When your waters break prematurely!

When your waters break prematurely


I was 25 weeks pregnant. For readers who are not currently pregnant — that’s the second trimester, more than three months away from the due date. The baby weighs around a pound and a half and is definitely not ready to be born. The mom has just started bumping out into obvious pregnancy and has likely not bought baby stuff, chosen a name, or even toured the hospital yet because she has more than a third of the pregnancy yet to go!

I suddenly started leaking clear liquid down my leg. I was so confused — this couldn’t possibly be my water breaking… but the liquid just kept gushing out, so I called my ObGyn’s pregnancy hotline and the nurse told me to rush to the hospital.

SO, WHAT HAPPENS IF YOUR WATERS BREAK EARLY (PPROM)?


During pregnancy, the unborn baby develops inside a bag of fluid known as the ‘amniotic sac’, which helps to cushion and protect the baby. When contractions start during labor, the membranes that make up the amniotic sac are usually broken by the baby’s head being forced downwards and the amniotic fluid (the ‘waters’) leak out of the vagina. In a small number of pregnancies (around 1 in 50), the waters break before 37 weeks of pregnancy – this is known as ‘premature, pre-term rupture of membrane's (PPROM).

How this is managed, and what it means for you and your baby, will depend on how early in your pregnancy your waters break.

WHY DO WATERS BREAK EARLY?


Factors linked to the waters breaking early include having had a previous preterm birth, vaginal bleeding, cigarette smoking during pregnancy, a severe infection of the bladder or a sexually transmitted infection, such as chlamydia. PPROM is also more common in women who are carrying twins or triplets or who have had an amniocentesis. In many cases, however, there is no obvious reason why the waters have broken early.

WHAT WILL HAPPEN IF MY WATERS BREAK EARLY?


If your waters have broken early, you will feel it as leakage of fluid from your vagina, but this could be just a trickle or it might be a gush of water. Depending on the flow, you might be able to use a sanitary towel to catch it, or you might need a towel. If the fluid is greenish or brown, you should go to the maternity unit as soon as possible, as you may have an infection. Otherwise, you should contact your midwife or hospital for advice straight away. A vaginal examination will be carried out to confirm that your waters have broken.

If confirmed, you will be admitted for assessment. Your baby’s heartbeat will be checked, and you will be tested for signs of infection by regular checks of your temperature and pulse rate. You will also have tests such as a vaginal swab and blood and urine tests.

Most women whose waters break early will go into labor shortly afterward. If this happens before 23 weeks of pregnancy, then sadly the baby is unlikely to survive as it will not have had enough time to develop in the womb.

OUR EXPERT SAYS...

If you do not go into labor, then having low levels of amniotic fluid this early in pregnancy may still affect your baby’s development and can increase the chances of miscarriage or stillbirth.

If you go into labor after 24 weeks then your baby will need special care when it is born. If your local hospital does not have the facilities and experience for dealing with premature babies, you will be transferred to another hospital where your baby can receive the care he or she needs.

If you do not go into labor after your waters break, then you may still be kept in hospital for 48-72 hours before being allowed home. If this happens, labor will probably be induced straight away to reduce the risk to you and your baby.

The risk of infection is lower after the first couple of days, but after you are discharged from the hospital you will be asked to measure your temperature regularly and look for discharge from the vagina. If you have a temperature of 37.5 or above, have any blood or colored or smelly discharge from your vagina, if your baby’s movements slow down or stop, or if you have any abdominal pain or contractions, you should contact your midwife and return to the hospital immediately. You will also be asked to attend the clinic every week to be checked for signs of infection, and you should not have sexual intercourse until after your baby has been delivered. Extra scans will be scheduled every fortnight to check your baby’s growth.

WHAT ARE THE TREATMENT OPTIONS AFTER PPROM?


If you go into labor after your waters have broken early, then unfortunately there is no treatment that can prevent it. If your waters break early, your baby is likely to be born prematurely, even if you don’t immediately go into labor. Babies born before 37 weeks may lack a substance called surfactant in their lungs, which helps them to breathe normally. Taking two doses of steroids 24 hours apart, either as tablets or injections, can help your baby produce more surfactant while it is still in the womb.

If you go into premature labor between 24 and 29 weeks of pregnancy, you will be offered magnesium via a drip, which can help your baby's brain to develop and prevent problems such as cerebral palsy. You may also be offered magnesium sulphate if you go into labor between 30 and 34 weeks.

To reduce the risk of infection after your waters break early, you are likely to be asked to take antibiotic tablets for a week. While you are likely to continue to have low levels of amniotic fluid for the rest of your pregnancy, as long as you are monitored carefully by your healthcare team this is unlikely to have any negative effects on your baby, even if the levels are very low.

LABOUR AND BIRTH AFTER PPROM


If you go into labor immediately after your waters have broken and your baby is in the normal, head-first position, then labor and vaginal birth can take place as usual. Your baby’s heartbeat will be monitored throughout labor and birth to make sure they are not in distress. If the baby is in the breech (feet first) position or shows any sign of distress or infection, then a Caesarean section is likely.

If you do not go into labor straight away and are discharged from the hospital, then you should continue with your normal plan for antenatal care with your midwife, GP, and consultant. You will also be seen by a specialist in the antenatal clinic to discuss a plan for your baby’s birth. To reduce the risk of infection, labor is usually induced when the baby reaches term (37 weeks). The exact timing will be discussed individually with each pregnant woman.

WILL PPROM AFFECT MY FUTURE PREGNANCIES?


Having PPROM increases your risk of having a preterm birth if you become pregnant again. If your waters have broken early in a previous pregnancy, you will be placed under the care of a specialist team if you become pregnant again and may be offered treatment to prevent early labor, as described above.

...NOW, BACK TO MY STORY


Here’s what I wish I had known as I hopped in the car. If your water just broke and you are frantically googling and came across this article while someone drives you to the hospital, I hope this helps you.

1. It’s not over.


On my way to the hospital, I cried. I thought it was basically over, that because my water broke, it was a sure thing that I was going to give birth within a day or two and my 25-week fetus would not survive outside the womb. Turns out I was wrong on both counts.

In fact, you can go for weeks or even months without giving birth after your water breaks! Who knew!?

Many women will go into labor within 48 hours of water breaking early (premature rupture of membranes). But antibiotics can help delay labor. About half of people make it to 12 days. And around one-quarter make it more than 6 weeks!

2. Every day you can put off labor helps your baby.


I initially thought that babies born in the second trimester were most likely to die or, if they survived, to have significant disabilities. That is true if you give birth at 22 weeks, but not true at 27. Every day you can keep that baby inside you is better for the baby.

The studies all agree that survival and long-term health improve with each week of gestational age. For example, here is a study of babies born between 22–28 weeks gestation in the early 2000s showing that only 6% of the 22-weekers survived, whereas 92% of babies born at 28 weeks did. Here is a study looking at rates of major disabilities at five years old, again showing that things get better every week from 22 to 27 weeks gestation.

3. Go to the right hospital.


If you are less than 32 weeks pregnant, you need a Level III or Level IV NICU. Call the hospital you are headed towards and make sure that’s what they have. If they have only Level I or Level II, they will transfer you to another hospital after you arrive. Except that once you step foot in the hospital, you lose a lot of freedom. I learned this the hard way. Even though my husband had driven me to the hospital, once they told me I had to go elsewhere, they wouldn’t let us walk back out and drive there. Now I had to go in the ambulance, which took more time and cost us thousands of dollars. We also wasted time with the first hospital running a bunch of tests that they just re-did at the new hospital.

Save yourself time, money, and heartache by calling first and making sure you get to a hospital with the right NICU.

4. Find out the hospital’s policy about resuscitation and decide what you want to do.


The hospital immediately gave me corticosteroid shots. The shots briefly hasten the baby’s lung development and their effect peaks about 48 hours after they are given and wears off in about a week. If you don’t give birth within a week, they will give you one more round of shots when they think you might go into labor. But they won’t give more than two rounds of shots because that could have negative effects. So it is a delicate game to try to anticipate labor and give the shots at least 2 days but not more than 7 days in advance.

After researching outcomes and seeing it was still likely the baby would either die or be severely disabled if born before 26 weeks, my partner and I decided it would be best to let nature take its course if the baby was born before 26 weeks (we didn’t think we should resuscitate). Because outcomes are a bit dicey before 26 weeks, the hospital will let parents decide whether to resuscitate. However, they didn’t tell us that and immediately administered corticosteroids without discussion. Had we understood the timing and our resuscitation decisions, we would have asked to hold off on the steroids until I reached 26 weeks. As it was, I got the shots at 25 weeks and he was born at 27 weeks after the corticosteroids had lost their benefits.

ASAP, your family should ask yourselves: Could we, should we, must we resuscitate if this baby is born at X weeks? Then make a decision about corticosteroid shots accordingly.

Here were my hospital’s guidelines about resuscitation based on weeks of gestation.
  • <22 weeks. Will not resuscitate.
  • <23 weeks. Strongly discourage resuscitation.
  • 23–24 weeks. Will not resuscitate unless parent requests.
  • 25 weeks. Will resuscitate unless parent objects.
  • ≥26 weeks. Will resuscitate even over parental objection.

If you are so early that you would not want to resuscitate and your hospital will let you make that call, then ask to hold off on the corticosteroids until you get to within 48 hours of the time when you would resuscitate.

5. There is not a lot the doctors can do for you.


The hospital is bustling with high-tech equipment and highly-trained staff and I was hooked to all manner of tubes and beeping machines. It seems like all of this diagnostic hubbub would be accompanied by a similarly dizzying array of nuanced treatment options. But for all the fancy equipment and sky-high medical bills, there is actually very little the medical profession can do when waters break early.

The main hammer the doctors have is to get the baby out faster, either by inducing labor or sending you for a c-section. They are continuously monitoring you and the baby to make one decision: do we need to get that baby out now? The doctors are gathering a lot of information, but ultimately, you can count on one hand the things they can actually do:

(Remember, I am just one person who experienced this and I have no medical training).
  • Give you antibiotics through an IV ASAP after your water breaks. This is critical for preventing infection to both you and the baby, and can help delay labor.
  • Give you corticosteroid shots, ideally 48 hours before baby is born. Two shots, 24 hours apart, can help the baby’s lungs develop a bit more before birth. My doctors told me the maximum benefit comes 48 hours after the first shot and the benefits largely wear off a week after the first shot. If you don’t go into labor within two weeks, they will give you one more round (two shots) when they think you are getting close to labor.
  • Give you magnesium sulfate through an IV to delay labor slightly and to improve the health of the baby.
  • Induce labor or perform a c-section to prevent infection from impacting you or your baby. The hospital will likely monitor your temperature, heart rate and blood pressure and the baby’s heartbeat either continuously or every few hours, and will likely press on your belly every day. All these things are attempting to detect infection. If they detect infection, the only thing they can do is get the baby out before the infection spreads. That means they will induce labor (if the baby is head down and the risk is not immediate) or perform a c-section (if the baby is not in a position or they feel they can’t wait for you to go through labor).

6. Premature birth is fairly common but mostly mysterious to the medical profession.


About 1 in every 10 babies is born prematurely (before 37 weeks). That’s not nothing. Premature birth is the biggest reason for babies dying and premature rupture of membranes (water breaking early) is a major reason for premature births.

Yet doctors and researchers know very little about what causes water to break, or how to stop it. The two big theories my doctors explained to me were that something is just wrong with the sac from the outset so it was only a matter of time before it broke, or that infection early in the pregnancy weakens it.

Yet, when I had two UTIs early in my pregnancy, my doctors were totally blase about it. If infection could cause waters to break early, and waters breaking early is basically a catastrophe for the pregnancy, shouldn’t doctors inject some urgency into dealing with infections in their pregnant patients?

Final word: Nobody expects their water to break early


Or, I guess people carrying twins do, or with other risk factors. But I sure didn’t. I had no risk factors. My first son went way past his due date. I was in complete shock and denial at first. If it happens to you, I hope this article helps.

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