Episode 95 Broken Waters

One of the possible signs of labour is breaking your waters - actually this happens less often that you might think. Here I discuss what happens next and what advice we are or are not giving women on their options if the waters break before contractions start.

Want to know more?
https://www.tommys.org/pregnancy-information/giving-birth/what-expect-when-your-waters-break
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005302.pub3/full
Prelabour rupture of membranes: induce or wait? - Evidently Cochrane
Recommendations | Inducing labour | Guidance | NICE
https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.14821
https://neonatalsepsiscalculator.kaiserpermanente.org/
You may also wish to revisit Episode 66 Group B strep.

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Transcript

Broken Waters

[00:00:00] Episode 95 Broken Waters. I'm doing this episode because Elisa, a midwife, got in touch and suggested it as a topic. It's a minefield. I've enjoyed exploring it and I can't think why I didn't think of doing an episode earlier. When I talk about broken waters, what am I talking? . Well, I'm talking about what we in the business would call prom, P R O M.

That stands for pre-labor rupture of membranes. That means the waters have broken the two membranes that contain the waters, the amnion, and the chorion. have broken that cling, filmy sort of layer has broken and the waters have started being released. But labor [00:01:00] hasn't started. Contractions haven't started.

This of course can happen earlier in pregnancy, but what I'm going to talk about today is prom term water's breaking at term. So that means anything 37 weeks or beyond. , this will happen to about one in 20 women. This will be the first signal that their labor may be about to start. And that's interesting in itself because often what we see on the TV depictions of birth in drama is the waters break, and then a few seconds later here is the baby.

We go from 0 to 60, as it were. But in real life, much more often, labor starts, contractions start, and then waters break right towards the end. [00:02:00] Only in one in 20 women, as I've said, are the water's breaking the first signal that something is up. So why is this an important topic? 60% of those women who break their waters before they go into labor, will go into labor in the next 24 hours.

So the following 24 hours, if left to their own devices, their contractions will start, the neck of the womb will start to open, the labor will get going, the baby will be on its way. But for some women, , that won't be the case. And then they'll be faced with decisions. Decisions to make about being induced or not possibly something they hadn't even contemplated.

Many of their thoughts about birth, [00:03:00] both in terms of type of birth and choice of place of birth, may be immediately affected if the waters break. Before the contractions start, before I go into those choices and those discussions, I'm gonna pause for a moment and just think, how do you know your waters have broken?

Sometimes it's true, there is a deluge, a little bit like you've weed yourself, but instead of being able to control it, it keeps on. . But for some women, it'll be much more subtle. Perhaps a slight pop or a tiny trickle. Not a great waterfall, not a great tap turning on. And so we often see women for checks to see if their waters have or haven't broken when it comes towards the end of [00:04:00] pregnancy.

One of the things for us as midwives and obstetricians is the. amniotic fluid has a very specific smell. It does not smell like urine. It smells slightly sweet, and unlike urine, which will usually be a yellowish color, it'll be pinky or clear unless, of course the baby has done a poo in the waters called meconium, in which case it may be green.

Either way. When the waters break, we want to see the woman in hospital. We want to check her pulse, her temperature, her blood pressure, how she's doing, is she contracting? How is the baby doing? Is the baby moving and listening to the baby's heartbeat? It's important to have a check. At that point, we will then do some tests to try and establish, have the waters definitely broken.[00:05:00] 

obviously if there's water pouring out, her pad is absolutely saturated heavy with waters while she's dripping on the floor. It can be very obvious. Yes, of course the waters have gone, but in those situations where it's a bit more subtle, will need to do an internal examination. with a speculum, a bit like a smear test to have a look and see if we can see a pool of fluid coming through the cervix.

And we may ask the woman to give a cough to increase the pressure inside the womb and see if a bit leaks out. Or these days we can do a test called amnisure, which is like a little indicator test. We take a little swab from the vagina and the woman can swab herself thus avoiding a vaginal examination. And we can put it in a little reagent pot [00:06:00] and it has a little strip and it runs, and it tells us, is this positive?

Have the waters broken, or is it negative? They haven't. If you're simply feeling a little bit damp and wearing a panty liner, chances are the waters haven't. normally, even if it's a slow leak, what we sometimes call a hind water leak, where it's broken behind the baby's head, chances are you will be getting wet.

And once those waters have broken, you're going to be getting wet until the baby arrives. It's not going to stop until then because the water is constantly being recirculated. At this stage of pregnancy, it's mainly baby's urine. You. . So it's critically important for us to establish, have the waters definitely broken.

And the reason for this is because there's a clock ticking from [00:07:00] that moment onwards. And this is why Elisa asked me to do an episode on this topic, because this is where the confusion starts. Once the waters have broken, we are worried. , the baby is now exposed to potential infection. Bacteria ascending up the vagina can cause an infection in the amniotic fluid, which is a lovely culture.

Medium bacteria grow very well in it, so if the waters have broken, we have to weigh up the benefits of waiting for the labor to start. spontaneously versus the risks of infection to the baby. As time progresses. We know the risk or chance of infection increases the longer the time passes. Since the waters have broken, within [00:08:00] 24 hours, 60% of women, six out of 10, will have gone into labor and by 72,

95% of women will have gone into labor, so there is some benefit in waiting. Okay, so the flip side, what are the risks of waiting? The risks are that if the waters have broken before labor, so-called prom, the risk of the baby having an infection may. from one in 200, if the waters haven't broken before labor starts to one in a hundred, if the waters have broken before labor starts, okay, that's double the [00:09:00] risk, but it's still relatively low.

The nice guidance, the National Institute of Clinical Excellence. On induction of labor gives waters having broken before contractions started as a possible reason for induction of labor. Let's take a look at that. Looking at that recommendation, it says, offer women with pre-labor ruptured membranes at term brackets at or after 37 weeks, a choice.

expectant management for up to 24 hours or induction of labor as soon as possible. Sorry. What induction of labor? As soon as possible. I don't think I've ever worked anywhere that has offered induction of labor as soon as possible [00:10:00] as an option. The woman comes. Her waters have broken. We start the clock ticking.

We tell her she has a certain amount of time to go into labor, and if not, we are recommending induction. And how long are we saying she can wait? Well, it's extraordinary. If you look on Google, which I did to prepare this episode, any number of hospitals. , their advice and information leaflets for women pop up.

So in the process of making this episode, I've looked at guidance or information leaflets from around 10 to 15 different hospitals up and down the country. It's true, many of them do not have a date on them, so some of them [00:11:00] are probably a little bit out of date. , for example, one has a date of 2008, but some of them have dates of 2019.

So are certainly the current version and regardless of whether they are the current version or not, if I can Google it, so can women. So with a quick straw poll, looking through this information for women. or guidelines that are shared on the internet. I can discover in the UK that you can be offered induction at 24 hours in one area, right through the options of 36 hours, 48 hours, 72 hours, and in one place 96 hours.

So we've got a range of 0 to 96 hours [00:12:00] of different hospitals up and down the country offering induction and the number of hours elapsed after the waters have broken. Wow. That's quite something. And it's funny because I actually came across this myself in my first pregnancy with my first daughter.

My waters. Before I went into labor, I was one of those one in 20, I remember at the time feeling really stressed. I was working in a maternity unit where if your waters went, we waited 48 hours before induction. So when my waters broke, I was relatively calm. I was contracting a little bit, but not. , I thought I had 48 hours.

When I rang my [00:13:00] midwife and went in for my check, I was utterly dismayed to find that the local maternity unit where I was having my baby, because I worked at too great a distance away, would allow me in inverted commas. Not 24 hours, not 48 hours. 12 hours. My clock was ticking faster than I could ever have imagined.

I remember stringing it out. I actually went into hospital about 15 hours after my waters had broken because I didn't want to be induced. But even I, with all my knowledge and all my experience, wasn't able to advocate for myself and when that pregnancy ended in an emergency cesarean section, [00:14:00] having only got to three centimeters dilated, I blamed myself.

I always had that question at the back of my mind. What. What if I'd been allowed to have longer? What if I'd been able to wait? What if my labor had been able to establish spontaneously? What if I hadn't had the syntocinon? What would've happened? And I never questioned what if my baby could have had a severe infection as it was.

We still ended up with her having blood tests and antibiotics. As a precaution, so no wonder women are getting a bit confused. I'm not saying infection isn't important. It totally is. You only have to go back to episode 66, group B [00:15:00] strap, my amazing conversation with Jane Plumb, founder and chief executive of the charity group B strep support.

to understand the impact of group B strep infection, which is is the predominant cause for concern. But if we're inducing maybe a significant proportion of that one in 20 figure of women who are breaking their waters before their labor starts. , are we over egging it? Are we doing a lot of intervention unnecessarily?

If you want to look a bit deeper into the evidence, there's a couple of great things I've found on the Cochrane website. One is a blog, evidently Cochran, pre-labor rupture of [00:16:00] membranes induce or wait . It's written by midwife Lisa Smith, and she examines how good is that evidence and what is that risk? What is the absolute chance?

And what it boils down to is a tiny difference. And what she's comparing is early birth. rather than expectant management, early birth being immediate induction. Her article is written in response to the planned early birth versus expectant management brackets, waiting for pre-labor ruptured membranes at term review, and I've enclosed both links in the program notes.

The review concluded that women who had planned early birth were at [00:17:00] reduced risk of maternal infectious morbidity than women who had expectant management, and their babies were less likely to have definite or probable early onset neonatal sepsis. But then it does comment that this is low quality evidence.

and in some places it even says very low quality evidence. In her article, Lisa Smith also examines the fact that the different studies have a wide range of induction protocols. So some women waited for 24 hours, some for 48 72, or yes, you guessed it, that 96. . And what about the fact that they're talking about comparison with [00:18:00] immediate induction?

Immediate induction as soon as the water's breaking induction? And why aren't we doing that? Why aren't we offering that? Sorry to say, but there's a practical reason why we're not offering that. . Yes, we do want to wait for women to go into spontaneous labor, but there's also something about a holding pattern.

If the labor ward is full, we don't have a bed or we don't have a midwife, we may not be able to offer a media induction of labor, and we've got so much into the habit of giving everybody 24. that we forget to give women that option, that they might want an immediate induction, or at least certainly that's how I feel we do.

It's taken for granted. She's going to wait 24 [00:19:00] hours.

The only exceptions to this are if the baby's passed meconium, done a poo in the waters, or if the woman happens to be group B strep. That is Group B strep has been picked up at some point in her pregnancy. And this is also slightly nonsensical because we don't screen for group B strep, so we've only picked it up by coincidence.

So there may be many women who are waiting and not having induction of labor who do have group B strep. And conversely, because group B strep is a transient. It may well be that we have women who had group B strep, but don't have group B strep now who we are inducing. We will often tell a woman to keep an eye on her temperature and how she's feeling at home, and we tell her if she gets a temperature or starts to [00:20:00] feel fluey or unwell or the waters change color or the baby's not moving as much, she needs to come back into hospital and that's good.

we're getting her to watch out for signs that might indicate infection while she's waiting to go into labor. But all too often what happens is we give the woman a time to come back now, this time to come back. In my unit, we certainly used to give an arbitrary time, so if you broke your waters, it didn't really matter what time of the day or night.

You broke them, you were gonna be told to come back at eight o'clock the following morning. So you might be waiting 12 hours or you might be waiting 36 hours, depending on how close to eight o'clock in the morning you broke your waters. And that was just for practical reasons really. It made our [00:21:00] ability to schedule our workload and try and start women off in the morning rather than inducing them overnight.

Now we've moved to being more accurate. So if a woman breaks her waters at three o'clock in the afternoon, she'll be told to come back at three o'clock in the afternoon the next day. But then what might happen is, again, we may have a shortage of beds or we may have a shortage of midwives. And having told the woman that she absolutely must have an induction because we are worried about the risk of infection and possibly having persuaded her into an induction that she doesn't want, she will then come in for that induction and then she will sit around waiting for us to have a midwife.

Room available to actually do that induction [00:22:00] and we can be in the situation where a woman has reluctantly come in for an induction. Maybe it's 48 hours, maybe it's 36 hours. She wanted to wait longer. We've potentially told her she's doing something risky. She's risk taking with the health of her baby because we are worried about infection.

And then when she comes, instead of us being on it and starting things straight off, she'll sit round waiting because we haven't got the staff. So this whole induction for the water's breaking is fraught with difficulties, partly because the evidence is difficult to interpret, possibly poor quality in some areas.

inconsistent. The studies that are looked at, and then also because of our [00:23:00] logistical reasons, our logistical problems with the fact that we don't have infinite capacity and infinite midwives available on our labor ward wards. The other massive variation in practice happens around antibiotic usage in.

So if a woman has group B strep, we will give antibiotics in labor. And the national guidance used to be that all women who'd broken their waters before going into labor ought to have antibiotics in labor. I remember 18 as being the magic number. So any woman that was coming. 24 hours after her water's having broken for an induction, the first thing we'd do is give her antibiotics.

They had to have two doses of [00:24:00] antibiotics, the first one at least four hours before the baby was born, and then we would assume that they were covered and that their baby wasn't at higher risk of infection. . Then a few years ago, the guidance changed. So instead of giving all these mothers who'd broken their waters before labor, antibiotics as a routine, once they'd reached a certain time point, we switched to watching for features of infection.

So that might be the woman developing a temperature during labor. , it might be her heart rate going up or the baby's heart rate going up. And then, and only then would we give antibiotics. You could say this is a good thing because we are [00:25:00] not hammering women with antibiotics the minute they hit the labor ward.

We're not unnecessarily treating. and we know that antibiotic over usage is a real worry these days because of antibiotic resistance. And of course some women don't want to have antibiotics even when we are recommending them. But the unintended consequence of this, I feel, has been high. We see far more women developing chorio amnionitis that is a temperature and becoming unwell during labor than we ever used to. And as a result, we have many more babies that are what we call screen and treated, have blood tests taken, [00:26:00] checked for infection, observations for infection, and given antibiotics until some of the results. than we ever used to, and I see this on the postnatal ward.

Our postnatal ward is full of women having extended stays in hospital of between three to five days so that the baby can have antibiotics through a drip. That can't be great for antibiotic resistance for the baby's microbiome. . It's not a great start in life, surely. So we need to find a better, happy medium.

Of course, it's really important that we prevent early onset neonatal group B strep infections. It's essential, but we also don't want to [00:27:00] subject well babies to lots of inter. blood tests and antibiotics in their first few hours and days of life. And mothers do not want to spend those first few days in hospital on antibiotics, worrying about the fact that their baby may have an infection and being unable to recover in their own home, surrounded by friends and. family

and this is particularly difficult at this point in time when visiting in hospital is very limited, limited to birth partners and that can leave a mother isolated, unable to show her baby to family and friends, and unable to access the support that she needs in those first few days. So we're in this difficult situation, almost chicken and.

Do we [00:28:00] give antibiotics to far more women or do we give antibiotics to far more babies? Do we induce as soon as the waters have broken or do we wait and try and give labor a chance to get going spontaneously? There's no right or wrong answer. I think , there is a slight chink of hope in terms of treating all these newborn babies.

There are some new ideas being adopted from the states. There is a sort of neonatal, early onset sepsis calculator, the Kaiser sepsis scale, and I've put a link to that, which quite a lot of hospitals in the UK are trying to. to try and come to a more rational conclusion about how to manage things.

[00:29:00] So where does that leave my zesty bit? I think the most important aspect of my zesty bit would be, let's be honest, with women, part of what we are recommending is because of what we logistically can manage as a maternity. And part of it is to do with the chance of maternal and neonatal infection. We can't pick and choose the guidance.

If the guidance is immediate induction or induction at 24 hours. Are we having those conversations about immediate induction? Do we offer that as an option? I'm not so sure we. . And when we're talking about induction at 24 hours, how much detail do we explain about the difference between 24 48, [00:30:00] 72 hours so that a woman can make a decision?

If you're pregnant and you're wondering about what you do in this situation, all your waters have. I really suggest you look at the links I've enclosed from the Cochran Review because it's clear that the evidence is much more nuanced and there is a nice plain language summary of the guidance, which also if you look is available in different languages.

If English isn't your first language . So if you want to delve into it in a bit more detail and look at the quality of evidence, the number of trials, the numbers of women and babies, and the relative risks, I suggest you do so because only you can [00:31:00] decide what is right for you and your baby. Only you can decide what chance of infection.

Is acceptable or unacceptable to you? And likewise, only you can decide what's an acceptable chance of you having intervention such as a cesarean birth. So I think with pre-labor rupture membranes or water's breaking before labor, the devil's in the detail. We need to have much more detailed convers. We need to give women this more detailed information, and then we need to give them time to think about what are their options, and don't underestimate how difficult it can be to stand up for what you want to do for you and your baby as a pregnant woman.

If I couldn't [00:32:00] stand up as an obstetrician and say I didn't want an induction, 12 hours as after my waters had broken then what hope is there for other women coming to our service? We need to make sure we are individualizing their care as best we can, given the finite resources we have, and at least be honest about what is the conversation we're having and the choices they are.

So I do hope you've enjoyed listening to the obs pod. If you have, please do leave me a review, subscribe and join me again to explore more about the day-to-day life of an NHS obstetrician. Please do share what you've enjoyed about listening, and particularly if you've done anything differently as a. I would like to confirm that although [00:33:00] I'm talking about my experiences in my working life, there is no intention to identify any specific woman or family under my care.

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