What do contractions feel like? How do I time contractions? When do I come to hospital? What do I bring to hospital? What happens when I get to hospital? What if my labour is progressing slowly? The researchers found that overall, there may be more pros than cons to induction with term PROM. Women who were immediately induced after term PROM had shorter durations from PROM until birth, were less likely to experience maternal infections low-quality evidence , and appeared to have no increase in the risk of Cesarean low-quality evidence.
Their babies were less likely to need antibiotics after birth and less likely to be admitted to the NICU, and both mothers and babies had shorter hospital stays. There were no differences between induction and expectant management groups in the risk of serious maternal infection very-low quality evidence , definite newborn infection very-low quality evidence , or perinatal mortality , a combined measure of stillbirth or newborn death moderate-quality evidence.
Two possible side effects of medical induction are uterine hyperstimulation and uterine tachysystole. In , the American College of Obstetricians and Gynecologists recommended abandoning the term hyperstimulation because it is vague and not defined. Instead, the term uterine tachysystole should be used. Uterine tachysystole is defined as the uterus contracting too frequently more than 5 contractions in 10 minutes, averaged over a minute window , and can lead to a possible decrease in oxygen to the baby as well as fetal heart rate changes during labor.
Four studies in the Cochrane review reported higher rates of hyperstimulation or tachysystole in the induction groups. The largest study that reported this side effect was carried out by Krupa et al. In this study, there were participants, and half of them were induced with misoprostol [Cytotec]. The researchers found that On the other hand, they found more fetal heart rate decelerations in the expectant management group Because it was such a large study, the Term PROM study results drive most of the findings in any meta-analysis, including the Cochrane review on this topic Dare et al.
Therefore, we will focus on the findings of the Term PROM study in this article, while occasionally mentioning results from other studies. Between the years of , a group of researchers from 72 hospitals enrolled 5, low-risk women from six different countries Canada, United Kingdom, Australia, Israel, Sweden, and Denmark into the Term PROM study. Women were invited to be in the study if they came to the hospital with PROM.
Everyone had a non-stress test before entering the study, and they were not included in the study if they had meconium staining of the amniotic fluid or any signs of infection when they arrived at the hospital. Everyone was swabbed to check for Group B strep when they entered the study, but in most cases nobody knew the results of the GBS test until after the baby was born.
People with term PROM were randomly assigned to one of four groups:. Those people who were assigned to the waiting groups could wait for labor to begin either at home or in the hospital. They were told to check their temperatures twice per day and were told to report any fever, change in the color or smell of the amniotic fluid, or other problems.
In the Term PROM study, there were no differences in Cesarean rates between the induction groups and the waiting for labor groups. Cesarean rates were low in all four groups When the researchers separated out those people who had given birth before, versus those who were giving birth for the first time, they still found no differences between groups. Among people giving birth for the first time, Cesarean rates were:.
About 1 in 4 of people giving birth for the first time had forceps or vacuums used during their births. Among people who had given birth before, only 3. There were no differences between induction and expectant management groups in rates of forceps or vacuum deliveries. Most other studies that compare the rates of Cesarean section in induction vs.
The chorioamnion or membrane is a physical barrier to bacterial invasion during pregnancy, so when the water or membranes break, this means the mother is at higher risk for infection.
Chorioamnionitis means inflammation of the membranes due to infection. For the rest of this article, we will refer to this condition as chorio. There were no differences in rates of chorio between people in the immediate induction with prostaglandins group compared to people in the waiting for labor for up to four days until induction with prostaglandins group.
This is a pretty high rate, and could be partially explained by the fact that very few people in the study had antibiotics for Group B Strep—a known risk factor for chorio. In , researchers published a large study that people with term PROM, and they found that with screening and treatment for GBS, the overall rate of chorio was 1. When we look at the Term PROM study, there are several potential reasons—other than the induction itself—that could help explain why those in the immediate induction with oxytocin group had lower rates of chorio.
These reasons include the fact that people in the immediate induction group had fewer vaginal exams, shorter labors, and spent less time in the hospital compared to women in the waiting group. Similarly, the Cochrane review found that induction is associated with a lower risk of infection in the mother.
However it is very important to note that most of the studies in the Cochrane review did not take into account the number of vaginal exams, nor they do not follow current GBS infection protocols. The number of vaginal exams that someone with PROM has after their water breaks is a very important possibly the most important predictor of whether someone with term PROM will develop chorio.
Compared to those who had fewer than three vaginal exams :. The strong link between the number of vaginal exams and the risk of chorio has been confirmed in many other studies. For example, in , Ezra et al. The reason vaginal exams can lead to infection is because even though care providers use sterile gloves, their fingers are pushing bacteria from the outside of the vagina up to the cervix as they conduct the exam.
In fact, vaginal exams have been shown to nearly double the number of types of bacteria at the cervix Imseis et al. In one small research study, five women had two sterile speculum exams, and their cervixes were swabbed to check for bacteria after each exam. There was no increase in bacteria on the cervix after the second speculum exam Imseis et al.
This is important because those people who were in the waiting groups took longer to give birth than those people who were induced with oxytocin. In other words, those in the waiting groups likely had an increased risk of infection due to the initial vaginal exam Seaward et al.
Not surprisingly, the Term PROM study found that people who are induced give birth more quickly than people who wait for labor to start on its own. Women in the immediate induction with oxytocin group gave birth an average of 17 hours after their water broke, and women in the immediate induction with prostaglandins group gave birth an average of 23 hours after their water broke—compared to an average of 33 hours among those in the waiting groups.
There was no evidence that term PROM increases the risk of cord prolapse. Cord prolapse only occurred two times out of more than 5, people with PROM who were enrolled in the study—once in the induction group and once in the waiting group.
There were no differences in newborn infection rates between any of the groups. The Term PROM researchers carefully defined what an infection would be and even had separate doctors evaluate for newborn infection. Several other studies have looked at risk factors for newborn infection. These risk factors included:. In some studies, mothers whose labor took longer to start after their water broke were more likely to have newborns who were admitted to the NICU, or having a longer stay in the NICU Akyol et al.
It was not clear if this was because care providers were being more cautious with these infants. In the Term PROM study, there were no statistical differences in stillbirths or newborn deaths between the groups.
Despite the fact that the study included more than 5, mothers, it was still not a large enough study to tell a statistical difference in deaths.
Because stillbirths and newborn deaths are such a rare event, you would need more than 28, people in a randomized trial to tell a difference in mortality rates between groups. There were two deaths in the expectant management oxytocin group, two deaths in the expectant management prostaglandins group, and zero deaths in the induction groups.
The fact that all four of these deaths occurred in the two waiting groups could have been due to chance, or it could have been related to the waiting for labor to begin. Because the study was not big enough to tell differences in death rates, we will never know the answer to that question.
In the Term PROM study, there were no differences between groups in the following newborn health issues:. Fewer babies in the oxytocin induction group 7. This may be because mothers in the waiting group were more likely to have chorio, and it is quite common for babies to receive antibiotics if their mother experienced chorio. The researchers suggested that these longer NICU stays might have happened because care providers are more worried about infants born to mothers with prolonged rupture of membranes and want to provide more monitoring for them.
In the Term PROM study, mothers in the oxytocin induction group were less likely to say that there was nothing they liked about their treatment 5. In other words, rates of satisfaction were high in both groups, but higher in the induction groups.
If someone chooses to wait for labor to start on its own, is there any evidence that it is safe to wait at home? People who were randomly assigned to the expectant management groups were given the choice of waiting in the hospital, or returning home to wait for labor to begin there.
Out of the entire study, women decided to go home, and 1, decided to stay in the hospital. The researchers found that there was an increase in some risks among people who waited for labor to start at home. Compared to those who stayed in the hospital, people who waited at home were:.
More babies born to mothers who waited at home received antibiotics Certain factors increased some of these risks. Mothers giving birth for the first time who waited at home were even more likely to need antibiotics before delivery. Mothers who tested negative for GBS were more likely to need a Cesarean if they waited at home.
Despite these increased risks, more people reported being satisfied with their care when they waited for labor at home Hannah et al. Because the evidence we have is limited, the benefits and risks of waiting at home are not clear. In the next section, we will talk about a recent, large study in which women waited for up to 48 hours for labor to begin. However, these people waited in the hospital, and they received antibiotics immediately if they were GBS positive, or at 24 hours for everybody else See below.
In , Pintucci and colleagues published a prospective research study in which they followed 1, people with term PROM Pintucci et al. The people in this study waited for labor to begin for up to 48 hours unless there was a medical reason for induction. People were not allowed to be in the study if they were already in active labor, had a baby in breech position, or a high-risk condition such as diabetes or high blood pressure.
So, in most pregnancies, your water will break after your contractions begin. Amniotic fluid is made up of hormones, nutrients, and antibodies. Your baby actually drinks the water-like fluid — and eventually pees into it as well. The fluid is responsible for keeping your baby warm and for helping develop their lungs, digestive system, and even musculoskeletal system.
Instead, they receive nutrients and oxygen from your placenta. In later pregnancy, the amniotic sac serves more as protection only. If the sac is broken, your baby is more prone to infection and other risks, like cord prolapse.
The key is monitoring. You, too, are at risk of infection and other complications. Related: How do babies breathe in the womb? In later pregnancy, you likely have a lot of discharge and other leaks going on. You may also have a physical exam, ultrasound, or other tests to assess the situation. Once confirmed, your care provider will take into account the following before creating your game plan:. Alternatively, if you have no risk factors, you may be given a short window of time in which you can wait and see if labor will start on its own.
Related: Tests for premature rupture of membranes. With this data in mind, you may have heard that doctors will give you just 24 hours before trying induction techniques. Again, remember: After your water breaks, your baby is supported by the placenta for oxygen and other needs. The main concern of your water breaking early is infection for both you or your baby. This management and exact timeframe may vary from provider to provider. Augmenting labor is also more likely in this scenario since the potential for complications is higher.
Typically, after your water breaks at term, labor soon follows — if it hasn't already begun. Sometimes, however, labor doesn't start. If you experience prelabor rupture of membranes, your doctor might stimulate uterine contractions before labor begins on its own labor induction. The longer it takes for labor to start after your water breaks, the greater the risk of you or your baby developing an infection. If your water breaks before the 37th week of pregnancy, it's known as preterm prelabor rupture of membranes preterm PROM.
Risk factors for water breaking too early include:. Potential complications include maternal or fetal infection, placental abruption — when the placenta peels away from the inner wall of the uterus before delivery — and umbilical cord problems. The baby is also at risk of complications due to premature birth. If you have preterm PROM and you're at least 34 weeks pregnant, delivery might be recommended to avoid an infection.
However, if there are no signs of infection or fetal health problems, research suggests that pregnancy can safely be allowed to continue as long as it's carefully monitored. If you're between 24 and 34 weeks pregnant, your health care provider will try to delay delivery until your baby is more developed.
You'll be given antibiotics to prevent an infection and an injection of potent steroids corticosteroids to speed your baby's lung maturity. If you're less than 32 weeks pregnant and at risk of delivering in the next few days, you might be given magnesium sulfate to protect the baby's nervous system. Corticosteroids might also be recommended starting at week 23 of pregnancy, if you're at risk of delivering within 7 days.
In addition, corticosteroids might be recommended if you're between weeks 34 and 36 and 6 days of pregnancy, at risk of delivering within 7 days, and you haven't previously received them. You might be given a repeat course of corticosteroids if you're less than 34 weeks pregnant, at risk of delivering within 7 days and a prior course of corticosteroids was given to you more than 14 days previously.
If you're less than 24 weeks pregnant, your health care provider will explain the risks of having a very preterm baby and the risks and benefits of trying to delay labor. During active labor, if your cervix is dilated and thinned and the baby's head is deep in your pelvis, your health care provider might use a technique known as an amniotomy to start labor contractions or make them stronger if they have already begun.
During the amniotomy, a thin plastic hook is used to make a small opening in the amniotic sac and cause your water to break.
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