PROM: Premature (Or Prelabor) Rupture Of Membranes

PROM: Premature (or Prelabor) Rupture of Membranes

PROM is when your water breaks before labor begins. 8-10% of labors start this way.

Everything I discuss here is related to PROM at term, or after 37 weeks. Before 37 weeks, it's called Preterm Prelabor Rupture of Membranes (PPROM) and may carry higher risks. 

What are the risks?

  • Cord prolapse: this is very rare (.3-.6%) but indicates an immediate Cesarean. Many sources said this is often cited as a risk, but PROM may not actually increase the risk.
  • ·Infection of the baby
  • Infection in the mother:
    • Chorioamnionitis (chorio): infection of the membranes (2-2.8%)
    • Endometritis: infection of the uterine lining; shows up several days later 

What makes PROM more likely?

  • A history of PROM. If it happened before, you may be prone to it happening again. 
  • Yeast infections
  • Not enough good bacteria (lactobacillus) in your vagina
  • Cigarette smoking
  • It may just be normal. Your membranes are designed to get weaker near the end of pregnancy so that they can rupture spontaneously at some point (usually 7-8 cm)
  • Weekly vaginal exams = 3x risk of PROM
  • Membrane sweeps = 9x risk of PROM

Once PROM occurs, what factors put mother at greater risk for infection?

  • the presence of meconium in the amniotic fluid (brown or green fluid)
  • GBS+ status
  • Longer labors
  • Signs of infection (fever, uterine tenderness, etc.)
  • VAGINAL EXAMS. As Evidence Based Birth points out, the biggest factor in whether or not a woman gets an infection after her water breaks is the number of vaginal exams she gets. If you want to reduce your chance of infection for you and your baby, avoid unnecessary vaginal exams! 

Once PROM occurs, what factors increase baby’s risk of infection? 

You'll notice many of these are the same. 

  • Meconium in amniotic fluid
  • Mother is GBS+
  • Longer labor
  • If the mother develops an infection
  • Vaginal exams

The standard of care varies from care provider to care provider. Usually, once your water breaks, your care provider will recommend that you head into the hospital. Once there, they may recommend an induction after a certain period of time. The length of this period depends on which care provider you see. Some will put you on a “24 hour clock,” meaning they think the baby should be out within 24 hours, even if that means a Cesarean birth. The 24 hour rule is based on very old and flawed studies that didn't account for GBS+ screening and protocols, and didn't differentiate between high-risk and low-risk patients, or whether the babies were premature or not. 

 What are your options for care? These are not medical recommendations, but should be discussed with your care provider, based on your personal situation and wishes as part of an informed consent conversation. Whether or not you want to wait for labor to start on its own may depend on whether you have some of the risk factors listed above, like meconium in the fluid, or GBS+ status. 

  1. Induce immediately using prostaglandin gel and/or Pitocin
  2. Wait for a predetermined period of time (12 hours? 18 hours? 24 hours? 72 hours? 96 hours?) before inducing using Pitocin and/or prostaglandin gel.
  3. Wait for labor to begin indefinitely. 

If you decide to wait, you can wait at the hospital or you can wait at home and monitor for signs of infection (change in color or smell of fluid, fever, etc.).

The Ontario Midwives issued a very detailed, research-based set of guidelines on this issue. Here are some of the recommendations from the Ontario Midwives Guidelines Bulletin:

  • Wait up to 96 hours before induction, and conduct daily checks to monitor for infection, including temperature and fetal movement. Instruct women to call for meconium or foul smell.
  • Refusing all vaginal exams seems to mitigate increased risk of waiting.
  • There is no research on risk of infection beyond 96 hours.
  • GBS+: wait 18 hours, then induce with oxytocin
  • Taking a bath in your own tub is not associated with increased risk of infection after PROM.
  • In the absence of meconium staining or signs of infection, there is no evidence that continuous fetal monitoring is required. You can opt for intermittent monitoring or auscultation.
  • Vaginal exams increases risk of neonatal infection, too.

Remember

  • Most women (up to 95%) will go into labor on their own within 24 hours.
  • Avoid an early epidural. After four hours, an epidural can cause a fever. Your care providers will have to assume you have an infection and treat it accordingly.
What's the bottom line? You have options. Whether you decide to be induced right away or wait for as long as you feel comfortable, those are both evidence based options. PROM is one situation where it is important to have an informed conversation with your care provider about how you want to handle it. If they propose a plan of action, ask about the Benefits, Risk and Alternatives, feel free to take the time to think about it, and trust your research and your intuition to make sure you choose the option that's right for you. 
And skip the vaginal exams!