Your Water Breaks First - A Date to PROM (Premature Rupture of Membranes) - The 24 Hour Clock

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The 24 hour clock rule means that in some places you will be allowed 24 hours for the birth of your baby or you will automatically need a Cesarean Section, but in other locations it means that a woman has 24 hours to go into labor before she is induced. Other doctors translate this to mean birth within 24 hours even if that means an immediate Cesarean Section.

In practice, in Pittsburgh, this likely means your doctor would prefer to begin induction upon your arrival at the hospital, irregardless of the actual timing of your rupture. Midwives are generally more lenient and in the absence of fever AND fetal and maternal stress will allow for expectant management in the 12-24 hour range, this also varies according to where your midwife practices.

The clock came in to being in the 1950’s - 1960’s and back then babies were more likely to die the longer a woman’s water was broken. According to the clock of infection, fetal mortality due to infection increases with the time of the duration of the rupture of the membranes.

There was genuine need for the clock back then, as studies from this time frame clearly showed that death rates were 2 to 3 times higher than for babies who were born within 24 hours of PROM.

Let’s apply a little perspective as 2018 is definitely not 1950. In 1950 the overall death rate for babies was much higher than it is today.  Hospital births could see rates as high as 4%. 

The infant mortality rate is the number of deaths under one year of age occurring among the live births in a given geographical area during a given year, per 1,000 live births occurring among the population of the given geographical area during the same year.

This translates to 19.2 deaths per 1000 births in 1950, 15.9|1000 in 1968,  9.2|1000 in 1980,  and 5.79|1000 deaths in 2017.

Neonatal mortality is the number of deaths during the first 28 completed days of life per 1000 live births in a given year or period. As of 2018 the US showed a rate of 3.7 neonatal deaths per 1000 births. As a comparison as of 2017— Japan 0.9|1000, Finland 1.8|1000 (2015), Canada 3.5|1000.

You may be asking: “What about the mothers?” So a little more perspective is still in order.  Delivery procedures were quite different back then, Cesarean Sections were still quite risky and were seldom performed, but the use of forceps was quite common.

I was born in 1961 and my mother gave birth to me vaginally but under some sort of anesthesia after laboring alone for hours in a curtained off portion of a giant labor ward. Women during this period also received very little prenatal care. My birth story.

The powers that be at the CDC calculate neonatal and infant mortality rates as the number of deaths per 1,000 births but for maternal mortality rates as the number of deaths per 100,000 births.

I think this is done because these ratios make for numbers that are easier for the general public to understand. However, it is a little confusing looking at the rates for moms and babies side by side because at first glance it appears that mothers are at more risk than babies, but the truth is that babies have always been at higher risk, ever since the beginning of birth.

While it is certainly true that in 1950 the rate of maternal mortality was alarmingly high at 83.3|100,000 births remember the overall infant mortality rate at the same time was 19.2|1000 (if you multiply this number by 100 you will see the comparable ratio).

Whereas almost 84|100,000 women died we see now in direct comparison that 1,920|100,000 babies died. If you do the math the other way around you will see that almost one (0.83) woman died for every 19.2 babies per 1,000 in 1950.

For the most part the United States seems to have gotten a good hold on neonatal management, care and treatment, not great, but better. This does not seem to be the case where the mothers are concerned.

I have given up more than once, I have screamed in frustration, I have repeatedly searched the internet for a simple answer to a simple question. What is the current maternal mortality rate in the United States?

For example: The journal Lancet put the US at a rate of 26.4|100,000 births whereas the World Health Organization (WHO) estimated the number to be 14|100,000 births in 2015. The reason for this discrepancy— well everyone calculates this rate differently—of course they do.

Today I found the following article:

The Embarrassing State of U.S. Maternal Health Care

“Its gotten to the point that no official count of pregnancy related deaths in this Country or an official maternal mortality rate even exists” 

I find this article reassuring only in the sense that I least I’m not losing my mind—it is virtually impossible to find consistent numbers.

Thanks to the medical advances in cleanliness, antibiotics, and cesarean deliveries, etc. the death rate plummeted from the 1950’s up until around 2003. The lowest reported rate was in 1987 7.2|100,000 deaths but it spiked up again around 2003 to 16.8|100,000 deaths.

While at first it was believed that the spike in birth-related deaths was due to a pregnancy related question added to death certificates in 2003, this is no longer the belief, as maternal mortality rates have continued to rise. It took until 2017 for all 52 reporting agencies to finally even add the check box to their death certificates.

Let’s just go with this statement that I found numerous places on the internet including the above article. It is generally agreed that 700-900 women die each year and many more women almost die each year for reasons tied to pregnancy and that many of these deaths and complications are completely preventable.

Whether you choose to go with the 26.4 (Lancet) or 14 (WHO) number when you compare either number against fellow developed nations such as Finland 3, Japan 5, and Canada 7 (all data WHO) our number is still an embarrassing disgrace.

I am going to let it go at that and move on.

I know it seems weird to be comparing giving birth today to giving birth in the 1950’s but I can almost guarantee you that your doctor/midwife will be using some version of this very same 24-hour clock.

While those early studies provided vital information and paved the way for a vast improvement in infant mortality rates today, in 2018, we have access to better quality analysis of the data regarding what happens when women wait for labor to start on its own or whether labor is medically induced after term PROM.

So shouldn’t your doctors be referring to this higher quality data when managing your care?  Nope, we are still in the lag time.

Since the 24 hour term PROM clock is also the “clock of infection”, a little perspective about infection is needed here as well.