Not long ago, one of my students returned to postnatal yoga after giving birth to her first child. I love seeing the mothers returning with their new babies and hearing about the birth experience. This one mother, upon telling me her birth story, laughed slightly and said, “I was the poster child for the ‘cascade of interventions’”. I paused and asked why. The story unfolded something like this.
It was a few days before her due date and she suspected that her water had broken. A visit to the doctor confirmed, her membranes did rupture. It was a slow leak, not a big gush. The mother was feeling mild cramping and not contractions yet. So her doctor admitted her and started her on a small amount of Pitocin, artificial Oxytocin. Slowly, after increasing the dosage over a 12 hour period, the mother grew tired and very uncomfortable coping with the waves of strong contractions and opted for an epidural. This allowed her to rest and relax for a bit. Labor continued to move slowly and after another 8 hours, her cervix stayed at 7cm. The doctor delivered her baby via cesarean.
Such incidents are not unlikely to happen and this article throws light on the tools and insights about the options available and decisions you should be taking in case you find yourself in a similar situation.
What Can You Do?
Know What To Expect From Your Care Provider
There are two ways in which ruptured membranes are handled before the onset of labor at term (meaning not before 37 weeks). They are:
- Active management – Where the care providers will start induction soon after Premature Rupture Of the Membranes (PROM).
- Expectant management – Where the care provider waits and sees if the labor starts on its own.
It would be a good idea to understand what would your care provider opt amongst the two.
The Nature And Odor Of Water
Make sure you have noticed the color and odor of the water when your water broke. Ideally, the amniotic fluid should be clear and slightly yellowish. If there is a strong smell and the fluid is greenish/blackish, that is meconium, the baby’s first bowel movement, which could be a sign of fetal distress. It is highly advised to head to the hospital in this case.
Minimizing Vaginal Examination
The mother is at higher risk of inter-uterine infections for a prolonged period from rupture until birth. Thus, every time the vaginal examination is done, there is a chance of introducing bacteria which can cause infections. Minimizing the same is the key.
What If You Don’t Immediately Get Induced?
Rebecca Dekker of Evidence Based Birth concluded in her article – What is the Evidence for Inducing Labor if Your Water Breaks at Term
•If women with PROM are not induced, around 45% will go into labor within 12 hours (Shalev et al., 1995; Zlatnik, 1992)
•Between 77% and 95% will go into labor within 24 hours of their water breaking (Conway et al., 1984; Pintucci et al., 2014; Zlatnik, 1992)
•In another large study, researchers assigned some women to wait for up to 72 hours for labor to begin after their water broke. Out of these women, 83% went into labor on their own and had a normal vaginal birth (Shalev et al., 1995)
The status of the baby and mother lets one know the steps to be taken further. If either of the ones is compromised, then induction is imminent. Another concern is compression of the umbilical cord between the baby’s presenting part and the cervical opening.
Relationship Between Vaginal Exams And PROM
This is the topic that really sparked this article. The student who had what she called “the cascade of interventions” actually had interventions start before she was even in labor. Her care provider was performing weekly vaginal exams starting at week 37. This practice has always been a pet peeve of mine. It either shows some cervical change that can get the mother overly excited and still wait for days or weeks for something to happen. Or on the flip side, a mother hovering around her due date may feel completely deflated to learn her cervix is still pretty closed. I asked my own OB about this. Here is what Dr. Harry Lee said,
“I don’t routinely do a vaginal exam until 40 weeks if there are no signs of labor. Most patients want to know when they will go into labor and the exam gives no such information. And it’s uncomfortable. I was taught to do them routinely starting at 36 weeks but stopped a long time ago. I got tired of shrugging my shoulders when patients asked what their exam meant.”
Though vaginal exams provide little information as to when labor will start or how the results of the exam will change the care providers way of managing labor; the relationship between pre-labor vaginal exams and PROM builds a lot of curiosity.
Through my research, I discovered there have been two major studies often cited on this topic, one lead by Lenihan and one lead by McDuffie. Both these studies compared the outcome of PROM associated with routine vaginal exams starting at 37 weeks before the onset of labor. Amazingly, the two studies came out with completely conflicting results. The results from the McDuffie study explain,
“The overall prelabor rupture of membranes rate was not significantly higher in the membrane sweep group (12% compared with 7%) (P=.19); however, patients with a cervix more than 1 cm dilated at time of membrane sweeping were more likely to have prelabor rupture of membranes if they were in the membrane sweep group (9.1% compared with 0%; relative risk 1.10, 95% confidence interval 1.03-1.18).”
Here is the conclusion from the Lenihan
“A total of 349 patients were studied. In 175 patients in whom no pelvic examinations were done until term or past term, the incidence of PROM was found to be 6%. In the 174 patients in whom pelvic examinations were done weekly starting at 37 weeks’ gestation, the incidence was 18%, which was a significant increase (P = .001). The primary cesarean section rate was comparable in both groups with PROM; however, the overall primary cesarean section rate when PROM occurred was found to be twice that of the remaining population. This, however, did not achieve statistical significance. The study suggests that pelvic examinations before term may be a significant contributing factor to the incidence of PROM.”
However, in view of the multiple experiments cited previously that confirmed the effect of bacteria, vaginal examinations should not be performed as a matter of routine from 37 weeks until the onset of labor. A discussion with your care provider on this regard is advised in any case.
