Your Water Breaks First - A Date to PROM (Premature Rupture of Membranes) - Definition, Transmission, Symptoms and Common Culprits of Maternal/Neonatal Infections

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Infection is defined as the invasion and multiplication of microorganisms such as bacteria, viruses, and parasites that are not normally present in the body. An infection may cause no symptoms (subclinical) or it may cause a variety of symptoms and be clinically apparent. Infections can also be localized (one spot) or systemic (spreading through blood and/or lymph vessels). Infection is separate from the normal bacterial biome that inhabits your body.

Each part of your body carries its own distinct bacterial biome, and the shifting of bacteria from one particular biome to another, even within the same body, also increases your risk of infection.

We will use GBS as an example because pregnant women are often asymptomatic carriers of GBS, a type of bacteria that can be part of a woman’s normal vaginal flora, and cause no outward infectious symptoms. While GBS was not treated for during the term PROM studies below, it was a factor in the results, and nowadays GBS is routinely screened for and treated. This type of infectious transmission is one of the reasons why:

Remember, vaginal tracts, birth canals, and cervical openings are generally “one way streets” designed to release down and out—secretions, fluids, and babies all flow down and out of the body. Therefore, during an intervention free labor and delivery, GBS bacteria that is present as a normal part of a woman’s vaginal tract flora will either stay put or get washed down and away with other secretions.

However, when a cluster of GBS organisms are moved further up the vaginal cavity and then introduced into the uterine cavity through the previously sealed cervix on the gloved tips of fingers or perhaps on the tip of a prostaglandin gel applicator, the previously benign bacteria enters a different biome, and in this “new biome” GBS is an intruder, it is now a potentially harmful infectious agent. In the case of ruptured membranes, GBS is then further transmitted into the previously sealed world of your unprotected baby.

Please avoid all medically unnecessary invasive procedures, as this is truly the #1 evidence based way to reduce the risk of neonatal and maternal infection. If I have to say this a million times I will.

Common symptoms of infection include but are not limited to: feeling run down, fever & chills, fluid drainage, foul smell, pus, continual or increased pain, redness & swelling, infection site is hot to the touch, rapid pulse, rapid breathing, even diarrhea and vomiting.

The primary culprits that put mothers at risk are: chorioamnionitis, puerperal sepsis, intrauterine infection, extrauterine infection, and of course, GBS. There are an abundance of others as well, but these are the typical types of maternal infection.

The two types of infection referenced in the evidence based studies that back up the prevailing management strategies in today’s medical practice for term PROM were clinical chorioamnionitis and Group B Strep. Unfortunately in this day and age both of these types of infection represent  a minefield of conflicting medical and midwifery opinion regarding their diagnosis and treatment.

I have come to the conclusion that there are NO simple answers to be found about anything surrounding term PROM. But I’m going to give it a go, as I feel one is best served when they have all the relevant information at their disposal.

 In regards to GBS, especially in the presence of term PROM, I will give my standard advice, while the likelihood of neonatal infection is uncommon, if certain criteria are met, a genuine risk does exist, and it can be quite devastating to the health of your newborn, so unless you feel incredibly and strongly otherwise, get treated with prophylactic antibiotics. At some point I will be writing more on this topic so that I don’t have to direct you elsewhere but in the meantime there is an extremely thorough presentation of the facts and evidence on Evidence Based Birth

I’m going to write a little more about chorioamnionitis especially as the term PROM studies referenced here used the clinical method in diagnosing for this infection and unfortunately this method of diagnosis is enmeshed in medical controversy today. The very word chorioamnionitis in your chart could have a significant impact on your treatment and your baby’s treatment after birth. So, yay, this just got that much longer.

My search for accurate numbers has also been frustratingly difficult, I am now simply presenting what I have found, if better numbers are out there I can’t find them or do not have access to look at them.

Here is what I found on pregnancy related infection rates, a search that started when I had what I thought was a simple question— How many women who present with term PROM actually develop an infection?  A recent nationwide average—nope nothing— couldn’t find one anywhere.

There are probably other reasons for the paucity of numbers but the lack of recent reliable evidence based studies doesn’t help the matter.  The studies that do exist are discussed later in this post.

And after reading up on the struggle to correctly diagnose and treat intrauterine infections such as chorioamnionitis, I guess I really should be used to the lack of numbers by now.  Another simple research question that once again uncovered yet another quagmire.

Perhaps this lack of numbers also stems from the fact that the mere presence of term PROM does not cause infection in and of itself. An infectious microorganism must also be present or be introduced into the equation and then multiply for morbidity (person gets sick) to present.

This infectious agent must be either added from an outside source in the presence of PROM to allow even the possibility of intrapartum infection to occur or the infectious agent may already be present in your body before labor begins.  In fact, this preexisting microorganism may have been responsible for the fact that your membranes ruptured, this is a common causation of rupture in preterm PROM.

Regardless, both term PROM and infections are classified as underlying conditions.  An underlying condition is defined as a disease or injury that initiated the train of events leading directly to morbidity and/or death. It is also defined as the circumstances of the accident or violence that produced the injuries and/or fatality.

So infection is an underlying condition that can allow for maternal mortality, and term PROM can be an underlying condition that allows for infectious morbidity to occur.

Throughout the history of childbirth infection has played a huge role in terms of both infant and maternal mortality. So that I may keep things “briefer” here I have promised myself that I can write a term paper on the history of infection in childbirth at a later date.

Chorioamnionitis, intrapartum, postpartum, puerperal infections etc. are the common culprits of maternal morbidity (mom gets sick) and account for 4-10% of all deliveries.

According to the CDC (2018) infection accounts for 12.7% of pregnancy related deaths in the United States, it is the 3rd most common cause of maternal death. They further state that more than 50,000 women suffer annually from “severe maternal morbidity” (you are really really sick but you survive). This translates to the statistic that for every 1 death 70 women nearly die.

What makes that statement so horrible is that infection is both preventable and treatable by the use of antisepsis and antibiotics, but medical interventions such as induction and epidural analgesics have made proper diagnosis of inflammation, infection or both a real struggle.