Water breaking...24hr "rule"

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The pressure to induce at my hospital comes from the peds. Chorioamnionitis (infection after rupture) is not really a huge issue for moms, as it's easily treated with IV antibiotics. It can make the uterus work less efficiently, though. The main issue is infection/sepsis in the baby, which is difficult to treat (since newborns have immature immune systems) and can be very difficult to diagnose.

Midwives, IME, do tend to view the baby until birth as one of their two patients (more so than docs do), but at my facility, a lot of the pressure for antibiotic use comes from the peds, which I can understand, since they see all the babies that do get infected.

Sepsis in a newborn is a huge issue, and I do believe in monitoring mom very closely for signs of chorio. I just don't think the 24 hour rule is very persuasive for improved outcomes.

Often there is no differentiation between ROM and hindwater leaks which easily reseal either. I've had 2 hindwater leaks with 2 babies, the second one a week and a half before birth and 8 days before that labour commenced. I know in the hospy system I'd have had trouble if I'd owned up to that. My membranes only released about 2 hours before my second babe was born after 50+ hours of labour. So I have quite an interest in this stuff This is what I give women to help them decide for themselves what steps to take in the event of ROM or HWL.

A hindwater leak occurs when only a small amount of fluid is released. There can be many reasons for this occurring rather than a full ROM. You'd be surprised how much liquor can be released in a hindwater leak and thus how easy it can be to confuse it with a full ROM.

http://www.gentlebirth.org/archives/prom.html

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Obviously, the risk of infection will be higher when there is a large opening in the amniotic sac directly over the cervix, and the risk of infection will be almost negligible when the fluid is leaking from a high leak in the hindwaters. Bacteria would have to be awfully clever to find their way against a tide of outflowing fluid to find a small opening high in the amniotic sac.

Some ways to tell that the fluid is coming from a high leak in the hindwaters:

Belly still feels full of fluid, and baby's body isn't clearly outlined in the belly
Without touching the cervix, do a vaginal exam with sterile gloves to palpate the lower uterine segment directly inside the vagina. If the baby is easily ballotable, meaning it kind of floats up a bit, then there's still fluid in the belly, and the leak isn't over the cervix.

Also:

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There are two layers of membranes - the outer sac (the chorion), and the inner sac (the amnion); it is possible for the outer sac to break while the inner sac remains intact; this can still release some fluid that might have accumulated between the layers. This would tend to be a small amount of fluid, and generally there is not a continuing trickle.
It is possible for baby to poke a hole through the membranes at some point. Then, as fluid is released, the sac may double over on itself at that point and, like Glad Wrap, stick to itself, forming a seal over the leak. Again, this would tend to be a small amount of fluid, and generally there is not a continuing trickle.

There is no inherent benefit either way. Some women find drippy labours irritating after ROM, some women's membranes do not rupture until crowning, some never do and the baby is born "in the caul". If you're birthing in a hospital, regardless of how much fluid has left the building, stay home until contractions are strong and close together or you'll be on a timetable and pressured to induce. You will be told that you are at risk of infection.

NICE guidelines from the UK state that women can go up to 96 hours without being induced. The likelihood of infection is significantly reduced if you put nothing in your vagina (this includes VEs which are a major way germs are spread) and stay home in your own friendly germ environment as long as possible.

http://www.radmid.demon.co.uk/prom.htm

5.5 Induction of Labour in the presence of Prelabour Rupture of the Membranes (page 2

5.5.1 ....Epidemiological data on time interval from term PROM to spontaneous labour demonstrates that most women go into spontaneous labour within 24 hours of rupturing their membranes.

86% of women will labour within 12-23 hours
91% will labour within 24-47 hours
94% will labour within 48-95 hours
6% of women will not be in spontaneous labour witthin 96 hours of PROM.

USA Midwife Archives page on Prelabour Rupture Of Membranes:
www.gentlebirth.org/archives/prom.html

NICE/RCOG guidelines on induction of labour (short form)
(www.nice.org.uk/article.asp?a=17321)

NICE/ RCOG evidence- based full clinical guideline on induction of labour
(http://www.nice.org.uk/pdf/inductio...ourrcogrep.pdf)

Premature Rupture of Membranes (PROM) By Elizabeth Bruce, on the Compleat Mother site. Discusses both prelabour and preterm rupture of membranes.
www.compleatmother.com/prom.htm

Preterm Prelabour Rupture of Membranes, from the Dartmouth Hitchcock Medical Center - Straightforward factsheet.
http://www.dartmouth.edu/~obgyn/mfm/...term_PROM.html

PROM guidelines from MoonDragon Midwifery Practice
http://www.geocities.com/HotSprings/...86/varia2.html

Midwifery Today e-news on premature (ie prelabour) rupture of membranes
www.midwiferytoday.com/enews/enews2n46.asp

http://www.empoweredchildbirth.com/a...turelabor.html

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And this is why I'm going to be homebirthing next time around... The whole stupid medical profession made me lose trust in my own body. My waters (the complete bag) had ruptured, and after 18 hours, I still hadn't started regular contractions (but somehow went from 3 cm to 6 cm in a really easy labor). They told me that because it hadn't happened, I wouldn't go into labor and they forced pitocin in me (which inevitably was what made Ryland's heartrate drop). Apparently the big rush was because I had a positive GBS screening, even though I had been on antibiotics since 2 hours after my water broke. And before the pitocin, every single freaking hour, they'd come in and break the new bag of water that formed, saying that I had a lot of bags that were in there and they were keeping me from dilating "fast enough". :

That chart showed that my body was perfectly normal. Sometimes I wonder if maybe labor is supposed to be that easy sometimes...just a peaceful slow dilation. The nurses kept telling me if I wasn't white-knuckling it and screaming, that my labor wasn't progressing... :

I think that the basis of the increased risk of infection comes from frequent vaginal exams.

IMO, once fingers are put up there, then the clock starts ticking.

Most of the time if baby is going to show signs of infection in a NORMAL healthy woman (sans vag exams), it will be within the first 12 hours of rupture.

Hind leaks and first layer leaks are common.

The rule in my practice is: pay attention to how you're feeling, what your baby is doing and keep fingers out of your vagina. Anyone's fingers!! The safest place for you to be with ruptured membranes is in your own home.

I usually pay close attention to position of baby if rupture occurs in a first time mom without labor starting within 12 hours or so. Typically, you'll see this happen with a posterior, asynclitic or even a breech baby.

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It is my understanding that the studies that the 24 hour guidelines are based on were done in teaching hospitals with women with inadequate prenatal care and VEs done by MANY people (because they were learning). It is not based on women who are at home with their own germs wiping carefully after bowel movements, nothing being inserted in the vagina, and monitoring temps every few hours.

I had a hind water leak with my first (didn't know that at the time) and was immediately given pitocin because my cxn's weren't "strong enough" and the epidural followed (pitocin hurts!) as did a c/s for fetal distress, a known side effect of pitocin.

With my second, prodromal labor for two weeks, then SROM (obvious ruptured membranes) prior to active labor. My OB wanted me to get abx at 12 hours because, according to him, the risk of infection starts going up then. Active labor finally kicked in for me 26 hours after the water broke and my daughter was born vaginally 31 hours after my water broke. The nurse tried to say "see your temp started going up" immediately after labor. I wanted to say "Lady, I just pushed this baby out and it's the most athletic thing my body has ever done. Yeah, my temp went up one whole degree birthing this baby. Sheesh" : No signs of infection in me or dd.