of satisfaction were high in both groups, but higher in the induction groups. If someone chooses to wait for labor to start on its own, is there any evidence that it is safe to wait at home?
People who were randomly assigned to the expectant management groups were given the choice of waiting in the hospital, or returning home to wait for labor to begin there. Out of the entire study, women decided to go home, and 1, decided to stay in the hospital. The researchers found that there was an increase in some risks among people who waited for labor to start at home. Compared to those who stayed in the hospital, people who waited at home were:.
More babies born to mothers who waited at home received antibiotics Certain factors increased some of these risks. Mothers giving birth for the first time who waited at home were even more likely to need antibiotics before delivery.
Mothers who tested negative for GBS were more likely to need a Cesarean if they waited at home. Despite these increased risks, more people reported being satisfied with their care when they waited for labor at home Hannah et al. Because the evidence we have is limited, the benefits and risks of waiting at home are not clear. In the next section, we will talk about a recent, large study in which women waited for up to 48 hours for labor to begin.
However, these people waited in the hospital, and they received antibiotics immediately if they were GBS positive, or at 24 hours for everybody else See below. In , Pintucci and colleagues published a prospective research study in which they followed 1, people with term PROM Pintucci et al. The people in this study waited for labor to begin for up to 48 hours unless there was a medical reason for induction.
People were not allowed to be in the study if they were already in active labor, had a baby in breech position, or a high-risk condition such as diabetes or high blood pressure.
The fetal heart rate was monitored every two hours. Antibiotics were started after 24 hours of ruptured membranes, immediately if the woman was GBS positive, or if she developed any signs and symptoms of chorio fever, meconium staining, fast heart rate in the mother or baby.
Labor was induced at 48 hours using oxytocin, prostaglandin gel, or both depending on cervical score if it had not begun on its own. The people whose labors began on their own had a 2. The authors conclude that people who were induced at any time point had 6.
However, these results should be interpreted carefully—participants were only induced if they had medical reasons for an induction such as infection , so this may explain why the Cesarean rate was higher in that group.
The length of time from rupture of membranes to birth was not related to Cesarean section in this study. In the Pintucci et al. The newborn infection rate was 2.
Newborn infection was defined as having at least one of the following: a low blood leukocyte count, high or low neutrophil count, elevated C-reactive protein a measure of inflammation , or two or more symptoms such as vomiting, low temperature, fever, blue color, not breathing, fast breathing, trouble breathing, or high blood sugar. When they only looked at babies born more than 24 hours after PROM, the rate of infection increased slightly to 2.
Mothers who developed chorio or had more than 8 vaginal exams during labor had an increased risk of having a newborn with an infection. The results from the Pintucci study are important, because this is the first large study to look at those with term PROM who had modern testing and treatment for Group B Strep. Basically, the results showed this group of people was able to wait for labor to begin on its own, with very good outcomes for both mothers and babies.
Again, they said there was Level A evidence, or the highest level of evidence, for this new recommendation. But the same evidence from the exact same research studies was used to support both the and the statements.
The consequences of the new guideline were strong. Many people in the U. To learn more about what happened during this time point, you can read this article on Science and Sensibility. In , ACOG replaced bulletin number 80 with bulletin number And then in , ACOG changed its recommendation again. The American College of Nurse Midwives ACNM states that women with term PROM 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.
These criteria for safe expectant management include:.
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