Your Water Breaks First - A Date to PROM (Premature Rupture of Membranes)

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Preface:

Full disclosure, dear reader, I have had a hard time remaining objective on this topic and have found it difficult not to let my personal experiences influence the information in this post. I have done my best but for the record:

  1. I am a PPROM (pre-term premature rupture of membranes). I have one child, my water broke almost a month before my due date, which led to further complications including maternal and fetal fevers, meconium staining, and by the next morning an emergency Cesarean Section. Scary beginning, healthy outcomes.
  2. My husband almost died from “strep throat” of the elbow. He bumped his elbow on a doorframe in the middle of a Friday night, long story short, he tore a tiny hole into one of his meniscus sacs (fluid filled pouches that cushion and protect your joints, much like the amniotic sac that cushions and protects your baby). The existing Strep bacteria in his body migrated to his meniscus sac and took advantage of the weakness.  The first morning his elbow was quite swollen, he called our primary care doctor, who was not concerned, didn’t even consider the possibility of infection, gave OTC advice, and said to come in to the office on Monday if it was still bothering him. Needless to say that was the entirely wrong course of action and our delay in seeking immediate treatment almost cost him his life. We certainly didn’t wait until Monday, we ended up bypassing that doctor and went straight to the emergency room when his elbow was the size of a large cantaloupe where he had very risky emergency surgery. Very scary, really long recovery, but a healthy outcome. I have a genuine respect regarding the risk of infection and popping your membranes whether it happens spontaneously or it is artificially ruptured by medical staff— these actions open the door. Also, there is an increasing amount of evidence that existing infectious agents can be an underlying cause of spontaneous membrane rupture especially in PPROM.
  3. At the time of this post I have seen “water breaks first” happen in about 30% of my Birth Doula clients, rather than the national 8-10% average. It is my hope that larger numbers will sort out my personal statistics in due time.
  4. My intense love of history, the massive amount of controversy I discovered, and researching all the many angles that surround this topic has turned this post into a mammoth adventure.  Alright let’s go!

 


 

Most likely your health care provider has already told you to call the office at once if think your water has broken especially if it all seems to gush out at once, and/or this happens well in advance of your estimated due date.

You’ve probably heard rumors about the 24 hour clock, the risk of infection to both mother and baby, and other potential birth complications, your doctors using scary language, the emphasis on immediate induction or else…time limits, rules, and ultimatums.

Just as likely you’ve also been hearing midwives, doulas, childbirth educators and physiological birth advocates say the 24 hour clock is based on faulty out-dated evidence, that there are better ways than induction to reduce the risk of infection and that the very same evidence that is used to advocate immediate induction works just as well to advocate expectant management (waiting for labor to begin on its own).

What does seem to be true is this:

There are two valid evidence based options for most women:

  1. Induction (active management) at term PROM (Premature Rupture of Membranes) or
  2. Waiting for labor to begin on its own accord (expectant management) after term PROM.
  3. This evidence, especially on the active management side, is fraught with problems and ACOG (American College of Obstetricians and Gynecologists) can’t make up its mind.
  4. I have done my best to present both sides.

I probably should apologize for the length but —this was indeed the depth of research I felt necessary as it has given me an extensive base of knowledge—something that I like to have to hand when I am teaching, when I am assisting a client as a Birth Doula, and when I am helping women work up a birth preferences plan. How lovely for you that I have done all the trudging through the books and the internet.

PPROM (pre-term premature rupture of membranes) ≤37 weeks is a genuine medical emergency, you need to be calling your caregiver on the way to the hospital, and from there determine your best decisions for moving forward.

If reassuring criteria is met then this scenario will generally involve a period of expectant management as delaying birth (giving more time for the development of lung function, etc.) far outweighs the lesser risk of potential infection and is safer for baby. Both of you will be continually monitored and most likely you will be required to remain in bed. Forgive me, if I hope that after you finish reading this post you find this protocol as ironic as I do.

Term PROM ≥37 weeks, however, requires a more complicated discussion, as several valid options for proceeding are available to mothers. 

According to Cynthia Gabriel, in “Natural Hospital Birth”, beginning labor with term PROM is one of the most common situations that result in medical intervention and unnecessary Cesarean Sections. I agree with her, and in this case an ounce of prevention is worth a pound of cure.

Once your waters break you will most likely feel at the mercy of your hospital’s and caregiver’s protocol. Unless you have properly educated yourself beforehand there is a strong chance that you will begin basing your decisions on fear rather than knowledge, your decisions being heavily influenced by the fear mongering language preferred by most doctors especially when they want a patient to agree to a medical intervention protocol such as immediate induction.

To best assure yourself and so that you give yourself the best chance of receiving optimal maternity care I believe you need to know the full picture, as having the right knowledge, will enable you to make informed decisions about how you would like to proceed after entering the elite term PROM club.

Knowledge equals Power


At times I have felt like I was conducting my own systematic review, except for the minor detail of not possessing the credentials to look at a lot of the articles I wanted to read, so I have instead looked for the best reference books and online resources that my Googling talents could muster up.  I am apologizing in advance and any mistakes printed here are entirely due to the faulty research skills of this author.

In addition to my usual go to source material this article owes a great deal to the following primary source material:

Best Practices in Midwifery: Using the Evidence to Implement Change, 2nd Edition Barbara A. Anderson, Judith P. Brooks and Rebeca Barroso Editors; Springer Publishing Co. 2017

Term PROM study Hannah, M.E. et. al. Induction of labor compared with expectant management for pre labor rupture of the membranes at term; New England Journal of Medicine 334(16)

Evidence on: Premature Rupture of Membranes, Alicia Breakey, Angela Reidner, and Rebecca Dekker, Signature Article on Evidence Based Birth 2017 blog article

When research is flawed: Should labor be induced immediately with term pre labor rupture of membranes? :Commentary on Hannah, ME, et. al. Term PROM study 1996; Henci Goer; Science & Sensibility blog article, last updated February 2017

When is evidenced based medicine NOT evidence based? Inductions for PROM at term, Mayri Sagady Leslie, Science and Sensibility blog article, last updated November 2016

The websites of the Merk Manual, the CDC, and WHO for statistics and guidelines

ACOG Committee on Obstetric Practice Opinion: Approaches to Limit Intervention During Labor and Birth No. 766; 133(2) by American College of Obstetricians and Gynecologists, Wolters Kluwer Health, Inc. Publishers, February 2019


While you are pregnant your baby is enclosed in a membranous sac filled with amniotic fluid, this sac cushions and protects the fetus while they are in utero, it is referred to by varying terms from your water bag to your amniotic sac.

These fetal membranes are designed to weaken towards the end of pregnancy and most commonly pressure from contractions during labor will cause the membranes to give way at a weak spot.

In medical terms “your water breaking” is termed as Rupture of Membranes (ROM) and this can happen at any time during pregnancy and has been experienced by women in all three trimesters.

For a variety of known but often unknown reasons, a rupture of membranes can happen at any time—it can happen pre-term, it can signal the start of labor, it can break during labor, it can be artificially broken by your caregiver, and it is possible that your baby is born with the amniotic sac still intact (born in the caul).

This post will mainly concern itself with at term premature ROM but I am also including a brief discussion of pre-term premature ROM.

In medical terms, when your “water breaks first” at term, which is characterized as  ≥37 weeks, you are classified as a term Premature Rupture of Membranes (term PROM). This is not a very common occurrence, whatever Hollywood (or my statistics) would like us to believe, typically only one in 10 women or 8-10% will begin labor in this manner.

When your water breaks at ≤37weeks, you are classified as pre-term Premature Rupture Of Membranes (PPROM).  According to The PPROM Foundation pre-term PROM is responsible for 30-40% of pre-term births and typically affects 2-4% of singleton pregnancies and up to 20% of twin pregnancies.

As I stated earlier, PPROM is a genuine medical emergency, you need to be calling your caregiver on the way to the hospital, and from there determine your best decisions for moving forward.

The rest of this article will concern itself with educating readers on all the relevant issues surrounding the discussion and debate on whether all cases of term PROM should be actively managed with induction immediately following rupture or whether women with non-complicated singleton pregnancies who meet certain criteria upon rupture should be expectantly managed, taking a hands off approach and waiting— letting labor/contractions begin on their own.


Your labor begins with your water breaking, it happens without warning, and often in the absence of any real uterine activity. It maybe a sudden rush or a slow trickle, you may not even be sure that this is what actually happened.

It most likely surprises you, maybe its a little scary, some women experience term PROM as a loss of control, so give yourself a moment before you start sounding the alarm. Take some deep breaths allow that surge of emotion and adrenaline to pass, this is undoubtedly not the start to labor that you wished for yourself and your baby.

But the fact is that the breaking of your waters means that you ARE in labor, even though you may not feel regular contractions as of yet. It is a far better strategy to just go with the actual circumstance of your particular labor instead of fighting it and wasting time wishing for different circumstances.

Ideally this moment happens in private at home, but since it can happen anytime, anywhere, it may very well be more of a “clean-up in aisle 4 kind of moment”. 

If you are still several weeks away (≤37 weeks) from your estimated due date then you would be very well advised to seek the security of your hospital at this point. If such is the case, gather up your birth team, call your health care provider and head towards the hospital.

Otherwise— there is no need for panic—being out in public makes for more of an embarrassment  than anything else (good for the birth story), if you are out calmly make your way home with the minimum of fuss.

Wash your hands and then clean your bottom half with antibacterial soap, you may even wish to take a shower. DO NOT insert anything inside of your vagina.  If you are using a pad to catch the draining fluids—change it frequently.  Examine ALL of them before disposing as well as your original undergarments.

Everyone that comes in contact with you (including yourself) from this point forward has washed hands as well as uses hand sanitizer, at the very minimum. Establish a good antiseptic protocol from the beginning.

At this point, if you haven’t already, you should let both your birth partner and your birth Doula know of these new circumstances, both will be key in making the best informed choices for moving forward.

You have assessment work to do and decisions to make.

Drink a large glass of purified water, continue to drink a lot of purified water, your body will continue to make amniotic fluid, there is no such thing as a “dry” birth—BUT you will need a lot fluid intake.

After achieving as much calm cleanliness as you can— you then need to determine the following: Time of Rupture, Amount of, Color of, and Odor of your Amniotic Fluid.

Remember this by using the acronym: TACO. Color and Odor are of most concern. Whether you accurately divulge the number for T to medical staff —well—that is totally up to you.

What you determine during your self assessment will help you to determine if you meet reassuring criteria standards, give you vital answers about your choices, and help in the decision making process.

Next up assess your TACO findings using the following criteria:

Reassuring Signs:

  1. You are at term (≥37 weeks) and are experiencing an uncomplicated singleton pregnancy.
  2. Your amniotic fluid is clear. It may have a slight pinkish tinge and/or a bit of brownish dried blood. You may have had a gush or a trickle but it is clear. It either smells slightly sweet or has no odor at all.
  3. You have no fever. Make sure you have an accurate thermometer.  You have checked your temperature several times.
  4. To your knowledge you have no type of infection and you have tested negative for Group B Strep (GBS).
  5. You can feel reassuring fetal movement.
  1. The following will also need to be assessed and these criteria are essential but usually not determined at home:
  1. At Hospital/Dr. Office: normal fetal heart rate. Normal maternal heart rate. (You will feel your heart/pulse if it continues to race after the initial adrenaline rush fades.)
  2. At Hospital/Dr. Office: no sign of umbilical cord compromise or prolapse. (It pays to have gathered accurate information about your baby’s position at your last exam. The knowledge that your baby is head down and engaged in your pelvis disallows for prolapse and is reassuring.)
  3. At Hospital/Dr. Office: no vaginal exam done to determine baseline, and vaginal exams kept to an absolute minimum. Politely decline the procedure unless it is of medical necessity.
  4. At Hospital/Dr. Office, or over phone: You have been thoroughly counseled about all the potential benefits and risks of both induction and waiting for labor to begin on its own-so that you can make the best choice for your unique situation. In fact, you have already discussed this possibility with your health care provider and have a mutual understanding about your preferences in this circumstance.

Need for Concern:

  1. You are pre-term (≤37weeks) and are experiencing any type of pregnancy. You are ≥37 weeks but are carrying more than one baby.
  2. Your amniotic fluid in any amount is green, gray, brown, bright red, and/or black. It has a foul odor.
  3. You have a fever of 99.5° or above. Take your temperature at least twice.
  4. You have some sort of infection be it a cold, a yeast, etc. You are GBS positive.
  5. Your baby’s movements or lack of movement are not very reassuring.
  1. The following will also need to be assessed and these criteria are essential but usually not determined at home:
  1. Non-reassuring fetal heart rate. Non-reassuring maternal heart rate.
  2. Possibility for Prolapsed Umbilical Cord. Your baby is still high, not engaged, or is not head down.
  3. Multiple recent vaginal exams.
  4. Call your caregiver about any of the first 5 assessments and they will rightly advise you to make your way promptly to the hospital. From there determine your options and best choices.

You will face four possible scenarios regarding uterine activity.

    1. your contractions will begin almost immediately (this happens for a few women)
    2. you will feel contractions within 12 hours (45%)
    3. you will feel contractions within 24 hours (77-95%)
    4. or you will theoretically still be waiting

When you have finished your home assessment and have your birth team at the ready, call your healthcare provider, make arrangements to come in and get checked so that all of your assessment criteria get answers.

If reassuring criteria is met, the best existing scientific evidence available shows that waiting up to 48-72 hours after your “water breaks” DOES NOT increase the risk of neonatal infection, nor the risk of infant mortality and it DOES NOT make it more likely that you will need a Cesarean Section.

Your healthcare provider very well may tell you differently— they often cite the risk of maternal and fetal infection as the basis for their recommendation of immediate induction. This is NOT evidence-based medicine. There are better ways than immediate induction to decrease the risk of infection after term PROM.

The number one place to pick up an infection is in a healthcare related setting and by agreeing to invasive procedures such as digital vaginal exams, IV administration, etc., this has always been true and remains true today.

The rupture of your membranes opens a door—providing a pathway for transmission of infectious agents through a barrier that was previously closed.

So while the decision to wait does increase the risk of you getting an infection—the majority of that increased risk comes from the continued exposure to the above stated risks.

So while prolonged rupture (greater than 24 hours) increases the risk for neonatal infection—the majority of that increased risk comes from your continued exposure to the above stated risks.

More on that below, getting slightly ahead of myself there, but hence the need for establishing your version of antiseptic protocol immediately upon rupture—AND—the lack of a genuine need to rush to the hospital and/or induction in the absence of any concerning signs.

If instead your assessment has uncovered areas of concern, then it is best to consult with your caregiver about how best to proceed, make your decisions based on their guidance and continuing to request non-invasive options including vaginal birth as your first choice.

It is your preference— your choice should be dictated by what gives you the most peace of mind—your best option for keeping both yourself and your baby healthy— that very well may mean for you, being in the hospital and choosing immediate induction—or equally it may mean that you feel at peace with waiting— or at least you strike a compromise utilizing the guidelines in this post. This all will be covered in more depth later, as well.


Term PROM is defined as the spontaneous rupture of the amniotic membranes prior to the onset of labor in a term gestation. It is a well established risk factor for maternal and neonatal infection.

Interventions to hasten birth are often undertaken to reduce the risk of infection, however the duration of rupture is not the only risk factor and multiple variables may interact in a synergistic fashion to result in inflammation, infection or both.

“The primary argument for immediate induction has always been reducing neonatal infections, which the American College of Obstetricians & Gynecologists (ACOG) acknowledges it DOES NOT DO [emphasis mine], and as can be seen…with optimal care the other [perceived] benefits are likely to be smaller than they currently appear.” Henci Goer 

Term PROM is considered a labor and birth complication, your healthcare provider’s primary management decision is an assessment of the risk of complications determining whether the pregnancy should be allowed to continue or if immediate labor and birth should be initiated via labor induction.

Although between 77-95% of women will begin labor spontaneously within 24 hours of rupture, expectant management in term PROM is an uncommon management approach today. However, it is a reasonable evidence based option that should be presented to women along with induction.

Unfortunately, because of the perceived risk of infection the medical world still considers birth to be the best option, in spite of the best evidence, labor will most likely be induced if contractions do not begin shortly after rupture.

There are several complications that have been associated with term PROM and PPROM, the most established being that of infection and therefore that perceived risk drives the whole medical protocol surrounding the management of term PROM pregnancies.

So let’s discuss the other less likely complications first.


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.


Of most concern, to women who present with a spontaneous rupture of membranes before labor is established, is the risk of maternal and neonatal infection and indeed, infection is a concern, this risk should be treated with the respect and caution that it deserves, but there also exists room for putting things in their proper perspective.

Infection is the most modifiable of all these possible complications as it is both preventable and treatable.

According to the Merck Manual (2018) infection in American women occurs in:

1-3% of all normal vaginal births

5-15% of all scheduled Cesarean Sections

15-20% of all non-scheduled Cesarean Sections

You may develop an infection during pregnancy (pre-existing), be an un-symptomatic carrier (as is seen in Group B Strep), acquire an infection during labor (intrapartum) or after delivery (postpartum).

The most common way to develop an intrapartum infection especially after presenting with term PROM is through what is called an Ascending Infection (microorganisms are introduced up into your body for example: by the helping hands of others as they perform digital vaginal exams, blood work, attach central lines, etc.). Easily preventable by simply keeping clean, insisting that others keep clean as well, and vastly limiting invasive procedures.

Vaginas and birth canals are for the very most part “one way streets”, these body structures are designed to release substances such as menstrual fluids and creations such as babies down and out. While it is certainly possible to acquire vaginal tract infections such as STDS, yeast, and GBS, these are commonly introduced into your body through transmission from an outside source.  Normally your birth canal contains a varied assortment of your body’s healthy normal flora and as such is important to the health of your newborn baby, not to mention your own health.

Common sense dictates that you drastically limit what gets inserted into your body, ensuring that is genuinely needed for your health and the health of your baby. Here are some guidelines.

To help reduce your chance of infection regardless of membrane status (CDC 2018):

  • up to date vaccinations
  • always ask if there exists a non-invasive option
  • SAY NO TO DIGITAL VAGINAL EXAMS
  • everyone who touches you washes their hands (including you)
  • contact your health provider if PROM occurs
  • request option for vaginal birth if at all possible
  • contact your health professional if you suspect you have an infection of any kind
  • continue your health professional’s guidelines for cleanliness after birth

And WHO (World Health Organization) further advises that you should assure that you have access to quality care during your pregnancy and during birth and that your health care providers follow proper infection prevention and control methods by providing the right medication in a responsible and timely manner.


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.


 

The primary sources for this section come from the following:

Executive Summary:  Evaluation and Management of Women and Newborns With a Maternal Diagnosis of Chorioamnionitis 2016 by The American College of Obstetricians and Gynecologists; Rosemary Higgins, MD et. al., 127(3) published by Wolters Kluwer Health, Inc.

Intrauterine inflammation, infection, or both (Triple I): A new concept for chorioamnionitis Peng, Chun-Chih et al. June 2018 Pediatrics & Neonatology , Volume 59 , Issue 3 , 231 - 237

Chorioamnionitis is a bacterial infection that occurs before or during labor. The name refers to the membranes surrounding the fetus, the chorion (outer membrane) and the amnion (inner membrane), this infection is also often referred to as amnionitis or intrauterine infection. The actual condition poses the potential of significant adverse outcomes for mothers and serious adverse outcomes for babies.

Chorioamnionitis is an acute inflammation of the membranes and chorion of the placenta, and while this condition can exist even in the presence of intact membranes it is more typically seen in the setting of membrane rupture and is typically due to ascending poly microbial bacterial infectious agents. 

In other words an infectious agent introduced up and into the body by the “helping hands” of others either by the transmission of an outside infectious agent or by transmitting a preexisting infectious agent —already present in a mother’s vaginal tract— up into the uterine cavity. Preexisting extrauterine infections acquired during pregnancy rarely account for chorioamnionitis, but it is possible. My husband’s battle with “strep throat of the elbow” is a case in point, extremely rare but it does happen.

The clinical signs and laboratory data usually used to diagnose chorioamnionitis during labor have poor predictive value, may be absent or appear late, and are unreliable for identification of acute chorioamnionitis. The best means to accurately diagnose chorioamnionitis during labor are very invasive procedures.

Best diagnosis comes from either sampling the flora of a clean amniotic fluid sample through amniocentesis, however, the more definitive diagnosis comes from a sample taken from the placenta, itself.

To make matters worse, the term chorioamnionitis has been appropriated and misused, used by health care professionals as a diagnosis for a multitude of various conditions and symptoms.

The clinical use of this term is both overused and outdated and implies the presence of an infection. As you will see the clinical means of diagnosis for chorioamnionitis was used by the healthcare professionals in the Term PROM studies to determine the presence of infection.

In 2016, ACOG published an executive summary of a 2015 workshop that was convened to address the issue that there exist numerous knowledge gaps and the need for evidence-based guidelines for the diagnosis and treatment of women with what “had been commonly called” chorioamnionitis and the neonates born to these women.

As of 2018, ACOG is working towards and funding studies to re-name this clinical condition, define recommendations for assessment and management.

ACOG now recommends the use of new terminology, specifically Triple I (inflammation, infection, or both), with the term chorioamnionitis restricted to pathologic diagnosis (a diagnosis that comes from the study and testing of the placenta after birth).

The term “chorioamnionitis” has been in existence for decades. Unfortunately, this term has transitioned from its original scope—in which it was only used to express what it actually describes— an intrauterine  bacterial infection that affects the chorion and amnion membranes, and is now commonly used as term that labels a varied array of often non-related conditions characterized by infection, inflammation, or both with consequent great variations in treatment and clinical practice in both women and children.   

In the strictest sense, the term chorioamnionitis implies that a pregnant woman has an “inflammatory or an infectious” disorder of the chorion, amnion, or both.

This diagnosis often implies that the mother and her fetus may be at increased risk for developing serious infectious consequences.  Because of its connotation, the mere entry of chorioamnionitis into the patient’s record triggers a series of investigations and management decisions in the mother and the neonate, irrespective of probable cause or clinical findings.

A maternal diagnosis of chorioamnionitis has serious implications for the management of newborns. Even in well-appearing infants, this diagnosis will subject newborns to much testing, longer hospital stays, sepsis workups, NICU stays, and treatment with antibiotics.

This protocol is all used today, to prevent the rare incidence of early onset sepsis in newborns. Early onset sepsis was of genuine concern in the 1960-70’s before the routine screening and prophylactic treatment of Group B Streptococcus with antibiotics. Since routine screening and treatment for GBS is now the normal procedure, the incidence of newborn early onset sepsis has drastically reduced. 

The majority of evidence based studies regarding management of PROM today are still the studies held in the latter half of the 20th century, well before routine screening and prophylactic treatment of GBS, which is why it is essential to look at the study data from a fresh modernistic perspective.

While the majority of the information found in these sources I will hold on to for now, I need to address several infection related complications that are of great importance to accurate assessment of your choices and decisions in the presence of ruptured membranes.

If PROM presents either at term or preterm, or if your membranes have been artificially ruptured by a healthcare provider,  it is characterized as a risk factor for infection.

The spontaneous or artificial rupture of your membranes represents a “weak spot” -the potential- that in the presence of an infectious agent the potential likelihood of a neonatal or maternal infection increases.

Prolonged rupture of the membranes (more than 24 hours) increases the risk of neonatal sepsis considerably because the presence of ROM facilitates the ascension of new infectious agents to the uterine cavity and this risk becomes much higher when the rupture is accompanied by the presence of an existing subclinical intrauterine inflammation or infection or both (Triple I).

This is also true in regards to maternal infection, although you have probably gathered by now that the wellbeing of mothers is not the priority that runs the majority of obstetrical/hospital managed care.

If you genuinely have a serious infection—hooray for antibiotics, I hope you get properly diagnosed and promptly treated. Medical interventions when truly necessary are indeed life saving. However…

Often a designation of chorioamnionitis is made when any combination (or even one) of the following elements is noted: maternal fever, maternal or fetal tachycardia or both, elevated white blood cell count, uterine tenderness, and purulent fluid or purulent discharge from the cervical opening.

And here is the problem—the presence of one (or even more than one) of these signs and symptoms does not necessarily indicate intrauterine infection, or that actual chorioamnionitis is present. These finding are all subjective (not definitive, open to interpretation) and are generally neither sensitive (relating solely to this diagnosis) or specific.

The term PROM study allowed that ONE sign was enough to determine a diagnosis of clinical chorioamnionitis.

Today, the presence of a maternal fever is a commonly used justification for a diagnosis of chorioamnionitis, even if fever is the only symptom present. This diagnosis is then used as a justification to speed up delivery either by induction or by Cesarean Section.

In the presence of term PROM medical staff is already on hyper alert for the risk of infection making it even more likely that they will jump the gun at the slightest of indications and rush towards medical intervention and birth.

In reality maternal fever complicates up to one-third of labors and has many diverse causes including infection, epidural anesthesia, and inflammation.

Intrauterine infection, extrauterine infection (outside of uterus), epidural usage during labor, hyperthyroidism, dehydration, elevated ambient temperature, and the use of pyrogens such as Prostaglandin E2 for the induction of labor are all possible causes of maternal fever during labor.

These “other causes” are all confounding factors in the evidence based studies on the relation of term PROM to infection and for the most part  these “other causes” are left unaddressed by said studies.

Recently, the descriptive term “intrauterine inflammation or infection or both” (Triple I) has been proposed by a National Institute of Child Health and Human Development expert panel to replace the term chorioamnionitis and this topic is the subject matter of my sources.

They also particularly state that it is important to recognize that an isolated maternal fever does not automatically equate to infection or to chorioamnionitis. The presence of an elevated maternal temperature is not enough to make a proper diagnosis of either condition.

As I work through the evidence, the studies, the secondary analysis, and the various guidelines, I hope to put all of these risks into better perspective including the risk of infection.

But before I move on just again consider the following:

Consider that instead of intervention in the form of induction the best way to avoid ascending infection after PROM is to avoid digital vaginal exams and other invasive procedures as much as possible. This advice is entirely evidence based and has been shown to be effective repeatedly in numerous studies. The best place to pick up an infection is and always has been from someone else at the hospital.


There are two valid evidence based birth options for most women:

  1. Induction (active management) at term PROM or
  2. Waiting for labor to begin on its own (expectant management) after term PROM.

Induction with Pitocin (intravenous artificial oxytocin) as well as induction with a prostaglandin gel, AND expectant management all result in similar rates of neonatal infection and Cesarean Section.

The data from the term PROM studies show a neonatal infection rate that ranged from 2-3%. Neonatal is classified as ≤28 days. There was no difference in newborn infection rates between any of the study groups.

The best I could find for today’s rate was (on numerous online websites) that intrapartum (during labor) fever affected moms and babies in 1-2% of all deliveries and of those chorioamnionitis accounted for 2-4% of these incidences.  These numbers are from 2017 and are for all births whether or not PROM was present, and what they meant by chorioamnionitis is not specified.

There exists a serious amount of lag time in medicine. It can take upwards of 20 years for research findings to be translated into routine clinical procedures. NON-evidence based care happens all the time in birthing situations, unfortunately, I find myself having to write about this frequently but I believe it is important to know now rather than after the fact so that you can better assure for yourself optimal maternity care.

As they say on Evidence Based Birth: Practice that is not based on the best evidence is not best practice.

The dance you will be sharing with PROM (hee hee) is a mash up of non-evidence based care, active precautionary management, time management etc. I will leave the malpractice CYA tactics to another time.

The largest concern surrounding term PROM is that during prolonged PROM (≥24 hours in the absence of contractions) women and their babies face a higher risk of infection. So I guess the logical place to “start” is with the 24 hour clock rule.

 


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.


A little bit of history surrounding childbirth, hygiene, and antibiotics. Now I have promised myself an “infection term paper” in the future, but for now I am just going to make a few points in this post that are relevant to our date with PROM.

Hard to believe a time when this was not so, but the fact that surgery needs to be sterile, is a standard that is barely 100 years old.

Medical knowledge has radically shifted in the last 150 years but people including doctors are still reluctant to wash their hands. According to a study in 2012, doctors who fail to wash their hands kills roughly 100,000 Americans a year and sickens 1.7 million more.

Even after the introduction and the acceptance of antisepsis, women would have to wait for medicine rather than doctors to kill off maternal related infectious illnesses.

Penicillin, the first antibiotic, was “accidentally” discovered in the 1930’s, developed for use by the military during WWII, and was made widely available to the public by the end of the war. The discovery of penicillin was one of the most important advances in the history of medical science, introducing a whole world of wonder drugs that are now becoming a victim of their own success—in other words these microorganisms are somewhat successfully fighting back.

During the Post World War II Era (1940’s-1950’s) a hospital infection rate of ~10% and a clean wound rate of ~5% was common. In the United States deaths from infectious diseases dropped dramatically— the annual mortality rate fell from 797 deaths per 100,000 persons in 1900 to 75|100,000 in 1952. But even in the 50’s germs were already becoming penicillin resistant.

In the 50’s and 60’s, antibiotics were new, their use varied from hospital to hospital from doctor to doctor. There also were no standards for sterilization and antisepsis. The only antibiotics available were penicillin and its early derivatives and they were not alway effective.

During this period treatment with antibiotics was not the routine prophylactic measure that it is today. Today you would typically get prescribed a round of antibiotics just as a precautionary measure-as seen in the standard protocol of administering antibiotics during labor after a Group B Strep positive result.

During the 50|60’s many women did not receive treatment with antibiotics until their symptoms were quite severe. GBS was not known, not understood, and not treated for during this time frame.

With today’s access and often proactive approach to antibiotics the 24 hour clock is no longer based on evidence.


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.

Scientific research data on term PROM comes from five primary sources.

  1. Research studies done in the 50’s|60’s.
    • This data is problematic because of various reasons, most of which can be attributed to the fact that these results were a product of their day and age. A limited list includes, antibiotics were relatively new and were not as popular as they are today, usually administered only after symptoms became severe, GBS was not known, understood or treated for, term PROM was not separated from Pre-term PROM, more than half of the women in these studies were “charity cases” who presented at hospital long after their membranes had ruptured and had received little to no prenatal care, and more importantly, these studies did not take into count the number of vaginal exams, one of the most important risk factors.
  2. Most of the data comes from a famous term PROM trial done in 1996. Hannah et. al.
    • The authors of this study concluded, “Induction of labor with intravenous oxytocin, induction of labor with vaginal prostaglandin E2 gel, and expectant management are all reasonable options for women and their babies if membranes rupture before the start of labor at term, since they result in similar rates of neonatal infection (2% -3% across all groups) and cesarean section (13.7% - 15.2% for 1st time mothers and 4.3%-4.6% for women who had given birth before across all groups).”
    • Women who were immediately induced with Pitocin were less likely to be clinically diagnosed with chorioamnionitis, compared to those who waited up to four days before being induced with Pitocin (4% versus 8.6%). There were no other significant differences across the remaining groups (induced immediately with prostaglandins versus waited up to four days before being induced with prostaglandins) at 6.2% versus 7.8%. The overall chorioamnionitis rate was 6.7%.
    • The problems with this study include but are not limited to the following:
      • the failure to consider the effect of epidural analgesia on intrapartum fever confounds the chorioamnionitis results.
      • Women who where GBS positive were not treated in labor. There were a total of 4 neonatal fatalities during this study and untreated GBS was the cause of one recorded death.
      • Chorioamnionitis rates already confounded by epidural use were further confounded by multiple digital vaginal exams. A secondary analysis of this data showed that the rate of chorioamnionitis increased steadily with the number of vaginal exams.
      • The confusion and controversy over what a clinical diagnosis of chorioamnionitis even meant in these studies and how many cases resulted in actual pathological diagnoses of chorioamnionitis versus how many were actually the “result” of one or more confounding factor.
      • In light of today’s stricter guidelines regarding this diagnosis, the coming changes in terminology, and other confounding factors is it very likely that the Term PROM researchers over diagnosed patients in regards to chorioamnionitis.
      • Neonatal results were confounded by digital vaginal exams at entry of the trial. These babies had a much higher rate of infection.
      • Neonatal results were confounded by multiple digital vaginal exams during labor.
  3. A Cochrane Systematic review done in 2006 that evaluated term PROM management, the reviewers reached a tempered conclusion. “Since differences in outcomes between planned and expectant management [induction vs waiting] may not be substantial, women need to be able to access the appropriate information to make an informed choice.” (Dare, 2006, p.12)
  4. The Pintucci PROM research study done more recently in 2014.
    • The results from this study are important because it was the first study to look at women who had modern testing and treatment for Group B Strep.
    • Researchers found that by screening for GBS, the overall rate of chorioamnionitis was 1.2% and included many women who waited for labor to begin on its own.
    • The women in the study who waited for labor to start on its own, waited in hospital and the study results showed that this group of women was able to “wait” with very good outcomes for both mothers and babies.
  5. In 2017, researchers at the Cochran database conducted a systematic review of studies that compared immediate induction with expected management, it found that the quality of evidence used to support inducing labor as a means of reducing risk of maternal infection and probable neonatal infection remains of very low to moderate quality. This review further states that “women should be appropriately counseled in order to make an informed choice between planned early birth and expectant management for PROM at 37 weeks’ gestation or later.”
    • Bearing in mind the general low quality of evidence, induction may mean:
      • Shorter duration from PROM to birth
      • less likely to experience a maternal infection (low quality evidence)
      • no increase in the risk of Cesarean (low quality evidence)
      • babies less likely to need antibiotics after birth
      • babies less likely to be admitted to NICU
      • both mother and babies had shorter hospital stays
    • There were no differences between induction and expectant management groups for:
      • serious maternal infection (very low quality evidence)
      • definite newborn infection (very low quality evidence)
      • perinatal mortality (moderate quality evidence)

It was a conclusion of all of these studies and reviews that in the absence of signs of infection, expectant management remains a viable option as long as a mother is properly counseled regarding the risks of prolonged PROM.


While the original report from the TERM PROM study showed no differences in neonatal infection rates over all, secondary analysis makes it clear that length of time between rupture and delivery matter, and that there are modifiable factors, meaning that the risk is less when a woman and her baby receive optimal care.

Secondary analysis of the data showed that the over all rate of chorioamnionitis (6.7%), while high,  was confounded by the fact that few women in the study had antibiotics for GBS, which is a known risk factor.

The Centers for Disease Control (2010) guidelines for management of GBS+ women say nothing about inducing woman with ruptured membranes at term, which suggests that awaiting spontaneous labor is acceptable provided that antibiotic therapy is initiated.

It seems common sense would dictate that women wait for the first round of antibiotics to be fully administered before making any decisions and even those who prefer not to wait for labor to begin on its own should delay induction until they have the initial round of antibiotics on board.

In any case, regardless of GBS status or decisions around whether or when to induce, to minimize the risk of infection, women should avoid digital exams until labor is well established and their use should be kept at the very minimum during labor.

It is very important to remember that most of the studies as of the 2017 Cochrane review did not take into account the number of digital vaginal exams, nor did they follow current GBS infection protocols.

The number of digital vaginal exams after rupture is probably the most important predictor of whether a woman with term PROM will be clinically diagnosed with chorioamnionitis during these studies. For example 56% of the women in the waiting groups had four or more exams versus 49% of the women in the immediate induction groups who had four or more exams.

Secondary analysis of the term PROM study clearly showed that a person’s risk of being diagnosed with chorioamnionitis increased as the number of vaginal exams they received increased. For example, a study done in 2004 (Ezra et. al.) found that seven or more vaginal exams were an important risk factor for infection. This number of exams increases a woman’s odds of being diagnosed with chorioamnionitis five fold.

The reason vaginal exams can lead to infection is the fact that even with the use of sterile gloves the care provider is potentially introducing bacteria from outside of the vagina and/or preexisting vaginal flora up to the cervix as they conduct the exam.  As previously noted this is termed as an ascending infection and is a primary cause of intrapartum infections.

You want to reduce your risk of acquiring an infection after your water breaks, stay out the hospital, and failing that politely but firmly say NO to digital vaginal exams and other invasive procedures.

The study data also suggests that intravenous oxytocin (Pitocin) is the induction agent of choice. It appears to reduce maternal chorioamnionitis rates compared to other methods of induction (4% intravenous oxytocin versus 6.2% prostaglandin gel).

The studies further showed that while there was no significant difference between immediate induction with prostaglandin gel or the expectant management group who waited up to four days before being induced via prostaglandin gel there was a significant difference in the oxytocin groups. (4% immediate/oxytocin versus 8.6% waiting/oxytocin) in regards to the rate of chorioamnionitis.

The secondary analysis of this data shows that there exist other factors than immediate induction that could provide reasons for this lower number.

Women in the immediate induction with intravenous oxytocin group

  • had fewer vaginal exams overall
  • had shorter labors
  • spent less time in the hospital compared to women who waited.

In other words, it is not necessarily immediate induction that decreases the risk of chorioamnionitis it is the fact that during the course of “waiting it out” women were subjected to many more digital vaginal exams and due to location more exposure to potential infection.

Furthermore, given the intensity of contractions during a Pitocin induction, of course labor and hospital stays were both of shorter duration.

Induction with prostaglandin gel is a common risk factor for intrapartum fever and furthermore is implanted up into the vagina via an invasive procedure, so it makes sense that it would show higher chorioamnionitis rates overall.  Especially considering the studies allowed that the existence of a maternal fever alone was enough to justify a clinical diagnosis of chorioamnionitis. 

Mayri S. Leslie posted an article to Science & Sensibility in 2009 in an effort to bring these issues into perspective, encouraging us to think about what we now know and how judicious care providers work with women today if their waters break before labor at term.

  1. Unless a woman declines, she is screened for GBS before term, so if her water breaks we can factor in whether she is positive or negative into our recommendation of whether she may be at less risk opting for induction or waiting.
  2. As indicated by the guidelines from the Center for Disease Control (CDC 2010) we treat women who are GBS+ with antibiotics prophylactically to reduce the risk of infection for her and her baby.
  3. For women who decline screening or whose GBS status is unknown we follow guidelines from the CDC which suggest we treat according to other risk factors such as length of time the membranes are ruptured, signs of infection in the mother and baby etc.
  4. In either case, we know NOT to do any vaginal exams until we know mom is in active labor and even then to minimize and avoid them until absolutely necessary because vaginal exams themselves are one of the highest risk factors for increasing infections once the water bag is ruptured.

“While inductions, like all medical interventions have their place and time when indicated—they cannot be justified as a standard procedure for a normal physiological occurrence in a healthy full term pregnancy.” Mayri S. Leslie

Personally—as always— I will continue to promote normal healthy physiological birth and a woman’s right to make her own decisions during her pregnancy.

Women who experience PROM should be properly counseled by their doctor/midwife about the potential benefits and harms of both induction and waiting for labor to begin, so that they can base their decisions on what is best for their unique situation, taking into account personal values, preferences, and GBS status.


 

All that I have written thus far represents the level and the depth of research I felt necessary to properly educate myself and comprehensively answer the question: Why are most women in the United States induced when their water breaks at term? 

I had no idea that it would get this complicated.

I’m going to try to break it all down into the four most typical scenarios that might present for term PROM.

Remembering that if your water breaks before 37 weeks, you need to call your doctor/midwife, gather your birth team, and head into the hospital as this is PPROM and a medical emergency. 

Ironically, expectant management (waiting) is the “go to” management protocol when this birth complication presents, as the value of allowing a premature baby to remain in utero far outweighs the minute potential of infection.

Scenario A:

Your water breaks at term and your at home assessment (TACO) leaves you concerned, perhaps you exhibit signs that infection and/or meconium staining might be an issue, such as the color and odor of your amniotic fluid, your temperature is high, perhaps you have a sore throat, etc. These are all things that need to get fully checked out by your doctor/midwife. So put in a call to your health care provider and ready yourself and your birth team to leave for the hospital. Once you get all your answers then you will need to make your best decisions armed with the best knowledge possible.

Scenario B:

Your water breaks at term and regardless of your TACO assessments you have tested positive for GBS, call your health care provider and ready yourself to leave for the hospital.

My standard advice is that 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.

The Centers for Disease Control (2010) guidelines for management of GBS+ women say nothing about inducing woman with ruptured membranes at term, which suggests that awaiting spontaneous labor is acceptable provided that antibiotic therapy is initiated.

It seems common sense would dictate that women wait for the first round of antibiotics to be fully administered before making any decisions and even those who prefer not to wait for labor to begin on its own should delay induction until they have the initial round of antibiotics on board.

In any case, regardless of GBS status or decisions around whether or when to induce, to minimize the risk of infection, women should avoid digital exams until labor is well established and their use should be kept at the very minimum during labor.

It is very important to remember that most of the studies as of the 2017 Cochrane review did not take into account the number of digital vaginal exams, nor did they follow current GBS infection protocols.

But for the record, ACOG as of February 2019, has this recommendation regarding management of term PROM and a positive GBS status.

“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.”

Scenario C:

Your water breaks at term and while nothing seems amiss, you still worry, call your doctor/midwife. Ready yourself to leave as health care providers, especially doctors, always want to check.

If your preference is to wait for your labor to begin on its own then if it is at all possible visit the doctor/midwife’s office rather going to triage station at your hospital. Your healthcare provider will want to monitor the baby and check for a prolapsed cord. Prolapsed cord is extremely rare in term moms even with PROM and remember there is no evidence that term PROM is even a risk factor for prolapse.

Both of these procedures can be performed without a vaginal exam being necessary, politely decline this type of exam and request that non-invasive techniques be utilized instead.

It is easier to get back out of a doctor’s office, hospital staff is likely to convince you to stay, get checked in, and you may have hours ahead of you without contractions being present.

If your preference is for immediate induction, gather your birth team, call your healthcare provider and head to triage at the hospital, you won’t get any argument from your medical team.

Scenario D:

Your water breaks at term, you have strictly assessed all the criteria, and have maintained hygienic protocols, to your best knowledge all is well, you take a deep breath, call your health provider, explain the situation, explain that certainly, your most important objective is a healthy baby, remind them of your previous discussions and your deeply felt desire for a physiological intervention free birth. Stating that you understand their need to assess your condition, assuring them that this will give you peace of mind as well, and then politely request to been seen in their office rather than in hospital.

Both Scenario A and B represent the need for medical intervention and decisions made in these scenarios are best left until you have a full picture of your direct circumstances.

If options regarding non-invasive procedures and vaginal birth remain a possibility and are important to you— then politely state that these less invasive interventions are your preference.

In Scenario C and D there exists the potential of a choice. The two viable options are immediate induction or waiting for labor to begin on its own after term PROM.

I now want to give some guidelines based on my research regarding both of these options.

Regardless of circumstance your doctors will state that they want to see you in labor by X amount of time, most doctors will press strongly for immediate induction and are likely to push that you be seen in triage at the hospital rather than in the office.


There exists some evidence (albeit not strong) that choosing Pitocin as your induction method of choice slightly decreases your odds of developing an intrapartum (during labor)  infection.

Induction with prostaglandin gel often cause a woman’s temperature to rise anyway, which is a confounding factor in diagnosing infection, and this increases your risk of being clinically misdiagnosed with infection.

As discussed previously, your labor and hospital stay may be shorter, overall.

So Pitocin induction does, on the surface at least, have a few benefits, HOWEVER…

Induction with Pitocin produces very strong, very persistent, very frequent contractions and when the uterus contracts this strongly and frequently it can cause cord compression, fetal heart rate changes and decrease in oxygen to the baby.

Term PROM is also a risk factor for cord compression. This makes Pitocin induction—the go to active management technique for term PROM— a compounding factor—thereby increasing the likelihood of the occurrence of cord compression. THEREFORE…

The choice of immediate induction also means an increase in the number of other technological interventions necessary during labor including continuous electronic fetal monitoring, IV fluids, blood pressure cuff, oxygen monitoring, possible bladder catheterization and almost always the mother’s need for additional pain medication.

All of these interventions limit your ability to move about and choose your own positions. They also potentially increase the risk that you will require a Cesarean Section, especially if you end up using an epidural for pain relief. The limiting of positions also means that there is an increased risk for more severe perineal injuries and lifelong issues with pelvic floor disorders.

One of the pitfalls of being induced is that the intensity of the resultant contractions often lead to the use of epidural pain analgesics. The medical world has yet to determine precisely why but epidurals are a common source of maternal fevers.

If during your labor, you do not have an epidural and you develop a fever, then it is very likely that you also have an infection.

Epidurals confound this diagnosis as epidurals are known to spike fevers and since it is almost impossible to distinguish the source of fever— epidural or infection wise— then doctors fall on the risk management side administering antibiotics and moving toward delivery by Cesarean section.

All of these confounding elements make it more likely that you will be misdiagnosed with infection, opening the door to unneeded antibiotics and a potential cesarean section, this misdiagnosis will have consequences for your newborn as well, requiring them to be tested and treated with unnecessary antibiotics as well.

It bears repeating: “While inductions, like all medical interventions, have their place and time when indicated—they cannot be justified as a standard procedure for a normal physiological occurrence in a healthy full term pregnancy.” Mayri S. Leslie


Along this path you will most likely hear your provider say something along the lines of “I can not allow you to…” or “ it is not my practice to allow women to…”

In light of all these studies, reports, reviews, and secondary analyses, medical healthcare providers who immediately offer induction seem woefully unaware of the contrary evidence.

You do not lose your right to informed consent or informed refusal in the light of this birth circumstance, the legal authority in the birthing room, office, etc. is you as the pregnant woman seeking medical guidance.

You have the legal right to make all decisions about your body and your baby, just like any American citizen, pregnant or not. This is your constitutional right and this right has been affirmed by the Ethics Committee of ACOG and it was re-affirmed in 2013.

So speak up—if you don’t want a procedure after proper counseling then politely refuse it.

If you plan on waiting for contractions to begin naturally then you should begin a practice of avoiding and refusing all vaginal exams until you are well established in labor and keep them at the absolute minimum even then.

Expectant Management of term PROM (waiting) is a birth preference that you need to discuss thoroughly with your care provider, well before birth. Approaching the discussion in a calm reasonable and accommodating manner.

According to Cynthia Gabriel you are unlikely to convince a healthcare provider who has developed a different style of handling term PROM management that you are right and they are mistaken.  Instead you will be better served by explaining how important a physiological vaginal birth is to you, that you deeply desire something different, that you believe it is better for your health and your baby’s as well, and make a heartfelt request for their support. 

I like Cynthia Gabriel’s “Natural Hospital Birth” phrasing:

“Certainly, my most important objective is a healthy baby. Your support for our birthing preferences would give me peace of mind. If I develop a fever or the baby isn’t doing well, I will gladly reconsider. But, if I do not get a fever and the baby is doing fine, I would really appreciate your support in allowing up to 24 hours before we talk about induction. As I am planning a vaginal birth, with minimal medical interventions, I’d also like to avoid all digital vaginal exams until I get close to the end of my labor always assuming that I do not have a fever and my baby is doing well.”

Henci Goer also makes an excellent case, using a combination of neonatal infection rates and the median time to active labor, she uses the numbers culled from the data.

“It therefore seems reasonable to wait about 18 hours before inducing labor. Half the group of women will have achieved active labor by this time, and, if induced at ≥18 hours, the remaining half are likely to have started active labor by the 24-hour cut point.”

If you can get your provider to sign off on these preferences with an air of mutual understanding then it will add an extra layer of assurance that you are being listened to and your wishes are being respected.

If you do make it your “plan” to wait, then make it a plan that entails you waiting without worrying about the “what if’s” so as to avoid turning your uterus into a “watched pot” by keeping a strong commitment that is geared towards giving your body the time it needs to adjust to labor.

If your mind is watching your body along with everyone else, then this added scrutiny has the unfortunate consequence of slowing down labor and especially true in a hospital setting.

It pays instead to get your mind involved elsewhere, maybe a good movie or a binge watch, a work project, baking, taking a walk, any activity that provides distraction.  Rest and near constant hydration as well, please.


Your body plays host to a mind boggling amount of single-celled organisms, they make up what is called your natural biome. This biome is essential for the healthy functioning of your body and its immune system. The natural flora of organisms that inhabit your birth canal and vaginal tract, as well as those naturally found in breastmilk are essential for your baby as well.

During the course of a normal physiological birth, as your baby moves down the birth canal he/she is inoculated with a dose of your normal microbiological flora that jumpstarts among other things your baby’s healthy digestion and their immunity system. Skin to skin contact and breastmilk also have vital roles that help ensure nature’s inoculation process.

This is yet another worthy topic that I promise to devote the time to giving it a full post, in the future. In this particular post, I just want to make a couple of points and suggestions.

The vast majority of antibiotics are NOT organism specific, they instead destroy the healthy along with the infectious bacteria. The benefit of destroying a microorganism that is capable of creating a fatal infection far outweighs the resultant destruction of your normal flora has always been the viewpoint of the medical world.

Antisepsis, germ theory, and antibiotics mark the greatest achievements in medicine thus far, they have saved countless millions of mothers’ lives.  However, this cure has brought about a rampant overuse of antibiotics over the years, with them often being prescribed prophylactically  “just in case”.

Such is the case after a positive screening result for GBS, where a laboring mother receives antibiotics prophylactically every four hours or so, until the baby is born. This is all well and good if they are genuinely called for and necessary.

However, here’s the thing. If term PROM presents, you will be advised to get your first round of antibiotics in promptly, which turns this into a bit of a Catch-22.

Do you decide to wait for labor, knowing that it may take up to 24 hours or longer for contractions to begin, in the light that this will mean 6-8 courses of prophylactic antibiotics?

Do you decide instead to get your antibiotics with a side of immediate induction, hoping that this will mean that you receive fewer doses of antibiotics overall?

How do you decide to treat a mystery fever?

Induction with a prostaglandin gel often causes a maternal fever, and induction via Pitocin often turns into the need for epidural analgesics which also cause maternal fever. These and other non-infectious forms of fever are often misdiagnosed as possible infections, or worse as “mystery fevers”.

Which in turn causes health care providers to move towards a risk management approach to your care. The provider says—as I don’t know exactly where this fever is coming from and I am reluctant to prescribe an anti-inflammatory such as Tylenol for fear it may mask an infection—   so let’s start antibiotics “just in case” and start considering that a Cesarean Section is what is safest for your baby at this point.

Ask for a more complete workup in the face of a mystery fever, get as much of the following information as is feasibly possible.

The new guidelines surrounding diagnosis of a suspected intrapartum inflammation infection or both (Triple I) requires not only a fever (greater than 102.5° OR between 100.4° and 102.5° for longer than 30minutes) without a clear source of origin plus any of the following: fetal tachycardia (greater than 160 beats a minute for 10 minutes or longer OR maternal white blood count greater than 15,000 per mm³ OR definite purulent fluid from cervical opening.

As discussed previously, neither mothers or babies benefit from unnecessary prophylactic antibiotics or from unnecessary Cesarean Sections.

Cesarean sections and infection protocols typically mean longer hospital stays and routine antibiotics for both moms and babies and a maternal diagnosis of infection has serious implications for the management of newborns.

Even in well-appearing infants, this diagnosis will subject newborns to much testing, longer hospital stays, sepsis workups, NICU stays, and treatment with antibiotics.


While your ultimate decision is entirely in your hands-decisions that are made between you and your healthcare provider, I have spent a lot time while writing this pondering “if it was me, what would I do?”

At first I was tempted to include my hypothetical decision making here at the end, but it is way too easy to armchair quarterback imaginary decisions and at the end of the day they are not my decisions to make—they are yours.

I think it is obvious by now that I will always promote normal healthy physiological birth, the judicious and considered use of medical intervention, and above all a woman’s right to make her own decisions during her pregnancy.

My actual experience, however, is mine to share and I think it speaks volumes that even now almost thirty years later, I needed this research project to finally set my mind at ease—at least in some regards.  I still have research to do in relation to my actual experience, a couple things still trouble me.

Your birth experience stays with you, I had mine held so deep that I didn’t even realize it was still in there festering away, in the terms of this project—like a lingering subclinical infection.

As an actual PPROM, I went to the hospital immediately after rupture, waited overnight in bed, developed both maternal and fetal complications, had an emergency C-Section the next morning. I am 100% positive that this was the right call, even if I regret agreeing to a bed pan, and having those decisions confirmed while writing this, made all this effort worthwhile.