Prelabor Rupture of Membranes

While you are pregnant, your body is constantly making amniotic fluid to surround and cushion your baby and to provide sealed protection against invading bacteria. The fluid is held in place by a two-layered sac, commonly called the membranes. When your membranes break 'rupture') the amniotic fluid 'waters') will leak out.

The membranes can break in several different ways, Most commonly they break at the very bottom of your uterus (called the forewaters), due to pressure from your baby's head with labor contractions, and there is usually a big gush. This most commonly happens towards the end of labor but can also signal the beginning of labor.

Membranes can also rupture higher up, commonly called a hindwater rupture or leak. A hindwater leak dose not usually gush, but can be a slow, prolonged trickle, which is most likely your situation. For around 10% of women, the membranes will rupture at term but labor does not begin. This is called a prelabor rupture of membranes (PROM).

If your waters break, your body will still continue to make more amniotic fluid, which is constantly replenished. In this case, it is important to drink adequate fluids, which will help to keep your baby's amniotic fluid levels healthy.

However the major concern for you and your baby is the risk of infection entering your uterus and baby, who will not have the protection of intact membranes. There is also a small risk of your baby's cord prolapsing through the hole in your membranes, if you have a forewater leak. The higher placement of a hindwater leak makes it harder for bacteria to enter or for the cord to prolapse.

Different hospitals and physicians have different approaches to a prelabor rupture of membranes (PROM). Some want to ensure that the baby is delivered within a certain time after your membranes have ruptured, and will want to induce labor after 18, 24, 48 or 72 hours. Others, especially those with a low-tech philosophy, may be comfortable with a wait and watch' or a^??expectant' approach.

The best medical evidence suggests that there is some benefit from induction, although 50 mothers would need to be induced to avoid one serious case of infection in a baby. Ideally, you will make an informed decision for yourself, based on adequate and accurate information from your carer.

It is important to know if you are a carrier of group B strep (GBS), as this bacteria can cause serious harm to your baby. If you have not had a swab in pregnancy, you should have one soon after your waters break, if labor is not looking imminent. Your carer needs to be very careful to keep germs away from your cervix and uterus while doing this. If you know that you are GBS positive, or your swab comes back GBS positive, I recommend that you consider induction and/or having antibiotics to protect your baby in this situation.

If you are not GBS positive, 'wait and watch' approach may suit you and your carer. This is most appropriate, as below, if you stay at home. There are some very important guidelines if you are following 'wait and watch' approach.

Firstly, anything that is put into your vagina will increase the risk of infection. This means that you should avoid having vaginal examinations, baths (even a shallow-hip bath), sex and using tampons. Generally you are more likely to avoid infection staying at home, although some doctors want women in your situation to be admitted to hospital for monitoring, as below. Multiple vaginal examinations are one of the biggest risk factors for infection.

Your personal hygiene is important also. You want to keep bacteria away from your vagina, and this may be helped by scrupulous toilet hygiene. Keep your bathroom clean, consider having one toilet for your exclusive use, if possible, and also have a shower or wash your perineum well after a bowel movement. It may also be beneficial to not wear underwear or a pad, as much as possible, or at least change your pad frequently. Don't use chemically treated pads: clean cotton diapers are a good alternative.

Monitoring is important, so that you can pick up an infection as early as possible. Most midwives would suggest that you check your own temperature in the morning and every four hours during the day , and report to your carer of it is over 100.4 degrees F (38 C). You also need to pay attention to your baby's movements and report if your baby is moving less than usual. You can also check your fluid, which should be clear with a sweet-salty smell: if the odour becomes unpleasant, or the fluid cloudy or green, also report this to your carer. Many carers will want more intensive monitoring. This may include blood tests every day or two and fetal heart monitoring (either listening or by machine) every day.

Some experts also suggest that you take supplements to reduce the risk of infection. Midwife Anne Frye suggests Echinacea 1/4 dropper four times daily plus vitamin C 500 mg daily and a good prenatal multivitamin. There is some evidence that good intakes of vitamin C in pregnancy make the membranes tougher and less likely to rupture before labor.

Hopefully you will, like most women with PROM, have already gone into labor and had a safe birth and a healthy baby.

References
Anne Frye Holistic Midwifery Volume 1 Care during pregnancy Labrys Press. Portland OR, 1998
Association of Radical Midwives Archives Prelabour / Prolonged Rupture of Membranes http://www.radmid.demon.co.uk/prom.htm
Gentle Birth archives http://www.gentlebirth.org/Midwife/prom.html