Have you thought about (or planned for) how you may respond to the way your labor begins? Do your plans need to change if your water breaks as the first sign of labor? Most moms are preparing for the hard work of coping with labor contractions in the thick of an active labor pattern. That is certainly a valid place for your energy to go, but as homebirth midwives, we notice many birthing couples get surprised by the way labor begins and can feel lost in how to respond to early labor events while they are happening. We aim to shed some light on this topic from a midwifery perspective and provide some helpful information and needed conversation.
We have jam-packed this post with all our best education and planning points for when water breaks as the first sign of labor. If you are here specifically for the worksheet, click ahead to number 8 below. Here's a lineup of what you will enjoy in this article:
What is PROM? (And am I hoping you ask me to it?)
"But what if my water breaks first?" We call this PROM, standing for Premature Rupture of Membranes. It is when the amniotic sac spontaneously breaks open and amniotic fluid begins leaking from the uterus and through the vagina before the uterine contractions begin. About 90% of women have their bag break after contractions have begun, the huge majority of those ruptures happening towards the end of labor. So that means the incidence of PROM is around10%. This surprises a lot of first-time moms who may have picked up in TV or other dramatizations of birth that water gushes everywhere (in public) to signal labor has begun.
Approximately 95% of women with PROM will go into spontaneous labor on their own within 24 hours from the rupture. However, the protocols surrounding the management of PROM vary widely depending on the care community, primary provider, and birth setting. It can be frustrating and confusing for women to navigate what to expect in their own births if PROM happens to them. What do you do when early labor is dreadfully slow? Check out our most recent post on What to Do During Early Labor, HERE for more ideas about that specifically.
Let's TACO 'bout It
If you have been around here for any length of time with us you know we are all about informed consent and giving clients the options to make the best decision for them. You'll have the benefit today of reading how we counsel our own clients in PROM management. We'll start with the instructions we give to each mama on how to report water breaking to their midwives. Our clients are asked to record 4 things if they notice any vaginal leaking:
Time
Amount
Color
Odor
It just so happens to be an acronym that spells TACO so it's easy to remember. We ask our clients to call us if this happens during the day, or first thing in the morning if it happens overnight. (Of course, they should always call us at night if something is abnormal or concerning- but clear water noted with spontaneous rupture of fluids and the absence of contractions is a variation of normal.)
We want to know what time the water broke, about how much fluid was noted, if it's continuing to leak and how much, what color the fluid is, and if there is any odor. If there is a brownish or green color to the fluid we will want to do some more investigating, as we would suspect the cause to likely be meconium, the baby's first bowel movement. If there is an odor, we may need to do some more investigating for possible infection. Most of the time, all fluid is normal and we chat about next steps for managing labor expectantly.
Is It Amniotic Fluid?
Every once in a while it's not super clear what the leaking fluid is or where it came from. We start to wonder this exact thing if something seems a little off in how the TACO items are reported. It's fairly common, although sometimes embarrassing, to leak urine at the very end of pregnancy. It's also possible that the fluid noted is simply a big increase in vaginal discharge, or sometimes semen after intercourse. One of the tests we do with our clients to figure this out a bit is to have them lay down flat on their side with a pad on for 20-30 minutes. The amniotic fluid should pool in the vagina during this time and come out in a gush when the mama rises from her rest. If we are very uncertain, we can use pH paper or other screening tools to test the fluid. We usually take a wait-and-see approach to this as we expect a true PROM to reveal itself eventually.
What's The Big Deal?
So far all we are talking about is a lot of detective work on stuff coming out of a vagina- why does this matter? The primary concern across all care models is that once the amniotic sac has broken, the protective barrier that keeps pathogens from the outside world away from the baby and her environment is now open. This increases the risk of infection quite a bit, which can be a danger to both mother and baby. However, I am excited to share with you a lot of ways we can decrease this risk by applying some midwifery model thinking.
Is PROM Preventable?
There are risk factors associated with the incidence of PROM, including a lack of prenatal care, mothers who are smokers, have untreated sexually transmitted infections or other brewing infections (like UTI or uterine infection) or a history of preterm labor/birth. Besides underlying, unknown infection, some other theories as to why some women are at a higher risk for PROM include a malpositioned baby (like posterior/sunny side up) and poor nutrition in pregnancy. You can keep your amniotic sac strong and healthy by eating plenty of foods high in protein, vitamin c, calcium, probiotics, and iron.
There is some evidence that a daily low dose of supplemental vitamin c with bioflavinoids in the second and third trimester can also help strengthen the amniotic sac. This is good news for the mom who finds her multiple labors repeatedly beginning with PROM. It's important to note that too much supplemental vitamin c actually has the opposite effect and can weaken the integrity of the sac. Whole food nutritional choices are a great way to let your body regulate the right dose- choose vitamin c food with the pith (spongy white membrane just inside the skin) attached like citrus and bell peppers.
Medical Management of PROM
Before we move through to how midwives handle PROM, one of the most important aspects of appreciating midwifery care for this is in comparing it to the way it's handled in the medical model. All providers and settings are going to differ in protocols but in our area of San Diego, it's most common for hospital-based providers to require parents to come in and begin receiving antibiotics right away. These antibiotics are administered through an IV port every 4 hours until the time of delivery. While antibiotics are quite effective at reducing infection risk, there are a few important things to consider when evaluating the risk.
Infection risk is generally higher all-around in a hospital setting because of routine vaginal exams given in an environment with many potentially hazardous and unfamiliar pathogens (germs). It makes sense there would need to be more precautions for infection with these conditions.
Antibiotics are not benign. There are risks, often long-term and compounding for years when gut health is disturbed. Antibiotics can be life-saving and we love them when they are truly needed, however, prophylactic use needs to be weighed carefully.
Having an IV in labor is an intervention that will impact how free you are to move and behave in an intuitive way. Even a small saline-lock, that only includes a port where tubing can be connected and removed as needed, will limit your movement and water options for pain relief.
Outside of questioning antibiotic use in labor, there are a couple more important things to understand about medical management for PROM24-hour. The first is coming into a high-intervention setting before your contractions have even begun. Many care providers will recommend induction before the 24 hour mark. This protocol is potentially setting a woman up for a cascade of interventions she planned to strictly avoid. Second, because of the care attitude around this normal variation of labor, the patient is put into a higher risk category that will likely decrease the already-limited options of experiencing a relaxed and supportive natural birth. The attitude of the birth setting and care provider alone on this issue can certainly seem to be a self-fulfilling prophecy in complicating the birth process.
Midwifery Management of PROM
Pulling way back from the snowballing scenario indicated above, we introduce the midwifery perspective. All midwives are going to have a different set of protocols, experiences, and comfortability. We are sharing our practice's stance for low-risk moms and low-risk pregnancies to offer a management outlook that relies heavily on trusting and supporting physiological birth. In most cases, we get to follow and honor this belief when it aligns with our clients as well- stay tuned through the next section on informed consent for the specifics around shared decision-making.
Once we have determined that we do in fact suspect PROM with one of our clients, we advise her to watchfully resume her normal life as much as possible. She will want to wear a pad or disposable underwear or keep a chux pad under her to help contain the fluid, and she will want to continue to monitor a few important items while she waits for contractions to begin. We advise women to work towards a balance of restfulness and distraction to pass the time and intentionally nourish their bodies. We expect roughly 95% of our clients to be in the researched category of women who begin having surges within the first 24 hours and if they are comfortable with waiting, we certainly are too.
Here are some ideas for waiting for contractions to begin:
Sleep if it is nighttime. Nap if it is daytime.
Stretch, walk, do hip circles on the ball, and spend time outdoors.
Eat full and nourishing meals, and keep hydration at a level that causes urination every 30-60 minutes.
Get a massage and visit your chiropractor or acupuncturist.
Spend time leisurely going through The Miles Circuit or Spinning Babies balancing activities.
Take your temperature every 4 hours and monitor baby's movements closely.
Begin an immune boosting protocol. (You can find our favorite one right HERE.)
Practice strict vaginal hygiene; changing pads often, nothing into the vagina, and wiping front to back.
We have the benefit of providing highly individualized care to our clients and getting to check in with them often and giving personalized recommendations as they wait. We may visit our client and check on mom and baby while offering encouraging words and activities. For the client whose contractions do not begin around the 24-hour mark from PROM, we get to take their lead in preferences for welcoming contractions. If they want to continue to wait for their bodies to initiate surges and all is well with them and baby physically, we are happy to support that desire. If they prefer nudging their bodies into action instead, we are happy to offer guidance on a natural home-induction protocol we have prepared. If at any point there are signs of infection, illness, or compromised wellbeing of either mom or baby, the safest decision is to transport to higher-level care.
Ongoing management of Rupture of Membranes (ROM), even once contractions have begun, includes extremely minimal vaginal exams, regular vital assessments, and immune boosting practices. We know that the vagina is a self-cleansing organ and we believe when left as an "exit only" orifice during birth we can drastically reduce infection rates. At the time this blog was written our infection rate for the past 4 years has been 0%, although we are ever-watchful no matter the circumstance. We are especially vigilant for signs of infection in mom and baby into the postpartum time and have the great benefit of returning to the home after the birth for skilled postpartum care 3 times during the first week alone.
Informed Consent and Shared Decision-Making
It's understandable (to us) how a hospital-based provider would react to a client who has PROM. The care provider has many patients to manage, in a higher-risk setting, with limited relationship and communication, and protocols to adhere to that increase risk for both mom and baby. When I was a doula many years ago I would describe this basic truth with, "if you buy the hospital ticket, you will get the hospital ride", although the ride itself is not always transparent until you are already on it. (Cue "Crazy Train" by Ozzy playing in the background of that ride.)
This is where consumers (in every single care setting) can advocate for better and individualized care. Sometimes the next steps in the labor process are shared in an authoritarian way that leaves very little else to be done but follow the professional's advice. We believe it is every provider's duty to take the time to explain the options and leave the decision in the hands of the woman herself. She is right and good to ask for expertise and information, but true informed consent is shared in the following way:
What are the benefits of the proposed treatment/intervention?
What are the risks?
What are the alternatives?
What is the provider's direct experience with outcomes that follow this proposed treatment?
When does a decision need to be made?
How can a second opinion be obtained?
Can we change our minds later?
Barring true emergencies, the birthing family should be given: this information, space made for asking questions, time given for discussing in private, and respect and support given for the final decision. True informed consent is sharing information in a way that empowers the patient/client to make a confident decision of their own. This is sadly not how care decisions are made in every setting, but this is the standard that we aim for in everything we do in our practice.
What if There is Meconium in The Fluid?
Mec, or the baby's first poop, will usually turn the watery amniotic discharge yellow, green or brown looking. Although a release of this first bowel movement can be a sign of distress in the unborn baby, it is almost always a sign of normal development and gastrointestinal maturity instead of something to treat as an emergency. We may monitor the baby more closely in labor, assuring that other signs of distress are not present. We will monitor the color and consistency of the fluid as labor progresses to determine if there have been multiple or recent bowel movements (and possible correlating distress).
We certainly will pay close attention to baby's transition at birth and consider the baby at a higher risk for Meconium Aspiration Syndrome (MAS)- a very serious breathing issue necessitating transport and higher-level care. (Click HERE for more information on how emergencies are handled at home.) Meconium staining of the amniotic fluid is noted in about 16% of all births, while MAS occurs in about 2% of all births where meconium is present.
Thankfully, in the absence of additional clinical concerns, midwives have the benefit of continuing to support a low intervention process, even when mec is present. A physiological vaginal birth does a pretty excellent job at squeezing most of the fluid out of baby's lungs, clearing the way for a normal initiation of oxygenating by air, without the use of routine or deep suctioning. Not surprisingly, we apply informed consent and shared decision-making when meconium is noted in the amniotic fluid and keep communication open with our clients as labor unfolds.
What if Mom is GBS Positive?
A mom who tested positive during her GBS screen in pregnancy will be at an increased risk for GBS infection with PROM- especially with clinical practices that include vaginal exams, an unfamiliar pathogen environment, and no guidance on immune support. Here are some of the considerations we share when we practice informed consent with our clients on this:
About 30% of women have an overgrowth of GBS at the end of pregnancy.
GBS is a transient bacteria which means it can come and go from one day to another. Testing positive once doesn't mean there is an overgrowth at the time of birth (or PROM).
Having an overgrowth of GBS does not mean that your baby will automatically become inoculated with it. If your baby is inoculated with GBS it doesn't mean an infection will automatically develop.
There are other dangerous strains of bacteria that we do not routinely screen for in the US. Not all first-world countries screen for GBS in pregnancy.
We are actively preventing and watching for all possible infections, regardless of GBS status.
One important tidbit about preventing GBS in the first place includes using feminine health probiotic in the last trimester of pregnancy, which can cut GBS overgrowth risk in half. So, moms on probiotics carry GBS about 15% of the time instead of 30%- yay for the preventative medicine approach of midwifery care. Lastly, and certainly not surprisingly at this point, we apply informed consent and shared decision-making when PROM occurs with a GBS positive mama, and keep communication open with our clients as labor unfolds.
How to Plan Ahead for PROM (or some other unexpected labor event)
Like so many things in birth, PROM can be a part of your labor story that throws you off a bit from what you were expecting and imagining. Staying flexible on expectations around your labor, while having some kind of plan in place to respond to the unknown can be a huge challenge to anticipate. We like to say all of this is *the* master prep for the real work of parenting- there are no wasted opportunities for growth through birth!
Communication is the real MVP when dealing with unknowns. Use some of the topics in this post to form some of your own questions to ask your care provider about this type of scenario taking place in your labor. (Get the entire low-down on interviewing midwives and sample questions HERE.)
We know that this elusive balance of managing surprise while maintaining your vision for your experience can feel impossible without the right tools. We created a free worksheet and checklist for pregnant moms to fine-tune their mindset and birth plan to include resiliency around the unknowns of labor.
This guide includes:
4 principals for flexibility in labor
How to choose mindset (not performance/ outcome) based affirmations and mantras
Harnessing your emotions and making set decisions to support a challenging labor
How to process your birth experience and postpartum in a healthy way
Click HERE to grab the instant download for yourself (or a friend)- Resilient Birthing: A Free Guide to Preparing for the Unplannable
Although we are licensed midwives by profession, we are not YOUR midwives. All content and information on this website is for informational and educational purposes only, and does not constitute medical advice. Although we strive to provide accurate general information, the information presented here is not a substitute for any kind of professional advice. For more information, click here.
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