p-PROM: desperately need ideas (very long post)

[lis0928]

First off, I am not sure I am posting in the right forum. So, if I'm not please let me know.

I am 31w5d along with my third pregnancy.

My first two times were easy as pie. The first time around, we did the Bradley Method and had an unmedicated, intervention-free vaginal birth in a teaching hospital at 40w4d. Perfectly healthy 7 lb 6 oz baby boy after 4.5 hours of labor.

The hostility and aggression from some of the medical professionals was a bit unnerving, though, so the second time around we went to a freestanding birth clinic.

I had a nearly identical natural labor (40w4d, perfectly healthy 7 lb 1 oz baby boy born in the caul after just under 5 hours of labor). But, oh what a different atmosphere!

So, that's the mindset I am coming from in this pregnancy, which was unplanned and happened just after we moved out of state; so my lovely midwives are not an option and even my acceptable, if unsupportive ob/gyn, is not an option.

I found a midwife practice about 90 minutes from my home, though, so fully planned on having another birth center birth.

Three weeks ago today, at 28w5d, my bag of waters broke. More like exploded, gushing, soaking, not good.

It took two days of seeing midwives, seeing the midwives' backup ob, having backup ob order repeated follow-up ultrasounds, and finally transferring me to Maternal Fetal Medicine doctors, but in the end, I was admitted to the antepartum unit the nearest hospital with a level III NICU. And, here I am, 19 days later.

The good news is, I had already been ruptured for 60+ hours when I was admitted here, so I already was beating their odds.

I will have been here three weeks on Friday and there is no sign of infection in me or the baby, no contractions, no dilation (that I know of. On Day 1, after a false negative test for amniotic fluid, my midwive did a digital exam and confirmed my cervix was closed). No one has come near my vagina since then.

Obviously, my plans are pretty much out the window and I am adapting on the fly. I consented to the steriod shot. I consented to the course of antibiotics. I consent to the daily hour-long NST. I consent to a weekly ultrasound to measure amniotic fluid levels. I consented to an amniocentisis to confirm there is no latent infection in my fluid.

At the same time, I am trying to do what I can. I am taking probiotics--luckily my sister and brother work at natural food stores, so they are keeping me supplied with probiotics and good yogurt. I asked for vitamin C, vitamin D, and calcium supplements, which the docs are giving me. I am taking my own prenatal vitamin and DHA supplement. I am drinking, no joke, 2.5-3 gallons of water every single day. My fluid has increased from 1.0 cm to somewhere between 7-8. But I haven't re-sealed, I still leak a bit.

After telling me every day for ten about a week that I would go into labor at any minute, the MFM doctors seem to have accepted that, really, I have no such plans.

So, they told me that, if I made it to 34 weeks with no infection and no signs of fetal distress, they would induce. After several tense discussions about evidence-based medicine and a little thing called informed consent, we have compromised and I have agreed that the one doctor in this practice who I am comfortable with (he did work with midwives in the beginning of his career and his wife has had 3 vbacs) would be responsible for my care. He and I will "discuss induction some time around 35 weeks or so." The other 4 docs have basically washed their hands of me, I think.

I am still not sure what I will do if and when that day comes. There's a limit to how far this doc can go in this environment (high-risk pregnancy, already not using their standard protocol). If I leave the hospital against medical advice, I have no backup. My midwives can't take me back and their back up won't.

So, assuming we reach a point where this doctor says no, really, we need to induce and deliver this baby pre-term, I honestly don't know what I'll do.

Has anyone been there, done that? Either refused induction and waited it out or agreed to induction. If you agreed to induction, did you use any homeopathic methods to try to get it started first? Did you agree to pitocin?

I am terrified of being on pitocin without pain meds but I will not get an epidural. I have had really really bad reactions to pain medication in the past, so I am terrified of an epi. Terrified of a c-section. Terrified of having a baby in the NICU. You get the drift. I feel like a trapped animal.

I would really, really appreciate any and all ideas!

[loveneverfails]

I haven't been there or done that, but I just wanted to tell you what a wonderful job you're doing. The extra weeks you've given your baby are wonderful. You should like you're doing a phenomenally good job, and should be so so so proud of yourself.

I think all you can really do is to hold tight and keep up your immune system.

[elus0814]

I wish I had some advice other than to stand your ground and keep saying why you feel the way you do about your decisions. It doesn't make sense to me that they would choose 34 or 35 weeks as a random date to induce but I don't know all the details. The only reason I can think of is that that is the date they have chosen as when the risks of infection begin to be more than the risks of prematurity.

I've had three babies that were p-prom. With the first my water broke at 32 weeks 6 days, I went into labor naturally 8 days later (after being told every few hours that I would go into labor at any moment) but developed a severe infection during labor. The baby was in the nicu for 8 days. With the second my water broke at 31 weeks 6 days and I went into labor naturally about 24 hours later, no infection. The baby was in the nicu for 22 days. With the third I had a few contractions at 35 weeks 4 days and went to the hospital. I stayed overnight without labor but my water broke during the night and labor began and was born that morning. The baby went home with me a day and a half later.

In labor, in the absence of an infection, there shouldn't be a reason to be constantly monitored, have an iv, have pain medication, pitocin, etc. It's just like any other labor until the baby is born. Be prepared for lots of people to be in the room. There were people walking in and out while I was pushing which really violated my privacy. I would estimate that 20 people were in the room during the birth of the 32 weeker. Even with all that, the baby was breathing well enough to stay in the room and breastfeed before going to the nicu for breathing assistance.

I wish you the best of luck!

[beep]

It sounds to me like you have done an absolutely magnificent job all around: found good midwives, gotten yourself to the appropriate care setting for your current situation, mindfully consented to those medical interventions that are likely to help your baby, looked after your own and your baby's health really well, negotiated skilfully and effectively, and identified your allies and their possible limitations. To my way of thinking, having done all that there isn't that much more for you to do at this time other than the all-important jobs of keeping up your own mental & physical health and growing your baby. Since you've gotten the concession of "around 35 weeks" from them and they wouldn't want to induce until 34 anyway, you should now have at least 2, maybe 3, weeks before you need to make any more decisions about checking out, accepting pitocin, etc. My impulse in your situation would be to table those issues until some specific time (say, 34 weeks) and then do whatever I could not to worry about them. Who knows, by then things may have changed anyway--the leak could seal, the doctors could get more used to the idea of waiting longer and intervening less, the baby could decide to be born without induction, etc...

Courage and peace to you, mama.

[MsBlack]

Maybe I'm just simple-minded, but I don't see why you have to consent to induction AT ALL, if the baby is doing well and you are doing well...?

Are you even leaking fluid anymore? Are you having contrax (beyond Braxton Hicks normal for pregnancy)? If so, do they have you on meds such as terbutaline to control contrax? Is baby still growing normally? The answers to these questions should of course influence your thinking, but if the answers are NO, NO, NO and YES then this is what I think:

With the support of evidence-based practice and that precious little thing called informed consent, do not consent to induction as long as you and baby are fine. The docs are under 'strain of potential lawsuit' and otherwise tend to think of themselves as far better equipped to 'finish growing your baby in NICU' than you are, in utero. So freakin what--by appropriating so much control over the knowledge and decision making in birth, by essentially and with great dedicated political and psychological effort over the last 100 yrs usurping natural parental responsibility and the wisdom of natural design, the med system has both caused it's own liability woes *and* has actually come to see itself as God. Not your problem and it really doesn't have to become your baby's problem either.

You are doing fantastically, miraculously well so far, mama! You truly awe me well beyond my typical awe for the power of loving motherhood. Keep up the good work! And consider talking to a lawyer--you may even find one willing to represent you for free, because handling such a groundbreaking case could make that lawyer rich later, when other families flock for similar representation under medical duress.

Again--if you and baby are fine, if all the risks at this point are 'potential' but there are no 'actual' signs of impending doom, then I just do not see why induction is on the table at all. There may come a time when you agree that induction is safest....and you can assure them that the minute they think those signs are appearing, you will indeed consent to induction or whatever is necessary for your own and baby's safety. But I hope that you will assure them now, that induction is not in your plans and that you intend to continue to insist upon evidence based practice *applied to you, individually*, NOT just the possibilities for 'all women/babies in this situation'; that you will continue to insist on informed consent...and that if they push the point too hard, only creating the kind of stress well known to be detrimental to the health of human beings, you will seek legal help in securing your own and baby's safety with the right care.

Just a thought

[owlgirl]

100% agree w/ Ms.Black!! You can grow your baby better than the NICU!!! Don't consent, follow your instincts. You already know!! More power to you mama!! You are amazing!!

[Tigerle]

Another poster who wants to extend her sincere and utter admiration. You are doing so well. You've even managed to get them to back off for now. You have another three weeks to go until someone is even going to mention the i word to you (and if others do, remind them of that deal - they can all just shut up!). As others have pointed out, loads of things could happen to take the decision out of your hands. Take care of yourself and the baby until then and let them all go to wherever.

About what could happen at 35w:
I had DS at 34w6d after pPROM and he was NOT ready to be out in the world, needed another two weeks in the NICU (I never had the steroid shots, though). He needed oxygen, a feeding tube, jaundice lights and had signs of infection so was put on antibiotics, too. But he was okay! I am told girls do better at around that age, but I would still think if you can avoid induction until 37 weeks, provided you can hold infections at bay it would be so much better. it does seem to be the age at which they consider all issues manageable, which is why I imagine they came up with that time frame. but really, what do they want to do if you refuse? Kick you out of the hospital? You are agreeing to all this monitoring and the antibiotics (which I think are all the right things to do really) and the baby is fine, so what is their problem apart from probably never having had this situation before? However, even if you are too tired to resist any longer at that point and agree to induction, it will be okay. The issues your baby might have are manageable, the NICU stay, if at all necessary will be short and with the shots, there is no reason why the baby shouldn't do a lot better even than mine did for instance.

So much for the baby. About your own concerns - that's harder.
I did go into labour on my own 12 hours after I ruptured (huuuge gush!) or so, but was given Pit to speed things up (that 24 hour window, you know) and pit contractions were no fun, I won't lie to you, but if I had been allowed to move around and make noises, I think I could have gone without an epi for a lot longer than I did. You have had very quick births in the past, you might just make it without pain killers again. For obvious reasons, i have been researching labour a lot recently, and was very surprised to find out how different pit contractions are supposed to be from natural contractions - but they are not that bad for everyone, I find. And if you realize you won't make it, I wonder whether with your issues with medication, a CS with full anesthesia and no painkillers after but ibuprofen, which most people do very well with, might even be the best option? i completely understand how you feel - I am looking at the very real possibility of a (medically necessary) CS within the next two weeks and I am scared, too and would take induction with an epi any day. But I btdt and know my body can handle it - I could totally do that again.

All of the rather disjointed above is really moot though if your body decides to give birth on YOUR terms while you are able to hold them off, which I still think is likely.

And maybe it helps to be less scared off the medical staff of the place you are in right now if you tell yourself that so far, they have been doing a FANTASTIC job, too - everyday that baby keeps growing in there is another day towards everything being okay.

Hugs!

[homemademom]

My sister was in the hospital for many weeks under the same circumstances, though she was induced at 34 weeks because the baby wasn't doing so well (congenital defects).

I think you're doing amazing, and my heart goes out to you! I just wanted to mention that you may not need much pit to get things going. Perhaps you can see if your doc is willing to use a foley catheter and/or cervadil to ripen your cervix and then, some pitocin to get things going if needed. Once you're in the swing of labor, I would ask them to turn it off.

Have you had a chance to talk candidly with the doc who is taking your case? Does he want to induced at 34/35 wks simply because of protocol? Would he agree to reevaluating at 35 wks to see that there is no infection and give you at least (if not more) another week?

I so understand your pain. One of my babes was a hospital birth and I had to accept a lot more intervention than I wanted because the doctor I had was the only one who would see me. It stinks to be in that position of dependence! Whatever happens, it sounds like you and your baby are doing wonderfully. And if your baby is born at 35 weeks, it will still be okay, but I sure hope you get more time.

[Sudonk]

I don't have any knowledge about this beyond what you already know, but I wanted to take a moment and let you know how proud I am of you and how lucky your baby is to have such a dedicated mom. You're doing a great job working toward the best possible start to life outside the womb for your baby, despite some pretty steep odds. Good for you!

As for induction, I agree that it might be best to put it out of your mind for a little while and then start re-examining the situation when you're closer to 35 weeks. Do you have any resources for finding out the pros and cons of inducing at that point. I know that some concerns with inadequate fluid is immature lungs or joints that aren't properly formed from being squished into an unnatural position. It doesn't sound like either one is an issue for you, since you are keeping the fluid level at a low, but normal range. As long as that continues, is there a true problem, or just an increased chance of developing a problem?

I know we don't want to make decisions based on anecdotes, but I thought you might like to know that one of my friends was a p-PROM baby. His mom was only around 4 months along when her water broke. Her doctor told her she would go into labor and lose the baby, but they agreed to let it happen naturally, rather than put her through the rigors of induction. After 6 months of trickling constantly as she moved through her day, his prediction came true and her body spontaneously birthed her 7.5 lb, perfectly healthy baby. Not useful in making decisions, but I thought it might give you a boost to hear how a similar situation turned out over 30 years ago.

[loveneverfails]

I don't know. If I hit 35-36 weeks, I'd probably ask for an amnio to check lung maturity and induce. My view is very colored by a 10 day NICU stay for a presumed infection that was never there, so if everyone was agreeing that there was no infection at that point and the likelihood of a NICU stay was low, I'd probably get induced. I would be worried about a situation where inducing before signs of infection meant I could take a baby home in 2-3 days and without the septic work up that would happen if they thought there was an infection in play.

I think the line is way later than what the doctors were talking about, but that there is a line there where the risk of sepsis and the nightmare that can happen if they think you have sepsis does outweigh the benefits of longer gestation. It's absolutely a judgment call based on individual values and comfort levels, but having been through the trainwreck that is "the doctors think my baby might have sepsis"... I'd do an awful lot to try to avoid that situation.

[liberal_chick]

My experience with pPROM was a bit different than yours (mine occured at 20 weeks with a partial [and slow] placental abruption at 30 weeks, so I had a c-section), so please know that it colors my perception. I welcomed the medical intervention b/c my rupture occured pre-viability and I just wanted my baby to LIVE and have working lungs.

The reason that they will want to induce around the 34 week point is that the risk of cord compression outweighs the risk of prematurity at that time, or so I was told. It honestly makes sense to me. An AFI of 7-8 post rupture while still leaking is great, but if you've got a 5-6 pound baby in there cord compression would be a serious concern of mine (it was a big concern of mine in my late-20s, but my AFI stayed around 4, for the most part).

I think you've been doing a great job so far and I applaud you!

[lis0928]

I really want to thank each of you who responded. You have no idea how very much your support, insight, shared experiences, thoughts, and the questions you've given me to consider help me right now.

What a wonderful group of women I stumbled into.

[MsBlack]

yeah, we're pretty wonderful!

Just know that we are here to talk with--and with you in spirit every minute, along with all the many generations of fierce, strong, loving mamas who ever made tough decisions for their babies well being...we all support you

[beep]

Please do let us know how it's going.

Best wishes to you and the babe.

[Tigerle]

Found a thread with more btdt stories.
http://www.mothering.com/discussions...ight=prom+wine

[Mrs.Music]

When I went in for pprom with my daughter at 27 weeks, they assured me that it was pretty safe to just keep on laying around there until term or whenever the contractions picked up on their own again. I see no reason to induce if you don't feel like it. I ended up having her only a few days later, though, so I can't really say from experience. Just what the doctors told me. I had my son at 33 weeks and he was home by 35, so if you do choose to induce at that time, it doesn't mean you'll end up with a lengthy NICU stay. Just trust your gut and fight for what you want. I'm sure whatever you choose will be right. Stay strong.

[lis0928]

Long update

Well, I was just re-reading this thread for some encouragement and strength, so I figured i would go ahead and update it. I am still in the hospital on bedrest, 31 days after my membranes ruptured. Currently, I am 33w1d.

Still no signs of infection, no signs of distress, no contractions. Last ultrasound, about a week ago, showed AFI of 8.8, baby's weight then was estimated (yeah, I know) at 4.8 pounds, all measures about a week ahead of gestational age.

I tried very hard to put the induction issue out of my mind for a few weeks and focus on staying calm. I had some success, but at 32 weeks, the head (senior) doctor in this group pushed the issue, unfortunately while my "ally" doc was out on vacation. (I doubt the timing was a coincidence.)

So, it got kind of tense for awhile. I called a high-risk ob on the faculty of a teaching hospital in another city (I used to work with her husband). She confirmed that 34 weeks was standard, that it was not evidence-based, and that if I were her patient she would not push induction given my situation. She told me what signs WOULD cause her to recommendation induction, and generally told me to stay strong. (So they are out there--those doctors who don't view pregnancy as a disease state.)

I talked to the neonatologists who confirmed that at 35 or 36 weeks, babies tended to do better than at 34. My ally doctor came back from vacation, talked to the head doc and the two of them agreed that ally doc would take responsibility for my care. He and I agreed that we would "discuss" induction at 35 weeks and make some decisions then.

I also got in touch with my former midwives and found a fantastic former CNM who is now a homebirth midwife (let her certification go because she's done with hospitals) who is willing to act as a doula for me here in the hospital, which I think will be helpful primarily if I go into spontaneous labor. My husband is a fantastic advocate--he's a real rock---but given the atmosphere, I think I need someone to watch my back and someone to focus on baby.

So, I have been feeling generally pretty good. Only concern is, if I were to go into labor spontaneously, I am stuck with whichever doc is on call, but I felt like I had planned for that.

WELL Yesterday, another doctor in the practice felt compelled to try to talk me into inducing at 34 weeks and he pulled out ALL the stops: dead baby card; pregnancy itself is dangerous, mine is especially dangerous because we already know there's something wrong with my body; nature doesn't always know best; NICU babies have no problems; the studies that say otherwise are all flawed methodologically (has he read them? no. well, one, that I gave him.); it's ALWAYS safer to go get the baby, but especially in a high-risk pregnancy. And on and on.

I sort of don't care with regard to the induction issue. If I decide to induce I will do so in consultation with good doc, not this guy. But the idea that I have a 25% chance of getting him if I go into labor spontaneously and a 25% chance of getting the junior doc, Dr. Knife, who--I believe, and I am not exaggerating, has not delivered a single baby vaginally in the month that I've been here---is freaking me out.

I actually ended up in tears with the doctor yesterday (which REALLY pisses me off) and asked him to leave. Of course, he's on call all weekend.

It's just so disheartening. I can't even get into how patronizing and dismissive he was.

So, that's where I am.

[MsBlack]

So glad to hear your great update

So sorry that doc tried to put the screws to you

Just so you know, it is perfectly within your rights to refuse to listen to that stuff. If he or anyone else tries that again, you can interrupt as soon as you know where they are going, and politely but FIRMLY say "I'm sorry to interrupt, but this is not a conversation I am willing to have with you. I understand your concerns and am taking all that into account as I make my decisions about care. Please let it go now, I am not willing to discuss it further". Or something to that effect....following up, if the dr should try to push the point, with something like "We simply don't agree here. I need you to stop now, I'm not willing to have this conversation with you"

Be clear and direct--even if quaking in your bedsocks at the time! You are NOT obligated in any way to give your time to this guy. He is committing a boundary violation by doing that, he may take it as his right to do so but you can correct him if you disagree.

Also--you can make it clear to the whole staff that he is not to bother you anymore--that you will only speak to him again at your own request and he is to be kept out of your room. Maybe he will be the one you get on birthing day--but at least you will have gotten to that point according to your own wishes of evidence based care, rather than under his duress.

And with your dh and the CNM in your corner, I doubt he will be able to mess with you even if he IS the one oncall when you go into labor.

You are doing so fabulously well, still!!! Still amazing me totally. Just let that unpleasantness go now, and gestate in peace. 4.8 lbs is fantastic, by the way...of course there is no guarantee w/a u/s estimate, but remember, your baby may be smaller than that but might also be bigger. Sounds like baby is doing great, and before you know it you'll be pushing her/him into your arms....stay strong, we are still holding you in our thoughts.

[Banana731]

I couldn't not post after reading this. Ku dos! I can't even imagine what's it's like dealing with these cp's on a daily basis in the hospital with the way you have stood your ground. You are a real inspiration! You are in my thoughts mama, I wish you the best!

[aramat]

Hi, momma, just saw this thread & want to wish you the best. I, too, had two textbook births and then with my third had pPROM at 32 weeks. (Birth story here)

It's all about the provider, so good for you for finding someone else!!! My labor started naturally two days after the pPROM, and they let me go ahead and birth, but they were not going to induce me before 35 weeks (and even then I wouldn't have let them). Best wishes to you for a strong & healthy baby.