Inducing Labor When the Bag of Water Breaks

I cover a lot with my doula clients in the "client interview" process, but I am no substitute for a good childbirth education class when it comes to first-time moms.  I must admit that given my meditative background, I have a fondness for Birthing From Within classes, but after a couple of births where mom planned to have a natural childbirth but ended up with exactly the opposite due to hospital protocols (the particular protocol being mom must be in active labor 12-24 hours after water breaking), I've decided I need to sit in on a Bradley class asap and learn more about this method.  From the book, it seems like the Bradley method is very clear about the strong chance of an unnecessary cesarean when delivering at a hospital.  Since I had two births in a row where the mom had a cesarean because of hospital protocols, I feel that a class that really goes over this piece with moms and their partners is priceless.  Maybe first-time moms planning a hospital birth need to take two childbirth classes.  One class could prepare mom find their inner strength and cope with the pain of labor and another that really tells it like it is when it comes to hospital birth and teaches you how to up your chances of normal birth in the hospital.  Or maybe (my ideal) a yoga class that helps you find your birthing power and a class that TRULY prepares you for hospital birth.

I've been wanted to do a post on premature rupture of membranes (PROM) for a while, so let's see what the Bradley Book has to say about inducing labor when the bag of water breaks:

One doctor reporting on a study involving women with ruptured membranes tells us that mere time passing is not related to infection rates.  As a result of his study, he tells us 'there would appear to be no real basis for the stimulation of labor in patients with premature ruptures of the membrane, especially before thirty-two weeks of gestation, since the risk of inection was unrelated to the duration of membrane rupture.'

He goes on to state that only a "hands-off" policy will reduce the chances of infection.1

The author goes on to say:

Three women in my last class of ten couples started with the water bag breaking.  One of these... birthed within or at forty-eight hours, and two birthed one week later.  All of them received good advice from their birth attendant.  They were told not to put anything whatsoever in the vagina.... and were asked to take their temperature regularly and report immediately if there was any rise in temperature.  There were no infections.  There were also no vaginal exams.2

Sadly, this was not the advice given to my moms who were induced.  

And from Varney's Midwifery "

The incidence of chorioamnionitis...increases in direct relationship to the number of pelvic exams performed.... an initial digital examination to determine cervical dilation is unnecessary, since knowledge of cervical findings is superfluous to the management".³

Hmm, so why are care providers so quick to get their fingers in there?????

I would like to point out that the risk of infection (the type of infection we are speaking about when waters break before labor are amnionitis and chorioamnionitis) is HIGH with cesarean section⁴ (along with a whole lot of other risks) and that your chances of cesarean are significantly increased with induction. 

Moms, in order to birth with empowerment, you have a LOT of work to do, especially if you are birthing in a hospital.  Please seriously consider scenarios, such as water breaking before labor starts, early in pregnancy.  How will your care provider handle this scenario?  Please understand that your care giver's actions may be motivated by hospital policy rather then by what is best for mom and baby.  It can be so hard to remain steadfast in your trust of birth, especially as a first time mom birthing in the U.S. (I know, I had a cesarean the first time around) but gather the resources and give it your all! 

1 Susan McCutcheon, Natural Childbirth the Bradley Way (New York: Penguin Books, 1996), 220.

2 Ibid

3 Helen Varney, Jan Kriebs, Carolyn L. Gegor, Varney's Midwifery (Boston: Jones and Bartlett Publishers, 2004) 867.

4 Maternity Center Association, What Every Pregnant Woman Needs to Know About Cesarean Section (New York: The Maternity Center Association) 2004.  Available online, http://www.childbirthconnection.org/article.asp?ck=10164.

Comments

[Melissa]

This is a great post! I would like to double, triple stress the importance of NO VAGINAL EXAMS if your water breaks and there is no labor. And when you go to the hospital that is the first thing they do (and probably will continue to do it every 2 hours there after!) If your water breaks and you aren't contracting regularly then you are not dilated...NO need to stick anyone's fingers up there to check! I've been doing more PROM research myself. I will definitely let you know when I post it.

~Melissa
www.nursingbirth.com

[maria]

Thanks for this post! I might print it and put it on an index card or something -- that way I can back-pocket it for when I've got clients in labor!!

[Kat]

Thanks Melissa! And I look forward to reading your post on PROM as well. Which OBs protocols were a bit more evidenced based...

[Kat]

Thanks Maria!

[man-nurse]

I just took my OB nursing class. There stated there was no real evidence-based justification for the 24 limit between ROM and birth, and while the nurses all kind of arbitrarily believed your chances of infection were kind of higher, they said the 24 limit might change at any time if some study or another comes out in favor of, say, 48 or 72 hours.

Pretty crappy way to practice if you ask me, but that's how hospitals have to operate...like factories. You can't set policy for every birthing mom out there, and not set arbitrarily restrictive policies.

[Kat]

Thanks for your comment! I just linked to your most recent post.

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[Karrie]

I'm 35 weeks along and my doctor mentioned me having to be induced if my water breaks and I'm not laboring within 24 hours. We are taking a Bradley Method birthing class and have covered a lot of what we prefer with her and she's been on board with just about all of it, except this. I'm a scientific person so I want to see the studies on why it's not necessary to be induced if labor hasn't started with in 24 hours. I want to see them because I like to see and read these things for myself AND I want to be able to show her that I've done my homework. I work at a university so I have access to just about every medical journal out there if someone could just direct me to a few studies on this? THANKS!

[wound infections]

Can you tell me how prevent an infection during labor

[Kat]

I would search the Cochrane Review (http://www2.cochrane.org/reviews/) because I am assuming you would have access to the full articles at a University Library. The thing to remember is that the risk of infection is connected to the number of vaginal exams performed. There isn't any good research on the risk of infection when vaginal exams are not performed. You might want to ask your doctor to limit or, better yet, avoid vaginal exams if your membranes rupture early in labor.

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Interesting site, always a new topic .. good luck in the new 2011. Happy New Year!

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[june]

loved the post im in this position just now my waters broke 4 days ago and have been under pressure to be induced but so far have declined daily checks on blood pressure babys eart rate but no internals. I am now having bit of spotting which doctor said it might be a show of labour they are not overly worried which suprise me when they are keen to induce me.

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[xl pharmacy]

so, the protocols are something that they have for a lot of reason. There has to be a way to get them to reach an agreement with it.