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

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Unfortunately the American Committee of Obstetricians and Gynecologists (ACOG) has been wishy washy about presenting this evidence.

In 1998,  ACOG recommended that women who present as term PROM should be offered the option of induction or waiting 24-72 hours, further stating that this recommendation was based on Level A evidence.

In 2007, ACOG reversed their decision and recommended that women who present as term PROM should be induced immediately, further stating that this reversal was also based on Level A evidence, on the grounds that inducing labor will reduce chorioamnionitis, febrile morbidity, and neonatal antibiotic treatments without increasing cesarean rates.

Here’s the issue: The same evidence from the same research studies was used to support both the 1998 and the 2007 statements. How can both be true?

In 2013, ACOG continued with the same recommendation as in 2007 but reduced it to a recommendation made using Level B evidence, in other words a recommendation made on the basis of limited or inconsistent scientific evidence.

In 2016, ACOG changed their minds again, they still use the 2013 recommendation but state also:

“However, a course of expectant management may be acceptable for a patient who declines induction, as long as clinical and fetal conditions are reassuring and the patient is adequately counseled regarding the risks of prolonged PROM.”

In 2019, ACOG states that in line with the knowledge that a large portion of women will go into spontaneous labor within 12-24 hours after term PROM and recognizing questions that remain unanswered:

  • Given the available (even if low quality) evidence, OB-GYS’s should recommend labor induction to pregnant women with term PROM who are candidates for vaginal birth, although the choice of expectant management for a limited time may be considered after appropriate counseling.
  • OB-GYN’s and other care providers should inform pregnant women with term PROM who decline labor induction in favor of expectant care of the potential risks associated with expectant management and the limitations of the available data.
  • For appropriately counseled women, if concordant with individual preferences and if there are no other maternal or fetal reasons to expedite delivery, the choice of expectant management for 12-24 hours may be offered.
  • For women who are GBS positive, however, the administration of antibiotics should not be delayed while awaiting labor. In such cases, many patients, OB-GYN’s, and other health care providers may prefer immediate induction.