Ruptured membranes after 37 weeks of pregnancy

Although your labour has not yet started, the membranes which contain the fluid around your baby have ruptured, commonly known as ‘the waters have broken’.

This is not unusual and occurs in six to 19% of all pregnancies at term (after 37 completed weeks of pregnancy).

What will happen?

You will need to phone the hospital for advice as soon as you are able to, the contact numbers will be available to you on the front of your hand-held notes.

Usually, you will be invited into the hospital for assessment of both you and your baby’s wellbeing and to discuss with the midwife or doctor your options for the safe birth of your baby. If you are planning a home birth you will need to contact the maternal assessment unit/delivery unit for assessment and care planning in the first instant. When you are first seen by a midwife, either in hospital, or at home, following the possible rupture of the membranes the following will take place.

Please remember as with all procedures it is your choice which course of action you follow. Your midwife will be happy to discuss with you the reasons for each intervention and their possible risks and benefits.

1. The midwife will take a detailed history from you to ascertain if your waters have broken. The midwife will also take your temperature, blood pressure, pulse and respiratory rate; this is so that any signs of infection or deviations from normal can be observed and considered when making plans for the birth.
2. The midwife will also palpate your abdomen to ascertain where the baby is lying in relation to your pelvis and will listen to the baby’s heartbeat.

This can be done either by a handheld doppler, a pinard, (commonly known as a ‘trumpet’ stethoscope) or if the midwife has any concerns, or you have had other risks identified in your pregnancy, an electronic recording of the heart rate known as a ‘trace’ or CTG.

You can also request to have a CTG even if your pregnancy has been low risk and there is no clinical need to do so.

Occasionally if you and the midwife cannot confirm if the waters have broken by the history that you have given, he/she will ask to perform an internal examination using a speculum so that pooling of the water (liquor) can be seen around your cervix. If you’re having a speculum examination, then the midwife will take a swab from your vagina. If you give a very clear history and there is obvious liquor to be seen on your pad or underwear a speculum may not be necessary. You will also be recommended to go to the toilet and swab the lower part of your vagina - a midwife will explain how this should be done. Alternatively, if you feel unable to do this the midwife will be happy to help you with this.

The swab from the vagina is to detect the presence of any bacteria which may increase the chances of your baby becoming unwell from infection, such as Group B streptococcus (GBS). You will not get the results of this straight away; it takes up to two days for the results to come back.

If you have already had a positive swab for GBS in the pregnancy, please tell the midwife so that she can consider this when she discusses your options for the birth with you.

If such bacteria are detected or you have already been swabbed in the pregnancy and have been informed that you have GBS, you will be offered induction of labour at this time, as the risk of infection to your baby may be higher. You will also be advised to start a course of intravenous antibiotics, which are given every four hours, until your baby is born.

You will be given an additional leaflet to inform you about Group B Strep infection if appropriate.

When all of this has been discussed with you and the procedures you consent to have been carried out; you will be given the following choices.

Choice 1: Waiting (expectant management).

If there are no risk factors identified, you may prefer to go home and await events. You can contact maternity assessment line for advice when you feel your labour has started.

By waiting the greater majority of birthing women and people will go into labour without medical intervention within 48 hours of the membranes rupturing.

Statistics show 60% of birthing women and people will do so within 24 hours, 90% within 48 hours and 95 to 98% within 72 hours. If labour has not established within 24 hours you will be offered the option of induction of labour. Induction will definitely be advised within 48 hours with the aim of the birth being achieved within 96 hours of the membranes rupturing.

The time for induction of labour will be discussed with you before you go home and contact details and when to telephone documented in your notes for you to refer to. If you change your mind at any time after discharge, you are welcome to telephone the unit and discuss your options further with the midwife coordinator.

The liquor (‘waters’) will continue to drain until your baby is born. Whilst at home you can bath and shower if you want to, as there is no evidence to support this increases the incidence of infections but having sexual intercourse may increase this risk.

If you choose this option, of waiting, you should contact the hospital immediately if any of the following occur:

1. You feel unwell or have a raised temperature - you will need to take your temperature three or four times a day until delivery, (your midwife will show you how if you are not sure). You will need to call the maternity assessment line if your temperature is 37.5 or more. You can purchase a thermometer from any local chemist store if you do not already have one at home.
2. You experience regular contractions.
3. The amniotic fluid is no longer clear, particularly green or brown or becomes very smelly. Pinky amniotic fluid due to ‘show’ is normal but fresh bleeding is not normal.
4. Your baby has an altered or reduced pattern of movements.
5. You have any queries or concerns.

You may labour and give birth on the Rosie birth centre if you experience ruptured membranes providing the interval from your waters breaking to the onset if labour does not exceed 48 hours. In which case, birth on the delivery unit will be advised.

Choice 2: Stay in hospital and be induced (active management)

You may prefer that your labour is induced as soon as possible.

However, please remember the workload on the delivery unit may not allow this to be undertaken straight away, as there may be other birthing women and people with risk factors who will need care.

The midwife on the unit will liaise with you until a safe and appropriate time for the induction to commence can be made.

You may need to be transferred to the antenatal ward to wait for this.

Sometimes there may be additional risks or complications in your pregnancy which will determine the risk to yourself or your baby (for example previous caesarean section) associated with the time of induction, these will be discussed with you on an individual basis by your midwife or the doctor.

How will labour be induced?

The same methods are used whether you opt for immediate induction or wait to see if labour establishes.

There are two ways to induce the labour. The most appropriate method will be decided by performing a vaginal examination with your consent. The options will then be discussed with you.

The first (and most common) method is to insert a prostaglandin hormone tablet into the vagina to make the cervix ripen (become soft and stretchy) and therefore more receptive to the hormone infusion, should this be necessary. The midwife will need to perform a vaginal examination to insert this gel to make sure that it is in the right place.

The hormone infusion (drip into a vein in the arm) is commenced six hours after the hormone gel in the vagina if regular effective contractions have not started.

The second method is to commence the hormone infusion straight away.

Either way, this is not a quick process, and in some cases can take at least 24 hours.

What are the risks to me and my baby?

The risks and benefits of induction of labour are discussed in the ‘Induction of Labour’ leaflet which you will be given to accompany this information.

There is a small chance of bacteria travelling from the vagina into the uterus causing infection to either you or your baby.

To minimise introducing infections into your womb, internal examinations will only be performed when necessary and kept to a minimum throughout your induction and labour.

You and your baby will be monitored closely throughout for any signs of infection and should there be any concerns the midwife/doctor will discuss this with you, and you may be offered treatment such as antibiotics during the labour.

For your baby, the longer the period of time from membrane rupture to established labour the greater is the likelihood of neonatal infection.

The incidence of serious neonatal infection is 1% compared to 0.5% those with intact membranes.

Currently the neonatologists (doctors who care for the babies) in the Rosie recommend that a minimum stay of 12 hours after birth is advisable in hospital if the time interval from membrane rupture to birth is equal to, or greater than, 18 hours or more, to monitor for any signs of infection in your baby.

The midwives/doctors will be happy to discuss any issues you feel uncertain about and will support you in whatever your decisions.

References

NICE (2014) Intrapartum care: care of the healthy women and their babies during childbirth. Clinical guideline National Collaborating Centre for Women’s and Children’s Health. RCOG Press, London.

The Rosie Hospital Guideline (2017) Prelabour Rupture of membranes (PROM) after 37 weeks Gestation.