Premature Rupture of
MembranesBy Elizabeth Bruce
Email the author: ABruce2418@aol.com
The topic of premature rupture of membranes (hereafter referred to as PROM)
is one of particular interest to me because its occurrence was the ultimate
cause of my cesarean. At the time my membranes ruptured (or more
leaked), there was no helpful information to be found in any of my mainstream
books except that one should go directly to a hospital, which is exactly what
I did. Although there were no signs of infection in either myself or the
baby, my doctor told me that the baby could die if I did not consent to
surgery. My doctor was genuinely concerned, as I had endured 10-12 digital
examinations by various residents and was only 34 weeks along. Soon after
son's birth, my mother-in-law told me about how her water had broken (gushed)
with her fifth child when she was only five months pregnant. She carried
baby for another two months and the baby survived its premature vaginal birth.
This was 1963, and they did not administer antibiotics. She negotiated
her obstetrician, who agreed to let her be on bedrest at home.
Unfortunately, the kind of wisdom and patience her doctor exhibited is rare in
our modern age of technological births.
The most fundamental problem with any discussion of PROM is in the way it is
defined. In general terms, PROM is when the membranes rupture before labor
begins. Unfortunately, most doctors still make no distinction between true
PROM and a leak. In three articles from The American Journal of Obstetrics
and Gynecology, a professional journal which is normally precise about
defining research parameters, there is not even a mention of the difference
between a leak and a rupture of membranes (Kurki et al., Owen et al., and Wolf
et al.). Nowhere in the articles does it say whether the women included in
the studies had true PROM, nor do they even acknowledge that such a difference
exists. In contrast, A Good Birth, A Safe Birth says "sometimes
the tear in
membranes seals over" (154). Similarly, Homebirth reassuringly
there is only a dribble of fluid, it is probably the hind waters, the part of
the bubble behind the baby's head, that are leaking, and they often reseal
themselves after a while. You can ignore it" (138-9). Bonnie
president of ICEA, notes that the nature and amount of fluid leaking are
important considerations in deciding on treatment (25-6), and presumably only
addresses the problem of true PROM. The issue of what to define as
an important one, because first-time mothers are likely to panic when seeing
any fluid, and judging by the OB-Gyn journals, it is doubtful that these
that a leak is different from a rupture.
Causes of PROM
Unfortunately, maternal guilt often results from an event such as PROM,
especially pPROM, or the premature rupture of membranes (before 37 weeks
gestation). It is therefore important to know what does, and probably does
not cause PROM. According to Korte and Scaer, pelvic examinations during
last three months of pregnancy have been shown to contribute to the incidence
of PROM (153). Kitzinger (138) and Cox (28) agree. Cox affirms that
cases, the cause of PROM remains unknown, although she says that subclinical
infection may be a factor. She reports on a study in which erythromycin
at 26-30 weeks gestation lowered the chance of PROM in high-risk women [but
more on this under Treatment of PROM]. The women in this study were
as those who had previous PROM or pPROM, smokers, (active and passive) and
those with chlamydial infections. Apparently, all these conditions are
assumed to put a woman at higher risk of PROM.
According to Kurki and Ylikorkala, sexual intercourse during pregnancy is
not directly related to the incidence of PROM. Their study consisted of
nulliparous women who turned in charts showing their frequency of coitus
during the last three months of pregnancy. In fact, there was found to be
negative relationship between coitus during the last week of pregnancy and the
incidence of PROM and preterm labor, with those women having sex then being
less likely to experience these complications (1130). While the research
somewhat imperfect, having to depend upon the self-reported charts of 407
women, it is still significant.
The researchers discuss flaws in previous studies which showed a
correlation between coitus and PROM. One possible flaw is that "women
delivered preterm are more likely to report intercourse and other possible
'harmful' events than are women who are delivered at term when both are
interviewed postpartum" (1133). An important factor in their studied
population is that all the women had a single sex partner, not many.
subclinical infections may be a factor in PROM, it seems wise to advise women
with many sexual partners (or whose mates have many partners) to abstain from
sex late in the pregnancy.
In any case, the research on PROM is hopeful in that women are rarely, if
ever to "blame" for its occurence. All sources consulted agreed
monogomous intercourse during late pregnancy is not responsible for PROM.
anything, a woman's OB may be to blame for insisting on cervical examinations
during the final weeks of pregnancy.
The Real and Imagined Dangers of PROM
One of the real bugaboos associated with PROM is cord prolapse. When a
woman's amniotic sac suddenly ruptures, there is a real danger that the cord
might be swept out with the fluid. However, doctors do not recognize that
such an occurence is very unlikely if the woman merely has a leak.
MDs put all women with suspected PROM to bed, which of course contributes to
the bigger problem of unnecessary cesareans for "failure to progress."
Good Birth, A Safe Birth. The authors cite a study of 29,960 deliveries,
of which there were 79 cases of cord prolapse (109). That's less than 3 in
1000 cases. Ten of those prolapses were caused by amniotomy! In
they were iatrogenic in nature. If you factor those iatrogenic cases out,
that leaves 2 in 1000 cord prolapses possibly natural in origin. [Since the
study was conducted at a university hospital, other cases may have been caused
by iatrogenic factors such as labor induction.] The reason I stress the
prolapse by avoiding interventions such as amniotomy, labor induction and a
prone position during labor. The only time a prone position would seem
advisable would be if the baby is less than 33 weeks gestation in order to
prolong the latent period.
In summary, cord prolapse is a serious, life-threatening complication which
is most likely to occur with a sudden gush of fluid associated with PROM.
HOWEVER, prolapse is extremely rare, and its threat should not be
overestimated. Kitzinger says, "A prolapsed cord is very
unlikely to occur
during a home birth or in any birthplace where invasive procedures are not
practiced. It is usually a consequence of intervention, in particular of
rupturing the membranes artificially when the presenting part is very high"
(140). To prevent a cord prolapse, then, perhaps the best thing a woman
do with PROM is to stay home as long as possible. In the hospital, there
looms the much greater threat of a woman being restricted to bed after her
water has already broken, since this position is known to contribute to the
use of pitocin, fetal distress and unnecessary cesareans.
If a woman's water breaks before she gets to the hospital (which is
basically the definition of PROM), then the danger would seem to be mostly
past, especially if the fetal head is engaged and blocking the cervical
opening. In the case of a premature leak of the waters, there would
be no increased risk of cord prolapse, although it's impossible to tell from
According to Bonnie Cox, the maternal complication of most concern with PROM
is chorioamnionitis, or inflammation of the fetal membranes. The syndrome
characterized by maternal fever, uterine tenderness, a foul-smelling vaginal
discharge, rapid fetal heartbeat, and maternal leukocytosis (30). She says
that the incidence of chorioamnionitis in the general obstetrical population
is 0.5-1%; but it is 26-28% in women with a latency period (time between PROM
and onset of labor) of 24 hours or more. Chorioamnionitis is probably the
reason that some doctors place a limit of 24 hours on the latency period.
aptly points out that although the syndrome's incidence was once thought to be
related to the length of the latent period, recent studies refute this
assumption. It is now believed to be caused by ascending infection,
cervical exams, and bacterial colonization of amniotic fluid preceding PROM
(30). It is maddening that doctors still arbitrarily limit the latency
to 12-48 hours, but continue to precipitate infections by conducting internal
exams on women with PROM.
In the case of pPROM, a very real complication is prematurity of the fetus.
Cox states that pulmonary hypoplasia and skeletal compression deformities are
two of the problems associated with pPROM. Here, she is discussing
infants between 24 and 33 weeks gestational age. She says that the younger
the gestational age, the more likely these problems are to occur. One
she neglects to mention is that pulmonary hypoplasia is often caused by
doctors trying to induce the baby before it is ready. It is recognized
with pPROM babies, their lungs are often more mature than expected of a baby
that age. Wolf et al. report that "the incidence of respiratory
syndrome in pregnancies complicated by PROM is lower than that in other
preterm pregnancies" (1237). Cohen in Silent Knife asserts that a
lungs develop rapidly after an amniotic rupture, possibly because of stress my case, it was fortunate for my son
delayed going to the hospital and that my water was broken for 72+ hours
before the cesarean. Even without the aid of labor contractions he
immediately and without assistance--an uncommon occurence for a 34-week baby.
Maternal infection is probably the most common risk of PROM. Ironically,
this complication is the one most likely to be caused by the doctor and
hospital environment. Cox says that at all gestational ages, patients who
have had only a sterile speculum exam have an average of 11.3 days of latency;
whereas those who have had digital vaginal exams only last 2.1 days before
labor starts (29). Obviously, the risk to the premature fetus is lessened
with each day it can remain in the womb, making digital exams a definite risk
to the baby.
Treatment of PROM
Because of the high risk of infection in the hospital, doctors have tried to
counteract it with antibiotic treatment while the woman is still pregnant.
a study conducted by Owen, Groome and Hauth on 117 women, half of whom
received antibiotic treatment and half who did not, they found antibiotic
treatment after PROM to benefit the mothers, but not the infants. In fact,
they found a higher incidence of neonatal necrotizing enterocolitis in the
treatment group (976). The average gestational age of the fetuses was only
weeks, presumably of a young enough age so that infection would be a real
threat to them. The eleven neonatal deaths in the study were almost evenly
divided between the control and the treatment group, all related to RDS.
this study, it would seem that, if anything, antibiotic treatment might have a negative effect on the infant. It certainly doesn't seem reasonable to
routinely prescribe prophylactic treatment to women with PROM.
Common Sense Treatment
Korte and Scaer list some common-sense precautions to be taken in the case of
PROM. They are as follows: avoid pelvic exams; avoid intercourse; avoid
sitting in water; stay home until labor starts; avoid contacts outside thefamily; check temp. regularly and watch for pain or tenderness in the abdomen;
drink plenty of fluids; keep in touch with your doctor; wait for labor to
begin; and go to the hospital if you have active genital herpes with PROM
Cox recommends avoiding digital exams and intercourse; bedrest; and
administration of antibiotics. She also recommends amniocentesis,
and the nonstress test to assess fetal maturity and well-being. From
experience, I can say that ultrasound for this purpose is useless.
confirmed that I had "enough" fluid (how much is enough?) but said
judging from the ultrasound, my baby only weighed about 4.5 pounds. Well,
hemust have grown quickly because the next day his actual birth weight was 6lb.
6oz.! Amniocentesis is dangerous to the fetus and the nonstress test is
notoriously undependable. In short, it seems most advisable to follow the
advice of Korte and Scaer.
The Reality of Hospital Management of PROM
As has been previously noted, midwives are likely to first determine whether
the woman has experienced a leak, or true PROM. In the case of the former,
she is apt to tell the woman to be patient, and to monitor her temperature to
be on the lookout for infection. On the other hand, MDs do not usually
such a distinction. Korte and Scaer say that doctors either take an
"aggressive" or a "conservative" approach to PROM.
They contend that most
doctors nowadays tend toward the "conservative" approach of waiting
to begin or signs of infection. Such was not the case for me at the
George Washington Hospital in Washington, D.C. As previously stated,
received numerous internal exams, was told I must lie flat on my back (so as
not to experience the mythical "dry birth"), and hooked up to a
of Pitocin, even though the baby was early and his head was
treatment is a disgrace considering what is known about PROM. I wish I
say that my experience was unusual, but I have talked to other women in
different parts of the country with similar experiences.
Since PROM is fairly common, occurring in one out of ten pregnancies, it is
important not to panic if it happens to you. In most cases, the best
is to wait it out while monitoring for signs of infection.
Cox, Bonnie. "Premature Rupture of the Membranes." Childbirth
Autumn 1993: 27-31.
Kitzinger, Sheila. Homebirth. Ny: Dorling Kindersley, Inc., 1991.
Korte, Diana and Roberta Scaer. A Good Birth, A Safe Birth. 3rd ed.
Harvard Common Press, 1992.
Kurki, Dr. Tapio and Dr. Olavi Ylikorkala. "Coitus during Pregnancy
Related to Bacterial Vaginosis or Preterm Birth." Am J Obstet Gynecol
(5) November 1993: 1130-4.
Owen, Dr. John, Dr. Lynn J. Groome and Dr. John C. Hauth.
of Prophylactic Antibiotic Therapy after Preterm Amnion Rupture." Am
Obstet Gynecol 169(4) October 1993: 976-81.
Wolf, Dr. Edward J., et al. "Do Survival and Morbidity of
Weight Infants Vary According to the Primary Pregnancy Complication that
Results in Preterm Delivery?" Am J Obstet Gynecol 169 (5) November 1993:
Elizabeth Bruce, M.A., CCE, is a Birth Works facillitator in Lorton, Virginia.
She currently stays home with her four children, ages 1,3,6 and 8. She can
contacted at Wals1@aol.com.
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