June 11, 2003
Volume 5, Issue 12
Midwifery Today E-News
“Premature Rupture of Membranes (PROM)”
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In This Week’s Issue:

Quote of the Week

"In trying to beat death, we have devised a monstrous system that hurts most women and babies and results in societal breakdown."

Gloria Lemay

The Art of Midwifery

It is not necessary to go to the hospital the minute your water bag breaks, especially with no contractions. But it is important to take precautions to keep infection from occurring. A woman should take her temperature every 4 hours and check her pulse rate. Any increase above 99 degrees with an increased pulse rate of 20 beats per minute (example: a normal pulse of 80 that increases to 100 with an increase in temp. above 99) indicates a trip to the hospital as infection may be occurring. Drinking lots of fluids (4 quarts per day) during the wait for labor is important because it helps maintain amniotic fluid volume during leaking. If labor does not start within 72 hours with the true ruptured BOW, an evaluation should be done to ascertain why labor has not begun.

Joan M. Dolan
Midwifery Today Forums

ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.

News Flashes

A British study screened expectant mothers for emotional well-being at 30 and 36 weeks gestation and again at six weeks postpartum. A disproportionately large number of women who had a cesarean birth reported symptoms of clinical depression. Women who felt they were "not in control" of the events or felt they received medical interventions that were not necessary were at higher risk for depressed mood.

Journal of Reproductive and Infant Psychology, 1990

DISCUSSION: What do you do in advance of birth to help women deal with an unexpected c-section or avoid a c-section?

IN RESPONSE TO Issue 5:11 news brief about cerebral palsy and twin birth:

Are the twins in the study c-section or vaginal births? C-sections have a higher incidence of CP, especially with babies weighing less than 2500 g. Also, with twins the cord is cut after the first baby is born. Early cord clamping is associated with CP. Does the study mention which baby (#1 or #2) was afflicted with CP? Was it the one whose cord was cut as soon as it was born?

Did the study identify the c-sec rates for the twin births vs. singleton births? OB George M. Morley, who is campaigning against the practice of immediate cord clamping (ICC) at births, suggests that ICC leads to much higher rates of cerebral palsy, and this is especially a problem with c-sec and/or premature births (both of which twins get more of, yes?). See cordclamping.com/advisors.htm

Jill Herendeen

This is certainly an attention-getting article, but I am very curious to know what interventions were commonly used in these twin births and especially those that ended in CP. What about the pulling and manipulations used in c-section? Or induced labors? How many of the twins with cerebral palsy were able to be birthed vaginally as opposed to being sectioned?

Aron, doula

Editor's Note: The study did not factor in cesarean birth, birth order, nor timing of cord clamping. Interventions were not described. Prevalence increased with decreasing birth weight. Among the extremely low birth weight infants, CP prevalence was marginally greater in like-sex than in unlike-sex twins. In all the other birth weight groups, CP prevalence was considerably greater in like-sex twins. The surviving twin of a co-twin that suffered fetal or infant death is at high risk, particularly if the twins are of like sex. To read the article, go to www.well.ox.ac.uk/~tprice/papers/adc2002.pdf.

Premature Rupture of Membranes

Morales WJ and Lazar AJ. Expectant management of rupture of membranes at term. South Med J 1986; 79(8): 955–958.

Women with term uncomplicated pregnancies (including women with previous cesarean) and PROM who were not in labor were randomly assigned to expectant management (monitoring for infection or fetal distress) (N=167) or induction (N=150). No digital exams were done until active labor. Most (85%) began labor within 48 hours. Women randomized to induction had internal electronic fetal monitoring and pressure catheter. "Failed induction" was defined as failure to enter active-phase labor after 12 hours of regular contractions.

The cesarean rate was 7% for women managed expectantly compared with 21% for induced women. No cesarean was done for failure to progress in expectantly managed multiparas versus a 15% cesarean rate for this cause in induced multiparas. Infection rates after cesarean section (24% versus 5% [no p value]) reflected the "well-documented significant increase in postpartum endometritis after abdominal delivery." Intrapartum infection and endometritis rates after vaginal birth were increased in the induced population (12% versus 4%, p <0.01). [Why? Did the internal monitor lead and catheter provide a route for ascending infection? Does induction predispose to infection?] No infant in either group was infected. Group B Streptococcus was isolated in 20% of cervical cultures. [I do not know if this prevalence is typical.] This resulted in 20 colonized infants because standard culturing takes two days, longer than the latency period of most women with PROM. No cases of neonatal infection occurred, but Group B Streptococcus is still a danger because although the infection rate is low (2–4/1000), the mortality rate is 50%. A "rapid latex particle agglutination test" is recommended to detect Group B Streptococcus antigen. If the test is positive, labor should be induced and prophylactic antibiotics given. "These findings...support the observation that, contrary to previously accepted belief, prolonged interval between rupture of membranes and delivery does not increase the maternal and neonatal infection rate. Rather, with PROM the interval from digital examination to delivery is the critical parameter in the incidence of infection."

Henci Goer,
Obstetric Myths versus Research Realities, Bergin and Garvey 1995. Bracketed comments are the author's.

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Forum Talk

My partner...is dealing with a VBAC mom who has diabetes (juvenile). Doctor wants to induce labour and is already talking about it before she is due.... What are the woman's risks, being diabetic...and a VBAC?... Any thoughts of how you would treat, or would you treat?



Question of the Week

Q: I was supposed to have a homebirth and ended up having a c-section because she was breech. When my midwife looked at the afterbirth she said the umbilical cord was short so the baby wasn't able to turn around to be born naturally at home. I'm puzzled why the cord was too short. I maintain a vegan diet. My entire pregnancy was very healthy, and my daughter weighed 8 lbs 12 oz at birth.

— Sue Gallant

SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line.

Question of the Week Responses

Q: I am a student midwife trying to find out what to do about PROM. I've researched it and everyone seems to have a different opinion! Some authors say to monitor closely for an infection, some say to try to induce labor, and some say to not do anything—the mother can go even four weeks with no danger at all.

— Anon.

A: What to do depends a lot on where the mother is. If she is in an unfamiliar place, especially a hospital, she is very likely to contract an infection. If she remains home, avoids tub baths, intercourse, vaginal exams, etc., she is very unlikely to develop an infection. It is a good idea to have her monitor her temperature, though. If it is a small leak and labor doesn't start, there's a good chance her amniotic sac will reseal itself. I had a client whose water broke a week before she went into labor, and it resealed. A few days later it broke again, but she didn't go into labor until two days later. She remained home until her contractions were less than two minutes apart, then headed to the hospital. At home she had enjoyed using the hot tub once active labor was established. It got her to transition quickly, so her labor was able to progress well without having to be in the hospital and putting herself at risk for an infection. She never developed an infection.

— Abbie Thomas, CD(DONA), CLD

A: 1) The questioner seems to assume that induction could potentially be safe. Some women have PROM before 30 weeks and little research has been done about them. Induction seems mad unless the intention is to terminate the pregnancy. In cases of early PROM the obvious approach would be to "watch and wait," using ultrasound to assess fetal distress/development. If labour does not begin naturally, waters do not return to normal, and fetal condition appears poor, counsel the parents to help them come to a decision about whether to terminate.

2) A substantial amount of evidence shows many women can continue with a pregnancy after waters have broken at 30 weeks plus. The common sense approach here should be to look for signs of infection or fetal distress until the waters return to normal or labour begins spontaneously. Any rush to induce should be weighed carefully—there may be a risk of infection as a result of waiting, but there will certainly be a risk of long-term harm to the baby if delivered before full term.

As a general point, the majority of midwives and doctors I have spoken with seem to want to rush to induce in order to be "safe." What they seem to mean is that they want to avoid the risk of a lawsuit stemming from inaction. In fact, by failing to weigh the risks adequately and favouring action over cautious and watchful inaction, they may be doing much more harm than good.

— Anon.

A: Take great care to prevent PROM by emphasizing hydration [30 ml/klg per day], watch for signs and symptoms of infection [primarily UTI], and maintain good nutrition. If the "house isn't good," PROM is the beginning of preterm labor. If pregnancy is far enough advanced to expect labor to begin, [35 or 36 weeks], do nothing. Encourage good hygiene, nothing in the vagina (no vaginal checks!), and wait. Take maternal temperature every 4 hours and watch for mom "not feeling well." She will usually labor in 24–36 hours. If babe is not viable, do all of the above and wait. Explain to the parents that she may abort. Be hopeful and supportive because the leak may seal over with no problems later. I have always felt if I do nothing and the outcome is poor, the parents and the midwife will feel better than if more had been done.

Take great care to prevent PROM by emphasizing hydration [30 ml/klg per day], watch for signs and symptoms of infection [primarily UTI], and maintain good nutrition. If the "house isn't good," PROM is the beginning of preterm labor. If pregnancy is far enough advanced to expect labor to begin, [35 or 36 weeks], do nothing. Encourage good hygiene, nothing in the vagina (no vaginal checks!), and wait. Take maternal temperature every 4 hours and watch for mom "not feeling well." She will usually labor in 24–36 hours. If babe is not viable, do all of the above and wait. Explain to the parents that she may abort. Be hopeful and supportive because the leak may seal over with no problems later. I have always felt if I do nothing and the outcome is poor, the parents and the midwife will feel better than if more had been done.

After 48 hours, I usually encourage labor. Use warm castor oil as a compress on lower back and lower abdomen. I use a labor support herbal tincture. I soak feet in a hot bath with cayenne pepper as hot as can be tolerated, then rub feet gently with olive oil or more castor oil. Watch for infection closely because babies don't tolerate infection well, during labor or after birth. Monitor this baby very closely. If infection develops, transport. Most importantly, pray.

— Claudia Toms

A: I am a Bradley Method instructor and doula. Recently the water of one of my students broke at 32 weeks gestation. she was a longstanding Type II diabetic with an insulin pump, excellent diet. Her OB gave her steroids for lung maturity and put her on magnesium sulfate for 48 hours (not sure she needed the mag.—she was having no contractions during that time). She remained in the hospital for seven days after the rupture, then was discharged with instructions to watch for signs of infection and labor and pretty much stay home. She had weekly ultrasounds to assess fluid levels. She drank plenty of water, so her fluid levels stayed acceptable (she had 7 or higher; recent research indicates 5 or higher is fine). She went into labor at 35 weeks and delivered a healthy 6 lb baby boy who needed no special care.

I can only imagine the agony of a NICU stay if her OB had induced labor rather than allow the time for accelerated lung development. A client's water broke at 35 weeks, and despite having no signs of labor, her OB insisted on an immediate c-section since the baby was breech. The baby spent 10 days in the NICU, and breastfeeding was compromised by hospital procedures (mom pumped for three months until the baby spontaneously latched on one day).

— Jenn Riedy

Homebirth twins [Issue 5:11]:

I also had homebirth twins. I would encourage you to remember that twins are a blessing, not an emergency waiting to happen. I hope you can be surrounded by people who can help you hold this image for you and your babies.

It's important to get enough calories, protein, and iron foods. But my biggest recommendation is to plan your postpartum so that you can breastfeed the babies on demand while getting some rest and connecting with your other children. I found that my emotional health depended on my feeling that my twins were receiving the same kind of responsive, loving care that I gave my single children. It truly takes a village to accomplish this.


Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Please indicate the topic of discussion in the subject line or in the message.

Midwifery Today Magazine Question of the Quarter

Theme for Issue No. 67: Fear in Midwifery and Birth
Question of the Quarter: What do you do to overcome your fears in midwifery and/or birth?

Please submit your response by June 22, 2003 to mgeditor@midwiferytoday.com. (All responses are subject to editing for space and style.)

With Woman

by Gloria Lemay, compiled by Leilah McCracken

Progress in VBAC Birth

Women who are planning a VBAC have emotions and fears about giving birth that are justifiably heightened. They have experienced major abdominal surgery and all the problems that follow. The VBAC client will require more time and patience than a midwife's or doula's other clients.

If the woman has dilated past five centimeters in the first birth, plan for it to be fairly fast, like any second baby. If the woman has not gone into the birth process or not dilated past five the first time, that's all right—she'll still give birth vaginally, but have extra attendants on call to bring fresh energy if the others get discouraged or tired. Plan for it to be like going to two births in a row.

The point that the woman reached in her first birth is often a psychological hurdle for her. If she dilated to six centimeters the first time, the news that she is seven or eight will be a relief and a breakthrough. One of my clients, a minister's wife, said over and over again in her pregnancy: "I just want to feel what pushing is. If I only get to push, I'll be happy. I just want to know what other women mean when they say they had to push." She'd had a Bandl's ring in the first birth process, and the cesarean was done at five centimeters. We were praying that the complication wouldn't repeat. She dilated smoothly and began to push. With each push she would exclaim, "Thank you Jesus, thank you Jesus!" What a wonder it was to watch her push out the baby, a girl she named Faith.

Gloria Lemay is a private birth attendant in Vancouver, BC, and is a contributing expert at BirthLove, www.birthlove.com
Read more from Gloria on Midwifery Today's website: “Pushing for First-Time Moms”
Note: This article is also published online in French and Spanish.

Exclusively on the BirthLove Site

Gloria Lemay, celebrated midwife and teacher, is offering advanced online doula education. She covers a vast amount of topics that today's doulas and student midwives need to know: herpes simplex II, medical terminology, pediatric exam of the newborn, prenatal diagnostic tests, business and professionalism, pregnancy-induced hypertension, gestational diabetes and so much more. The course is free for all BirthLove members. Check it out!


Someone asked if anyone has an English version of the legislation regulating midwifery practice in The Netherlands and maternal morbidity and mortality statistics for The Netherlands [Issue 5:10]. I do not think there is an English language version of the law, but there is an English version of the guidelines that regulate the relationship between midwives and gynecologists at:

See "Birth by Design" for stats on mortality and morbidity in several European countries (and the US and Canada). Also my forthcoming book, A Pleasing Birth (Temple University Press, 2004), describes the Dutch maternity care system in great detail.


Irregular heartbeat [Issue 5:09]:

Several of my babies had irregular heartbeats during labor. Only one of them had problems afterward, lack of a specific adrenal hormone. The others were healthy and fine. Often irregular heartbeat is caused by a lack of B vitamins. I have found Cataplex B by Standard Process to be the best for helping with the condition. If the mother is having severe heart palpitations, it could be one of two things:

  1. Hyperthyroid. Rapid heartbeat and heart palpitations, often wake up in the middle of the night and are unable to go back to sleep, and trouble gaining weight. The best treatment I have found is Thytrophin PMG and Iodomere from Standard Process.
  2. Adrenal problem. Other symptoms include tiredness, light headedness, especially if you stand up quickly, rapid heartbeat and feeling your heart is going to beat right out of your chest. Sometimes it can even cause panic attacks when you respond too much to the symptoms. The best way to check for it is do a lying and standing blood pressure check. You must lie down for at least five minutes before taking your blood pressure. Then stand up and retake the blood pressure immediately. There should only be a 4-point difference between the two numbers. If there is more, your adrenals are not working as they should. The best treatment I have found is Drenatrophin PMG and Trace Minerals from Standard Process. Standard Process products are not sold over the counter but can be purchased through any healthcare professional, most often chiropractors.

Judy, CPM

Editor's Note: Only letters sent to the E-News official e-mail address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.


Michigan School of Traditional Midwifery 6th annual Midwifery Skills Workshop, August 17–20, 2003. Early registration discount extended through June 1, 2003—$335.00, $395 thereafter. Registration includes lodging, meals, workshop materials. For more information visit www.traditionalmidwife.com or call 989-736-6583.

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