Your Water Breaks First - A Date to PROM (Premature Rupture of Membranes) - Uncommon Complications of Term PROM and PPROM

Article Index

1. Prolapsed Umbilical Cord. 

This is defined as a cord presentation in which the umbilical cord has slipped between the fetal presenting part and the cervix. This is exceedingly rare and rates range from 0.1-0.6% (so an average of 40 cases for every 10,000 births). While the incidence of prolapse is rare, when it does occur it is a genuine medical emergency and the incidence of neonatal mortality rises. Fortunately, medical science has made a lot of progress in the management of prolapse over the last several years. 

According to the Evidence Based Birth signature article regarding term PROM there is little to no evidence that term PROM is even a risk factor for umbilical cord prolapse. Prolapse is even less likely at ≥37 weeks because the majority of babies are head down and well engaged in the pelvis at this point.

The prolapse of an umbilical cord is more generally seen in preterm PROM and in other premature deliveries and while deaths can occur with prolapse the actual causation is almost always due to the prematurity and not the prolapse.

This makes sense as preterm babies have yet to descend and engage, they might even be breech, in other words there is plenty of room for the cord to slip down and through towards the cervix. Also some women present as polyhydramnios  (excess amniotic fluid) which means that there is even more liquid space which makes for more of risk.

So if your water breaks spontaneously at ≥37 weeks and your baby is head down and well engaged into your pelvis, you have a normal amount of amniotic fluid, the A in your TACO assessment is a steady slow leak you have almost zero to worry about in terms of a possible cord prolapse issue.

If, however, your water break spontaneously at ≥37 weeks and at your last exam your baby was still not fully engaged, head a little off to one side, and your water comes gushing out like there is no tomorrow, call your healthcare provider, as no doubt getting your baby promptly checked out would bring you better peace of mind.

If a spontaneous rupture happens before 37 weeks, then call your healthcare provider, and follow their instructions, and head to the hospital.

One final word, if you have genuine reason to believe that your umbilical cord has prolapsed, for example: you can feel its presence in your birth canal or in your vaginal opening, then immediately assume the following position:

Grab your phone, come to hands and knees and then down to your forearms, your bottom should be well above your head, assuming this position will take the pressure of the presenting part (e.g. the head) of your baby off of the umbilical cord. Then call 911, this is a medical emergency.

2. Umbilical Cord Compression

This is a somewhat more common occurrence during ALL pregnancies and is typically seen in 1 out of 10 deliveries. Sometimes the umbilical cord gets stretched or compressed during labor leading to a brief decrease of blood flow to the fetus. The usual causes are pressure from an outside source (usually due to the position of fetus) or knots and entanglements of the umbilical cord itself.

Cord compression usually results in sudden short drops in the fetal heart rate, that are usually not a major deal, they come and go, and birth occurs without complication. The best relief comes with switching positions frequently during labor which will relieve these minor bouts of compression.

If the compression is more severe, the fetal heart rate decelerations will also be more pronounced and the fetus will begin showing other signs of distress, at which point perhaps a Cesarean section becomes the better option for the safe delivery of the baby.

Prolapsed umbilical cord and oligohydramnios (insufficient amniotic fluid) are both complications of spontaneous membrane rupture that can possibly lead to cord compression.

Furthermore, it must be said, compressions during uterine contraction may also occur, and it is evidence based that contraction based cord compression is a common side effect associated with induction using intravenous Pitocin.

3.  Placenta Abruption

This is defined as a childbirth complication in which the placenta either partially or completely separates from the wall of the uterus before delivery.  Based on the severity of the abruption this can decrease or block oxygen supply to the baby and cause heavy maternal bleeding.

This is an uncommon yet serious complication, and some degree of abruption is seen in 1% of all births in the United States annually, but particularly severe cases that lead to fetal death are only seen in 0.12% of the total instances.  According to MedScape the primary cause of abruption is usually unknown but well established risk factors include maternal trauma (9.4%) and maternal hypertension (44%) of all cases in the United States.

Other established risk factors are the sudden decompression of the uterus and a rapid loss of the majority of the amniotic fluid surrounding the baby such as could be seen during some spontaneous ruptures of the membranes or during the delivery of the first twin.

Reasons for concern during your TACO analysis would your water breaking in a gigantic gush and copious amounts continue to flow and/or the presence of bright red blood that is more than spotting.

As a PPROM I can speak from experience, I didn’t have any of the above complications but I did have a gusher, I eventually grabbed a bunch of beach towels and sat on them in the car during our mad dash to the hospital, as I could not staunch the flow.  We dashed so fast on account of the prematurity, because while the gush was more like Niagara Falls the fluid was clear and odor free.

4. Fetal Malposition

A complication that is characterized by babies who do present as head down at or near the onset of labor BUT the head is not situated in the way that is most optimal for birth, typical examples include but are not limited to babies who present “sunny-side up”, heads cocked to one side, or with one hand up beside their face “super man style”.

The fluid filled amniotic sac cushions and protects your baby, and as long as the membranes are intact a malpositioned  baby has the potential to shift into a position that is more optimal for birth. This maneuverability is lost when the membranes rupture. This holds true whether your membranes have spontaneously ruptured on their own accord or whether your OB/midwife has artificially ruptured your membranes to “speed things up”.

Yes, I find it ironic that during a labor that features intact membranes, medical staff is quick to suggest breaking your membranes as this will “bring on and speed up labor” and yet when you present with term PROM medical staff is quick to insist on induction because ruptured membranes are not  an efficient means of bringing on or speeding up contractions.

As a matter of fact all of the information in this section has come from sources talking about the associated risks that come from an Artificial Rupture of Membranes (AROM). All the SAME rules and all of the SAME complications come with allowing a health care provider to break your water.