E-News 2:46 - Premature Rupture of Membranes

Premature Rupture of Membranes (PROM)

Two Abstracts from Henci Goer's book, Obstetric Myths Versus Research Realities

Lenihan JP. Relationship of antepartum pelvic examinations to premature rupture of the membranes. Obstet Gynecol 1984; 63(1): 33-37.
Women with uncomplicated pregnancies were randomly assigned to one of two groups: weekly pelvic exams beginning at 37 weeks gestation or no pelvic exams before 40 weeks in multipara and 41 weeks in nullipara. Eighteen percent of those having routine pelvic exams had PROM versus 6% of those having none. The author theorizes that the probing finger carries up and deposits on the cervix bacteria and acidic vaginal secretions capable of penetrating the mucous plug and causing sufficient low-grade inflammation to rupture membranes.
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Gorodeski IG, Haimovitz L, and Bahari CM. Reevaluation of the pH, ferning, and nile blue sulphate staining methods in pregnant women with premature rupture of the fetal membranes. J Perinat Med 1982; 10:286-291
Women were grouped into those known to have intact membranes, those known to have ruptured membranes either because of history and confirmation by the attending physician or because membranes were deliberately ruptured to induce or augment labor, or a test group of equivocal cases. The equivocal cases were classified as ruptured or intact retrospectively based on whether rupture was seen to occur before delivery.

High false positive rates for all three tests were found in the women known to have intact membranes, especially in those with copious vaginal discharge. In women with ruptured membranes, high false negative rates were obtained for all three tests. The false negative rate increased over time, and by 24 hours postrupture it reached 50%, or no better than chance. Performing all three tests on multiple samples for the test group reduced the number of incorrect results, but even so, correct, unequivocal diagnosis was made in only 61.5% of cases.
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If your membranes rupture on their own prior to labor, you must believe that this is exactly the way your particular body needs to start this particular labor. Accept it as a sign that labor will begin sometime within the next hours or days. Stay close to home, relax, eat well.... Increase your vitamin C and fluid intake. Before agreeing to be induced, you can try several natural induction suggestions: visualization, herbs, or castor oil (under the direction of a qualified midwife), for example. Lovemaking (without sexual intercourse) and orgasm may encourage labor to begin....

Many physicians worry that an infection will begin now that the protection around the infant is gone. Some prescribe antibiotics prophylactically. Others ask you to take your temperature and report any rise. Some take blood tests to check your white blood cell count. Most tell you that if you haven't had the baby in 12 to 24 hours, a c-section will be performed to prevent an infection from occurring.... A cesarean to *prevent* infection? You already know the risk of infection from cesarean section is very high. Most women can go days without an infection after their water has broken, especially if they stay out of the hospital and refuse internal exams. (In a single year, 1.5 million patients were victims of hospital-acquired infections.)
- Nancy Wainer Cohen, Silent Knife, Bergin & Garvey 1983

E-News asked readers, "A 1996 study at the University of Toronto randomly assigned 5,041 women with premature rupture of membranes (PROM) to either have their labors induced or to wait for up to four days for labor to start spontaneously. In both groups, about 3 percent of babies developed infection, and about 10 percent were delivered by cesarean section. The study concluded that physicians should present this research to patients, who should choose the option they prefer. Comments?

My concern is that this study disregards the effects of the induction itself and any secondary consequences as a result of interventions arising from the induction. Measuring the outcome only by infection and c-section rates leaves out the impact on mothers and babies of the induction. Just because an induction doesn't necessarily result in a c-section doesn't mean that the labor may not be more intense, more painful, more rapid, and possibly require more pain medication than the labors of the mothers who waited for spontaneous labor to begin. While I am not aware of studies that have examined the short-term and long-term effects on babies of various types of induction, anecdotal evidence is piling up that Pitocin inductions are not benign for infants--that certain behaviours and preferences characterize those induced with Pitocin (among them, difficulties with transitions, need for constant stimulation or easily over-stimulated, later addictions to caffeine and other stimulants, ADHD-like behaviours, etc. There are certainly a few studies of the effects of epidural anesthesia on newborns which suggest that these babies do suffer adverse effects, so if the induced group in the above study received more epidural anesthesia than the spontaneous labor group, these babies may be affected by the anesthesia, and their mothers may also have experienced consequences from the epidural.
- Claire Winstone, M.A., R.C.C.

I've had two primips and one multip whose water broke and they wanted to wait and do nothing. Of course, they were strong, healthy, educated women. The multip went into labor at four days; everything was fine. Both primips ended up with c-sections. One was ruptured seven days and the other nine. The babies and mothers were fine. Malposition was the reason for the sections. The OB explained to me that often, when the baby's head isn't nicely seated in the pelvis, i.e., posterior, military, etc. the bag of waters ruptures before labor commences. You do what you can to get the baby to adapt him/herself to the maternal pelvis, but it doesn't always work.
- Mary Ann Durbin, CNM
Toledo, OH

I would *love* to do watchful waiting for my PROM clients. But in this community, all the OBs and pediatricians are terrified of GBS (we have had our share of very sick babies and babies who died), and the CDC guidelines specify starting IV antibiotics at 18 hours. I have no way of giving them outside the hospital. You all know what happens when a woman is hospitalized and ruptured and not in labor. All my clients know and are reminded that they have the right to refuse any treatment, but I also do tell them about the CDC guidelines in order to keep the peace with the OBs who consult with me.
- Anon.

I had PROM with both of my sons. The first labor was induced using Pitocin after waiting three hours for contractions to start. I had a horrific, three-hour labor, which took me two years to recover from. I researched a lot before my second, and decided on a homebirth. With the second labor, I did not begin contractions until almost 48 hours after PROM. I had a wonderful nine-hour labor that did not leave a mark! Not only should physicians present the research to their patients, but the pregnant families should also. It is up to them to do what is right for themselves and take control of "their" labors.
- Lindsay W.

Check It Out!

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Midwifery Today's Online Forums

Question of the Week

I recently attended a birth where both the primary midwife and myself suspected that the baby had Down syndrome because of low ears and other facial features. How do other midwives handle situations like this? All parents want their child to be perfect, so how do you approach this topic in a supportive, caring and helpful manner? And what do you look for when trying to rule out something like this? Down babies have such a distinctive look, but what if we were wrong and caused undue stress for the parents?
- Shannon, student midwife

Question of the Week Responses

Q: The baby of a woman who is due in two weeks has been trembling or shivering quite hard several times a day for a week. It lasts about a minute or at most two, and is unpredictable as to when it occurs. She saw her OB several days ago and he has no idea what it might be. The baby's heartbeat was in the 140s and she was not shaking during the appointment. The OB did not seem overly concerned about it. The mother thinks the baby is having seizures. She is certain it is not hiccups because the baby also gets those daily and the mom can identify them. As a doula I have worked with many women over the last 17 years but I have never run into this. Any ideas?
- Eileen Ryan
Maryland

A: Last year I served a client (as a doula) who described similar trembling of her unborn baby at around 30 weeks gestation. She did not report this seizure-like trembling to her CNM until it was discovered that her 31 week fetus was no longer living. At delivery, she had a what seemed to be an unusually large amount of amniotic fluid (not polyhydramnios) and the baby's two-vessel cord was wrapped very tightly around his neck. The autopsy report was inconclusive. Shortly after this situation the same CNM had another patient report such trembling. The midwife told her to go immediately to the ER. An emergency c-section was performed. The CNM said she had never learned about this seizure-like trembling nor had she ever seen it mentioned in the medical journals she has read, but she now takes it seriously.
- Kristin Schuchmann

A: I would recommend this woman receive a second opinion from another OB and see a pediatrician. Pediatricians know more about unborn babies than most people give them credit for. They will be able to give her information about what to expect after delivery.
- R.W.

A: When I was pregnant my daughter had several "bizarre" movement patterns I couldn't explain. One was a peculiar rhythmic fluttering in my pelvic region. This was explained when she started sucking her wrist after birth--the motion was her hand fluttering up and down as she suckled on her wrist. The other was an all-over shaking too fast for hiccups. This was explained when she abruptly went into a strange breathing pattern after birth, in and out very, very fast with a slight noise to it for about a minute. This only happened when she was falling asleep or had been asleep for a while; it stopped happening within a month or so. My daughter is now a very healthy, bright, normal, active seven-year-old.
- Jen Rosenberg CD(DONA)

A: I also had a baby who tended to do this. My midwife didn't seem concerned, and offered no possible explanation. My baby is now thirteen months and has never had seizures. I did notice the movements most prevalently when I rolled over in the night, or upon just lying down. Usually it happened when going onto my right side, and as the pregnancy went on, I felt less comfortable on that side and uneasy about his suddenly frenetic motions, so I avoided sleeping that way.
- Sabrina Blais, RMT/doula/aspiring midwife
Toronto, Ontario, Canada

A: The first questions I would ask is, How long does the shivering last and how strong are they? The baby is still developing and maturing in every way, especially neurologically. Newborn babies tend to quiver a little when they cry, and it is attributed to their underdeveloped neurological systems.
- Dinah, BSRN

A: [Consider] hypoglycemia or seizures. Have mother note time of day and what she was doing. Has mother had lab work? A BMP? Also look at magnesium levels. How well do you really know the mother? Any possibility of substance use?
- L.B., RN

A: I felt what that mother described, during my eighth pregnancy. I was carrying twins who were born after seven months. My doctor didn't confirm it as a seizure. A midwife and my doctor monitored my baby (I didn't know I was having twins until they were born) and said everything seemed all right. I had a strong feeling that something was wrong but couldn't bring myself to say so. Three days later I lay down to take a nap. I felt very strong fetal movement that felt normal. The next morning at about 3:00 am I woke up feeling impending doom. I tried to tell myself that I was just having normal worries. Later I called the doctor and told him I had not felt the baby move since the afternoon before. That day an ultrasound showed that my baby no longer had a heartbeat.

One week later my girls were born. The second twin was delivered with the placenta. When the doctor unfolded the placenta, there she was. We could see that their umbilical cords had become entangled and caused their deaths.

I think mothers know what their babies are doing. After my experience if a mother were to tell me that it felt like her baby was having a seizure, I would believe her and take it very seriously.
- K.J.

A: Several clients have reported this "shivering" during later pregnancy. All of the babies were born uneventfully with no signs of neurological or other problems. I think it is probably the startle reflex happening in utero.
- Molly Germash, CPM

A: A pregnant client told me she felt restless-like movements from her fetus. She said it was like her fetus was in a struggle. When in labor, the fetus never descended through the pelvis. The cervix was fully dilated but filled only with the membranes. During the cesarean the father took photos that showed the baby's unbilical cord was wrapped around its ankles several times with no slack at all. We concluded that this prevented fetal descent and was also the cause for the movements that the mother correctly described as a "struggle."
- L.B., RN

A: With my first baby I had the same feeling. He is now 10 years old and never had any neurological problems. I have had three more pregnancies and have never felt the seizure activity with my other babies. I have cared for two women over the last 15 years who have had this complaint, and had all kinds of testing. Nothing was ever found on sonos, and both delivered healthy full-term babies. I haven't had any follow-up with either of them to know of any long-term conditions.
- Nan, RNC

A: If the mom thinks the baby is having seizures, she should be listened to. Even though a lot of pregnant women these days are overly "medically dependant," most moms love their babies and want the best for them (if they know how to get that).
- Karla

Coming E-News Themes

1.INTACT MEMBRANES: What are the fetal benefits to labor with intact membranes? Do you have any documentation to share with E-News readers?

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QUESTION OF THE QUARTER for Midwifery Today magazine

Issue No. 57 (Theme: Cesarean Prevention/VBAC) How do you prevent cesareans?
Deadline: Dec. 15, 2000
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Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!

Could you explain more about why you state that HDN is virtually untreatable [Issue 2:45]? I have a packet of vitamin K information I give to mothers, and have tried to fairly represent both sides of the issue. A couple of the studies I have included (which support vit. K administration) say that the treatment for HDN is IV infusion of vit. K, which would arrest the problem within two hours. It did not sound as if there was great risk of adverse sequelae unless the disease had continued for some time without being recognized.
- Janelle Wahlman, CN

Three years ago I attended a mother who delivered her beautiful 7-lb. baby boy (her second) at home with no complications of any kind. The parents refused eye ointment and vitamin K after doing their own research as well as reading and discussing materials I routinely include in the homebirth packet I give to all my clients. They based their decision to refuse these things mostly on statistical evidence that shows that problems are actually fairly rare, and they strongly didn't want to expose their new baby to anything that would make him unnecessarily uncomfortable for the sake of prophylaxis. Unfortunately the baby developed hemorrhagic disease of the newborn (HDN) the next day. His bleeding sites were gastrointestinal and nasal. He was hospitalized and treated for four days and made a complete recovery. Although this has been the only case of HDN I have seen in my clients who have refused prophylactic vitamin K , it was traumatic enough to induce me to highly recommend it to my clients. The parents of the baby that developed HDN are dealing with guilt and regret because they feel that though the incidence is rare, their child ended up suffering and the prevention (an injection) was readily available and would have been much more noninvasive than what their little guy had to go through.
- Alda Bales

I was dismayed to read the submission from C.R. regarding four babies dying from hemmorhagic disease of the newborn because of no vit K shot. This is anecdotal and worse, anonymous. It scares the pants off people and is not true. I live in Canada and make it my business to know what happens at homebirths right across Canada. I would challenge C.R. to come up with cities, dates and citations before putting out this kind of bogus claim.
- Gloria Lemay
Vancouver, BC

Provided that all the possibilities have been ruled out, such as structural problems (cystocele, urethrocele, narrow bladder neck, etc.) including a previous history of bladder problems even when not pregnant, the problem may be hormonal due to an insufficient level of progesterone to support the smooth muscles (e.g. the bladder and urethra). We know that after conception the natural progesterone level rises considerably but that in some women it may not rise quickly enough to meet the need before the 12th week when the placenta is developed and then takes over the production of progesterone for the remainder of the pregnancy. Some women exhibit symptoms of low progesterone in early pregnancy with extreme nausea and vomiting and some women will bleed or in some cases will miscarry. One of the symptoms of low progesterone, pregnant or not, is the problem of a spastic bladder, which encourages urinary retention which then leads to a "set-up" for an infection.

Based on the information provided in your inquiry, it sounds like the same phenomenon of low progesterone occurs in your ninth month. We do know that near term the placental production of hormones is decreased and the symptoms are most commonly insomnia, hot flashes, diminished appetite, sometimes even a loss in a little weight, increased uterine activity (hint: the uterus is a smooth muscle just like the bladder and urethra and all smooth muscle has the potential to react symptomatically to a drop in progesterone). We also can notice a change in attitude and moods just like in PMS which, by the way, is also proven to be related to an inadequate production of progesterone during the luteal phase.

I would recommend that you get Dr. John Lee's book What Your Doctor May Not Be Telling You About Menopause.

Logical treatment or prevention may be to use evening primrose oil, chamomile and the appropriate dose of vitamin C, drink a lot of fluid, watch for signs of infection and take antibiotics only if necessary and use a catheter only if necessary.
- Marcia McCulley, NP

The mother's bladder may have become detached or out of place or changes place with the colon. Lying on a slant board with head down may relieve this problem. It may allow the organs to resume their proper position. If the problem is caused because there are stones in the bladder, an herbal kidney cleanse may help. Herbs such as uva ursi, cranberry, and parsley have been used traditionally to alleviate discomfort due to blockage. If this doesn't work, it might be time for a checkup by a specialist to see what the problem really is.
- Robe

What a shock to read of MANA's proposal to exclude some members! [Issue 2:45] It makes me think of the medical profession, which systematically worked to exclude midwives, naturopaths, homeopaths, chiropractors and any other healing modality at the beginning of the 1900s. The Midwives of North America (MANA) folks seem to be following the example set by medical practice. How arrogant. How righteous. How stupid.

Birth by any sort of midwife is under attack right now in the USA. Right now, for example, in Pennsylvania, the AMA is working to further restrict CNM practice. So what are we doing to ourselves, by dividing our energies still further and pointing fingers at each other because some people have initials after their names and some don't? What are we thinking of, to even consider such a thing when the trend in mainstream obstetrical practice is toward elective cesareans, more inductions and increased epidural use? Initials are no guarantee of good practice--never have been, never will be. This is true in breastfeeding circles as well as birthing circles and with lawyers as well as with teachers. So let that struggle go.

My prayer is that all the birthing folks (including doulas and childbirth educators) and all the breastfeeding folks unite and take back birth. Those working with mothers and babies before birth need to join forces with all those working with mothers and babies after birth to turn back the technological tide. The only way we can do that is together.
- Nikki Lee RN, MSN, Mother of 2, IBCLC, CIMI
Elkins Park, PA

A simple thought: As regards MANA's decision to become so exclusive, I think all American midwives need to reread George Orwell's book, Animal Farm! This kind of exclusivity comes from wanting to be accepted and fit in with the oppressor (the medical profession) or a desire for greater power and/or profits. The same pattern has been seen all over the world when people give in to the pressures of commercialism and imperialism. Instead of sharing, someone has to be squeezed out so others can get more. And it's usually the majority who are sacrificed to benefit a few. Please think very carefully about this decision!
- Harriet Kaufman RN MSN, midwife

This is just to say hello and thanks for E-News every week. All your comments are so important. I am an occupational therapist who has offered prenatal courses in Monteria, Colombia for 11 years. I feel worried about why doctors don't want women to have vaginal births. Every day we see more cesareans.
- Carolina
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In response to Anon's comment on doulas [Issue 2:45]: You ask why a woman would birth in a place where she needs an advocate. I think you are assuming a lot by believing that every woman has a choice. Many women birth in hospitals by necessity for the health of themselves, their baby, or both.

I am an RN working in a hospital setting who used to work as a doula. I aspire to be a midwife, but I struggle with choosing the best route to take based on where I will be most helpful. I agree that sometimes hospital birth can be abusive and that many women are way too complacent and relinquish control. But I have no shame in being a part of it. I am here to be an advocate for those women. In fact, I find strength in helping women get through their birth experience regardless how it turns out, and to hopefully be able to provide them with what they need to make informed choices. I also think it is healthy to acknowledge the loss of the "perfect birth" and allow a woman to mourn that loss. But I by no means pass judgment on that woman's decisions.

Frankly, your comments make me question whose expectations are being disappointed more, yours or the mother's? It is sad when we feel disempowered by our environment rather than seeing our need and ability to empower a mother in that environment. Please, don't turn your back on hospital birth. Instead, be an agent for change.
- Luisa Lucero, RN
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My sister is in her ninth month with her third child and her cervix seems to be "falling out." Her doctors tell her it is because it is her third pregnancy and because the baby is pushing down on her cervix. Is this going to cause problems for her during and after delivery? What causes it? Also, how long after losing the mucous plug do women usually deliver? My sister has been losing her plug for several days and nothing seems to be happening.
- Brianna Ybarra
Reply to: jlybarra@earthlink.net
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I'm an aspiring midwife trying to network with other deaf or hard of hearing aspiring midwives, doulas, and childbirth educators. I would love to hear from you from anywhere.
- Audrey
Reply to: Doula4Deaf@aol.com
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I am a third-year student midwife in the UK, about to qualify and writing my dissertation about how best to care for women whose babies present by the breech. Does anyone out there have any personal clinical experience or better yet, audit information on standing breech births under the care of midwives? I badly need your input to counter the arguments in the recently published paper by Hannah et al. in the Lancet.
- Liz Nightingale
Reply to: Elizabeth.nightingal@which.net

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