Today on Evidence Based Birth, occasional contributor Rebecca Dekker, Phd, RN, APRN, provides a comprehensive research review - What is the Evidence for Inducing Labor if Your Water Breaks at Term? When membranes are released at term, before a woman is in labor, this is referred to as premature rupture of membranes, or 'PROM'. There does not seem to be a consistent agreement amongst doctors and midwives on what is the appropriate protocol for women who experience PROM. Rebecca examines the research and helps us (and the families we work with) to understand what might be acceptable options when PROM occurs. I had a chance to preview the article and ask Rebecca some additional questions that I had. Her review article along with the questions/answers here can help you to provide the families you work with an update of the most accurate information available. What are you currently sharing with patients, clients and students about best practice around PROM? What are you seeing in your communities? Will this information change what you are saying? - Sharon Muza, Science & Sensibility Community Manager.

Sharon Muza: What approach do you suggest women and families take in discussing this scenario (PROM) with their health care providers both prenatally and in the moment if PROM should occur? How can they assure themselves that they will receive evidence based care in either situation?

Rebecca Dekker: Given that one in ten women who give birth at term will experience premature rupture of membranes (PROM), it is important to talk with your health care provider ahead of time about what their recommendation is for PROM that happens at term.

Evidence suggests that in women who meet certain criteria, both waiting for labor to start on its own and inducing labor immediately are evidence-based options. If you hear things like, 'You must' do this or 'You're not allowed' to do this in relation to PROM, and those recommendations don't line up with the evidence, then you may want to seek a second opinion before you go into labor!

Similarly, if you find out that your birth setting has strict requirements for giving birth after PROM (for example, you MUST give birth within 24 hours or you're required to have a Cesarean, or we NEVER induce for PROM even if it takes you a week to go into labor), then you may want to look into a different birth setting.

The best-laid birth plans are often sidelined by PROM. If you are facing strict rules - either by your provider or hospital - that do not take into account your individual clinical situation, preferences, values, and goals, then you might face pressure to conform to their policies, procedures, or standard practices.

On the other hand, if you know you have a trustworthy care provider and birth setting who will provide you with accurate, evidence-based information about your options, and actively elicit and respect your preferences, then experiencing PROM does not have to be a bad thing!

SM: Women are often told that a 'sterile speculum exam' does not increase their risk of infection after PROM. What would you say to this?

RD: We found limited evidence that a 'sterile speculum exam' does not introduce extra bacteria to the cervix. In one small research study, five women had two sterile speculum exams, and their cervixes were swabbed to check for bacteria after each exam. There was no increase in bacteria on the cervix after the second speculum exam (Imseis et al., 1999).

In contrast, when they swabbed the cervix before and after a digital vaginal exam done with sterile gloves, they found a doubling in the number of types of bacteria on the cervix after the exam. There was also an increase in the growth of bacteria when they cultured the post-exam swab.

So for some reason, vaginal exams using sterile gloves are more harmful than exams using a sterile speculum. The researchers did not say why this might be, but my guess is that perhaps it has to do with the fact that the speculum is made out of a material that does not easily transfer bacteria.

Here's a funny story for you - when our Evidence Based Birth retreat team was working on the literature search for PROM, we were talking through the whole problem with vaginal exams and the increased risk for infection. One of the clinicians on our team wisely pointed out that it's not that the gloves are dirty (they're supposed to be sterile) - it's that the sterile gloved hand is touching the outside of the vagina and then those germs are delivered by the glove to the cervix. One of us called it the 'hostile vagina' syndrome. That term made us laugh really hard.

But in the end, we decided that women's vaginas aren't really hostile (and we're tired of people blaming childbirth problems on women's bodies!) - it's that clinicians are using their sterile gloved hands to push bacteria from the lower vagina up to the cervix. Instead of calling it a hostile vagina problem, let's call it a hostile exam problem!

SM: While conducting your research, did you come across any information that mothers with malpositioned babies were more likely to experience PROM? How about more PROM during a storm with an extremely low barometric pressure in place?

RD: After an extensive search, we could not find any research that directly looked at the relationship between posterior-positioned babies and the risk of PROM. I did find this book written by Johns Hopkins Medical Center in 1916, where they mentioned anecdotes about posterior babies and PROM. There was also one paper published in 1994 that found 21% of mothers with persistent posterior-positioned babies started labor with PROM. But we have very little evidence to go on here, so not sure if we can say with any certainty whether there is a relationship or not.

There is very little evidence on the topic of PROM during storms with low barometric pressure. This relationship is theoretically possible, but the evidence is limited. I found two studies that found a correlation between low barometric pressure and PROM - however, both of these studies were limited by retrospective (looking backwards in time) designs (Akutagawa et al., 2007; Polansky et al. 1985).

I'm not sure if the barometric pressure relationship with PROM has any clinical relevance, though - what are we going to tell women? Avoid storms at the end of pregnancy?

SM: You wrote that researchers found that 8-10% of women will have PROM, but anecdotally, many HCPs, doulas, CBEs etc., state that it happens more frequently than that. Do you think it could be higher than the 10% stated, and why do you think experiences do not align with the research?

RD: The reference that most people point to for the one in ten number comes from a really interesting paper published by Gunn et al. in 1970. In this article, they reviewed all of the previous studies on PROM, and they also looked at the rate of PROM in their own institution. Gunn et al. found that previous researchers reported incidences of 2.7% to 17%, with most incidences falling between 7% and 12%. In their own review of medical records at UCLA during a ten year period (1956-1966), they found an overall PROM rate of 10.7%. This rate included preterm and term births, and they defined PROM as the water spontaneously breaking any time before the start of labor.

In the Evidence Based Birth blog article on PROM, we spent a lot of time discussing the known risk factors for PROM. You have to take into account the fact that this 10% is an average, and it may fluctuate depending on risk factors. For example, if you live in an area where most clinicians are doing weekly prenatal vaginal exams starting at 36-37 weeks and routinely stripping the membranes, then you are probably going to see a higher rate of term PROM.

SM: If you could design a study that wanted to determine the best practice for PROM, how would you go about it?

RD: I actually think that the Hannah (1996) TermPROM study was really well designed (with a few exceptions that would need to be changed), and future researchers can learn a lot of lessons from how they went about looking at induction versus expectant management.

If we were going to conduct another study, it would obviously need to use modern protocols for Group B Strep screening, and a better definition of chorioamnionitis. We also don't know what would happen if care providers kept their hands out of the vagina - one-third of women in the Hannah study had vaginal exams right away when they entered the study. So making it part of the study protocol to keep those hands out of the vagina at the beginning would be important.

I would also like to see this topic studied in various settings with both low and high Cesarean rates. The Hannah study took place in countries and hospitals where the C-section rates seemed to be pretty low overall - about 15% for first-time moms - which isn't great, but it's much lower than the one in four primary Cesarean rate we have in the U.S. It's quite possible that the Hannah findings about Cesarean rates are NOT generalizable to the U.S. and other countries where Cesarean rates are very high.

Finally, I would love to see a secondary data analysis from the AABC Birth Center study about outcomes from women who gave birth in U.S. birth centers after experiencing PROM. This would not be a randomized trial of course, but it could give us really great information about the general rate of complications women might experience if they give birth in a low-intervention setting with PROM.

SM: In the research you examined, is there any information about women who had PROM in a previous pregnancy more likely to have it again? (i.e., is this just how labor starts in general for those women.)

RD: In the studies that we did review, I did not find any research about this topic.

SM: Given that the risk of a prolapsed cord is around or less than 1%, (and some risk factors make that more likely: breech baby, SGA, preterm, multiples, polyhydramnios for example) what should women consider when they are told by their HCPs to come in immediately after PROM, even when there are no contractions and labor has not yet started. (I am assuming that is why they are told to come in immediately, even though prolapsed cord would be an obstetrical emergency, not a 'head this way now' thing.)

RD: I would recommend finding out more information about your care provider's intentions and treatment protocols. Prolapsed cord is really rare (reported range with PROM is 0.3% to 0.6% per Gunn et al.'s 1970 extensive review of the literature) and it's an immediate, life-threatening emergency for the baby, so if they are saying, 'You can take a shower, but then you need come to the hospital,' then that can't be what they are worried about.

As a mother, I would want to know, 'Why do you want me to come in immediately? And what are you going to do when I get there? Are there medical reasons (such as GBS) that I need to come in for right away?' Are they just going to verify that the water is broken with a sterile speculum exam and do a quick check with the monitor to make sure baby is doing okay? Are antibiotics indicated? Will the mother be given the choice of induction versus expectant management, and be told that if she wants to, she can wait for labor to begin either at the hospital or at home? Or are they going to insist that she start the induction process as quickly as possible? This is where it is really helpful to know the standard procedure that is practiced in your birth setting, and how rigid their protocols are.

Looking at the evidence that we have available to us, it seems that waiting 6 to 12, or maybe 24 even hours at home for labor to start is probably not going to be harmful - as long as the mom is GBS negative, the fluid is clear, and she is monitoring her temperature and baby's movements. It is also certainly evidence-based to go in and get evaluated (after all, that was the protocol in the Hannah and Pintucci studies that have given us evidence on the safety of waiting).

It's best if you figure this out ahead of time - before you experience PROM. It takes honest and careful communication with your care provider, and that discussion simply has to take into account your own personal situation, risk factors for infection, and preferences. It's so important to find a care provider you can trust, consult with them, and ask their opinion about any information or research you have uncovered. Have open discussions about the evidence with whomever you have hired to take care of you, but find a trustworthy care provider! I can't emphasize that enough.

ImprovingBirth.org just launched a really great article about how to find care you can trust, and I highly recommend reading it!

SM: Have you read anything about the amniotic membranes being able to reclose after breaking? I have heard that sometimes if there is a high leak they will 'repair' themselves?

RD: Yes, this is possible. In the Gunn et al. (1970) literature review, they referenced studies from the 1950s and 1960s claiming that a break can happen in the membranes in an area above the lower uterine segment. The break can then re-seal itself so that no more fluid loss occurs.

Then in 2006, Devlieger et al. published a review of the literature in the American Journal of Obstetrics and Gynecology on the topic of membrane healing. If you're interested in this topic, I would recommend reviewing their article, although it mostly focuses on the possibility of resealing the membranes after preterm premature rupture of membranes (not term PROM).

SM: For all the childbirth educators reading this post - what key points should they be sure to cover during class to help their families feel prepared if PROM should happen to them?

RD: Evidence shows that in women who meet certain criteria (single baby, head-first position, clear fluid, no fever or signs of infection in mother or baby, negative Group B Strep test), waiting for labor to start on its own for up to 2-3 days is as safe for the baby as inducing labor right away, although the mother is more likely to get an infection herself. In other words, both inducing labor and waiting for labor are evidence-based options. Families need to know that their preferences and values matter in this situation, and if they are in a setting where the care provider has strict rules that 'must' be followed, their preferences might not be honored.

However, you have to keep in mind that as always, there are caveats with the information about the safety of waiting for labor to begin. In the most recent study that we have (Pintucci et al., 2014) showing great outcomes with waiting for labor to begin on its own, women did their waiting in the hospital, and started antibiotics at 24 hours. In the Hannah et al. (1996) TermPROM study, women in the 'expectant management' arm of the study came to the hospital first, were assessed and had a non-stress test, and then were given the choice to go home and monitor their temperature there, or stay in the hospital to wait for labor to begin.

Finally, probably the single most important thing that women need to know is to not let people put hands up your vagina after your water breaks! That is the single most important risk factor for infection, and hands need to be kept out as much as possible. A vaginal exam when your water first breaks with PROM is not necessary, and is probably harmful, and can cause infection in you and your baby. Sterile speculum exams are probably okay.

The more vaginal exams you have after PROM, the higher your risk of infection. Keep all hands out!!

SM: Anything else you would like to add or include as a follow up to your informative article?

I want to publicly thank Alicia Breakey, a brilliant PhD candidate from Harvard who is about to graduate very soon (and is looking for a position in maternal health!). Alicia served as first-author on this blog article, and I really couldn't have published it without her diligent help. I'd also like to thank our clinician expert, Angela Reidner, MSN, CNM, who was also a co-author with us.

Photo source: By Saltanat ebli (Own work)

References

Akutagawa, O., Nishi, H., & Isaka, K. (2007). Spontaneous delivery is related to barometric pressure. Archives of gynecology and obstetrics, 275(4), 249-254.

Devlieger, R., Millar, L. K., Bryant-Greenwood, G., Lewi, L., & Deprest, J. A. (2006). Fetal membrane healing after spontaneous and iatrogenic membrane rupture: a review of current evidence. American journal of obstetrics and gynecology, 195(6), 1512-1520.

Gardberg, M., & Tuppurainen, M. (1994). Persistent occiput posterior presentation-a clinical problem. Acta obstetricia et gynecologica Scandinavica,73(1), 45-47.

Gunn, G. C., Mishell, D. R., & Morton, D. G. (1970). Premature rupture of the fetal membranes. Am J Obstet Gynecol, 106(3), 469-483.

Hannah, M. E., Ohlsson, A., Farine, D., Hewson, S. A., Hodnett, E. D., Myhr, T. L., ... & Willan, A. R. (1996). Induction of labor compared with expectant management for prelabor rupture of the membranes at term. New England Journal of Medicine, 334(16), 1005-1010.

Imseis, H. M., Trout, W. C., & Gabbe, S. G. (1999). The microbiologic effect of digital cervical examination. American journal of obstetrics and gynecology,180(3), 578-580.

Pintucci, A., Meregalli, V., Colombo, P., & Fiorilli, A. (2014). Premature rupture of membranes at term in low risk women: how long should we wait in the 'latent phase'?. Journal of perinatal medicine, 42(2), 189-196.

Polansky, G. H., Varner, M. W., & O'Gorman, T. (1985). Premature rupture of the membranes and barometric pressure changes. The Journal of reproductive medicine, 30(3), 189-191.

Stapleton, S. R., Osborne, C., & Illuzzi, J. (2013). Outcomes of care in birth centers: demonstration of a durable model. Journal of Midwifery & Women's Health, 58(1), 3-14.

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