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Uh-oh! My waters just broke! After these words, off to the hospital or birthing centre go the expectant mother and father.In the uterus, the growing baby floats in a sac of fluid. The sac is a double layer of membranes that act as a barrier to infection and contamination. They also keep a good amount of fluid around the baby. The baby “breathes” this fluid and uses the space it creates to stretch and grow.
Towards the end of pregnancy, the membranes change and become more susceptible to breaking. About 80 per cent of the time, this occurs after the start of labour. In some women, it happens before labour begins. This is called Prelabour Rupture Of Membranes or PROM.
Although it may be obvious the membranes have ruptured from the sudden gush of clear, colourless, odourless fluid from the vagina, sometimes it is more difficult to know. There may only be a small amount of fluid. It may be pink in colour if there is some blood in it or greenish-brown if the baby has had a bowel movement. Some women mistakenly think they are leaking urine from their bladder because they are constantly a little bit wet. It is hard to tell the difference. Pregnant women who notice any changes like this should consider that the membranes may have ruptured.
Unless advised otherwise by her doctor, a woman should be seen in the office or at the hospital to confirm the diagnosis of PROM. It is likely the baby’s heart rate pattern will be assessed using a fetal heart rate monitor to ensure the cord is not being compressed. This can occur if there is very little fluid left to float the cord in.
To confirm that the membranes are ruptured, a sample of the fluid needs to be assessed by an experienced obstetrical care provider. This may require using a sterile speculum to get the fluid. The pH of the fluid will be tested and the sample will be studied under the microscope to look for the typical fern-like pattern the amniotic fluid gives.
A digital exam (examination in the vagina using the fingers of a gloved hand) may increase the risk of infection to both the mother and baby and should not be done until there are signs of active labour.
The woman should avoid sexual intercourse and putting anything in the vagina such as tampons. Showering is permitted, but she should get advice from her care provider before taking a bath or Jacuzzi with ruptured membranes.
If the baby’s head is not low in the pelvis, there is a risk the umbilical cord may slip through the cervix when the membranes break. If the woman can feel the cord at the opening of her vagina, it is an obstetrical emergency. The woman must get to the hospital as soon as possible, probably by ambulance. In the meantime, lying with the feet and buttocks up higher than the woman’s head may help to keep pressure off the cord.
In the past, women who experienced PROM were thought to be at risk of a 'dry birth.' The concern was that difficulties could occur because all the fluid was gone. In fact, the placenta and the baby continue to produce fluid even after the membranes are ruptured. (The baby produces fluid by peeing.) It is possible for the fluid to collect again, especially if there was only a little leak to begin with and the hole seals over.
When PROM occurs at or near the due date, most women will start naturally into labour soon afterwards. Difficulty can arise in trying to decide what to do when labour does not happen on its own. Should labour be induced or would waiting longer for natural labour be better?
Once the membranes have ruptured, there is an increased risk of infection as the membrane barrier is no longer present. It is also possible an infection led to the membranes’ rupturing in the first place. Induction of labour also has risks including contractions that are too long or too frequent for the baby to tolerate well.
Studies have shown that either inducing labour or waiting up to four days for labour to begin on its own are both appropriate. If it is decided to wait, it is important to make sure both mother and baby stay healthy. The mother may be asked to come in to have the baby’s heart rate checked every 12-24 hours. She should keep checking to make sure the baby’s movements stay normal. There should be at least 10 movements in a 2-hour period of close observation. She should also check that the fluid stays clear and she does not develop fever or bleeding. If any of these problems occur, she should return to the hospital immediately.
Because of the risk of infection with prolonged rupture of membranes, it may be appropriate to use antibiotics in labour. After birth, the baby may need to be observed and, if necessary, treated for infection.
PROM may occur prematurely, several weeks before the expected delivery date. This is known as preterm PROM or PPROM. If there is no sign of infection such as fever, tenderness of the uterus or odour to the vaginal fluid, waiting is usually recommended.
Antibiotics may be used to reduce the chance of infection. If the baby is markedly premature (less than 32-34 weeks of pregnancy), steroid medication will be given to help the baby’s lungs work better if premature delivery occurs. Some pregnancies will be monitored by frequent ultrasound to see if the fluid re-accumulates and to monitor the health of baby.
Although many women are afraid their waters may leak in a public place, most of the time the leaking is either associated with active labour or so subtle that no one else is aware it has happened. If the baby’s membrane sac does rupture before the start of labour, the woman needs to be seen to confirm this is what has happened. At this point, she and her care provider can discuss the wisest approach to managing the problem.
The rupture of the membranes can be an exciting event as it often signals the beginning of one of life’s most important adventures, the birth of a child.
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