May 21, 1999
Volume 1, Issue 21
Midwifery Today E-News
“Premature Rupture of Membranes (PROM)”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) The Problems of PROM
5) Question of the Week
6) Question of the Week Responses
7) Switchboard
8) How I Became a Midwife
9) Midwifery Today Conferences 2000
10) Coming E-News Themes

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1) Quote of the Week:

"Life shrinks or expands in proportion to one's courage."

- Anais Nin

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2) The Art of Midwifery

I incorporate the amniotic fluid thrill check at each prenatal visit past 34 weeks so I have a baseline for each woman. When a woman's water breaks prematurely, I have strict protocols, and among them is to check daily for fluid thrill. Have the woman relax in a semi-sitting or almost flat position. Put your hand on one side of her abdomen, flat against it. With your other hand, very gently flick your finger against her tummy. You should be able to feel the ripple of the water against the hand that is flat on her tummy. Do this all around, feeling for pockets of water, until you have a general sense of how much water is around the baby.

- Patty Sherman, Midwifery Today Issue 31

If a primip thinks she has ruptured membranes, find out when she took your class on labor with ruptured membranes. Odds are she has it "on the brain" because you emphasized it in class, and wants to make sure the mucus she is seeing is not ruptured membranes. Once you check these women, you'll find that most of them don't have ROM.

- Sister Angela Murdaugh, CNM, Wisdom of the Midwives: Tricks of the Trade Vol. II

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At Midwifery Today, we have lots of tricks up our sleeves! Purchase our two volumes of Tricks of the Trade and you'll see what we mean: Save $5 when you purchase both Tricks of The Trade. Volume I and  Volume II. Only $40 plus shipping! Call today to order: 800-743-0974. Please
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3) News Flashes

Management for PROM

A retrospective cohort study of women delivering at two New York City hospitals between 1988 and 1990 was conducted to assess the outcomes of two kinds of management for PROM. The patient populations of the two hospitals were similar. One institution practiced induction of labor if spontaneous labor had not begun within 12 hours of rupture of the bag of waters; the other hospital, with nurse-midwifery management, admitted the women but did not induce unless signs of infection occurred.
The records of 909 women with PROM at term were reviewed. Those who were managed conservatively experienced one-third the rate of cesarean sections, with no increase in intrauterine or neonatal infections. Though the expectant management women spent as long as five days in the hospital, the average hospital stay was only a half-day longer than those who were managed with early induction.

- Journal of Nurse-Midwifery, Vol. 38 No. 3, May/June 1993

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4) The Problems of PROM

A study of the association between time of rupture and time of day found that not all cases of PROM are alike [Cooperstock, England and Wolfe in Obstet Gynecol 1987; 69(6)]. Women who began spontaneous labor within a day or so after membrane rupture were highly likely to have had membranes rupture late at night. Women with infected membranes did not show this circadian rhythm. Neither did women who were not infected but who did not begin labor within that time frame. Observing that labor onset shows the identical circadian pattern, the authors theorized that in the first case, hormones regulating the onset of labor were probably responsible. The second case suggests that infection precipitated membrane rupture. In the third case, some as yet unknown mechanism appeared to be at work.

The study illuminates the problems of PROM. It explains why inductions often fail: women whose uteruses are not primed for labor--that is, women in categories two and three--will not labor effectively no matter how much oxytocin is given [Steer, Carter and Beard, Br J Obstet Gynaecol 1985; 92].

It explains the seeming relationship between length of time postrupture and infection. Women in the second category (comprising very few term pregnancies) have an incipient infection. They are not ready to labor and will have a long latency period, which will allow that infection to blossom. In women of the third category, vaginal exams and internal monitoring start infective processes that, as with the second case, have time to take hold because these women too have a long latency period.

Finally, it explains why almost all studies of PROM management at term done since the 1960s show major benefits for expectant management (watching and waiting) in women with no signs of infection: women who are not infected are not likely to develop infections--provided people keep their fingers and monitoring devices out of the vagina--and will do best if left alone.

Not only does leaving women alone do best for most women, but standard management could hardly do worse if it were intentionally designed that way. Standard management causes infections and fetal distress, the very things it is supposed to prevent.

One might think that the deleterious effects of the 24-hour rule have been so thoroughly documented that expectant management would replace it. But doing nothing is anathema to mainstream obstetricians, so the expense and frustration of prolonged antenatal admission for observation became justification for induction, even though waiting for labor does not extend hospital stay by much [see above].

- Henci Goer, Obstetric Myths Versus
Research Realities: A Guide to the Medical Literature

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Learn more from these Midwifery Today issues:

No. 18, The Challenging Birth (Regular price $7.00)
No. 31, First Stage (Regular price: $7.00)
No. 44, Trusting Birth (Regular price: $10.00)

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5) Question of the Week: What is your favorite technique for educating the public about midwifery and natural birth? (repeated from last week)
Send your response to:
mtensubmit@midwiferytoday.com

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6) Question of the Week Responses

Q: What is your protocol for premature rupture of membranes? Why?

I do no vaginals--I really do feel this is a causative problem of infection. I will watch for awhile and if after about 4 hours nothing is happening I will start the bag of tricks, herbs, homeopathy, castor oil and/or enemas.

- Ollie Anne Hamilton, LDEM, CPM

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If the fluid is not clear or there is bleeding or fever, or reduced fetal movement, or any suspicion of cord prolapse, I see the woman immediately and consider admission to the hospital. In most cases, I see the woman to check heart tones, but depending on the time of day, I may defer this. If the woman is known to carry Group B Strep, I advise her to go to the hospital for immediate induction and IV antibiotics--most do and some don't!

For planned hospital births, I usually wait about 24 hours (depending on the time of day) and if there is no labor, I recommend 100 mcg cytotec orally or tincture of blue and black cohosh (1/2 dropper every half hour), whichever the mother prefers. If I know the baby was at zero station and the woman had started to thin and dilate before the rupture, I also offer her the option of 2 oz. castor oil well-mixed with 2 oz of the beverage of her choice (usually either a soda or apricot nectar) followed by more of the beverage.

I don't insist on any of this, but if the woman wants to wait longer, I have her sign an informed consent in the chart. I don't do labor checks until it appears that labor is well on its way.

For out-of-hospital births, I wait up to 48 hours with mothers and babies who are healthy and want to wait. I offer all mothers the option of immediate hospital induction, explaining that physicians in our area recommend this and why they do, and tell them to call me with any sensation of cord prolapse, reduced fetal movement, bleeding, colored fluid, or fever.

- Cynthia Flynn, CNM, PhD

Recently I had a situation with an Amish client whose membranes had ruptured three days before onset of labor. When I got to her house for a prenatal visit, she told me she was sure her membranes had ruptured, and I confirmed it with an amnicator. She told me she had tried castor oil and nipple stimulation the previous day to get labor started. She was full term and there were no signs of infection, but she was having no contractions. I ruled out a slow leak that might be inclined to close up. There still was plenty of (clear) fluid coming out every once in a while. We agreed to go in to the hospital. I called ahead, and the doctor on call happened to be one with whom I have a good working relationship (she wants to come to a homebirth with me to see what it's like). She told us to come on in, and that I could just plan on delivering my client's baby there. My client seemed relieved that the baby would come soon, and was very glad that I would be able to continue care. On the way to the hospital (40 minutes away) she started having contractions, so we stopped at my house to see what they would do, and maybe have some dinner. Three hours later, a healthy baby girl was born in my bed!

I have noticed that Amish women seem to have a higher rate of premature rupture (>12 hours before onset of labor).Perinatal infection does not seem to be a problem in the communities I and other midwives work in.

- P.B.

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Q: At what rate in your practice do babies pass meconium before birth, not counting breeches? Are your statistics from a homebirth practice or hospital practice? Also tell us how you handle the problem of meconium.

I have an active homebirth practice and I do 2-10 births per month and attend an average of 50 births per year. In my practice the incidence of meconium comes in spurts, just like all complications--you might have a run of fetal distress, then heavy bleeding, next meconium. Out of the last ten births I attended, I had four babies with meconium. That sounds like a high percentage, but I might not see any meconium for the next 6 months to a year. Of the last four, the first baby was 2 and a half weeks overdue, cord wrapped twice around the chest and three times around the waist, plus shoulder dystocia, and yes, mom also hemorrhaged. Birth number two was a castor oil induction, birth number three was a first time mom who was scared and a week over EDC, and for birth number four, there was no rhyme or reason for meconium being passed. I realize that babies pass meconium when they are under stress, and I also feel sometimes they can be scared by something, or someone has scared them, like a frightened mom.

I am NRP certified, so I know the protocol for suctioning on the perineum with a DeLee trap. However, I have found that if I treat all my babies the same, the meconium births are not suctioned any more than the normal deliveries. I do not suction my babies routinely; I feel this procedure is a man-made thing. When I deliver my babies, I turn them over onto their stomachs with their heads down and brush up their back and they will spit up what they need to. With suctioning of any kind, mucous is forced down the throat as well as meconium. Unless you plan to intubate and suction with a vacuum tube like in the hospital, the only meconium you will be suctioning will be down the esophagus. This is traumatic to the baby and throws him into the vagal response, which increases his respiration and heart rate at a critical time when he should be stabilizing. I find that most of the meconium babies will spit up a large mucous plug, tinged with meconium within the first 6-8 hours after birth. If baby's respiration is slightly elevated from normal, a small amount of sterile water can be given to him and he will soon spit up a large mucous plug and be just fine. If you are concerned that baby may have aspirated meconium, about the only thing that you can do is watch for the signs of infection if you do not plan to intubate and suction.

- Cathy O'Bryant CPM

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7) Switchboard

My water began leaking at 37 weeks. My midwife recommended waiting, walking, castor oil to induce labor. I took no baths, and had no vaginal exams to reduce the chance of infection. After almost 72 hours with no labor, I was finally transported and induced with Pitocin. But I had no infection, and we all felt perfectly comfortable waiting this long with ruptured membranes. Others have been appalled at the waters being broken for so long. I'd like to see this issue explored more, as many people believe that the baby must be born immediately after membranes rupture.

- Angie Robinson

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I am a post graduate student undertaking a research module in midwifery. Please could readers send me any information that may assist me in critical evaluation of qualitative and quantitative research?

- Leola Taylor,
MTa9128150@aol.com

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I specialize in urogynecology and pelvic reconstructive surgery, and am trying to develop rational guidelines for managing birth in ways to prevent incontinence (fecal and urinary) and pelvic organ prolapse. Do midwives have suggestions?

- David Chapin, MD

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I responded to Dawn Robinson-Walsh, dawnaur@dircon.co.uk, a UK journalist specialising in pregnancy and birth [Issue 20]. She immediately responded with questions from the UK but was interested in some of the reactions I had found while doing my work in Mexico and South America. How far is it from California to the UK? Just a click away! Thanks not only for that opportunity for making the connection but your continued excellence with the journal.

In response to Rose Evans, Issue 20], think about exposing the women to wonderful role modeling such as can be found in my two birth videos, Dar A Luz Con Amor (Giving Birth with Love) or the one with English narration, Yes! You Can. Check out my website for more information:
http://www.birthprep.com My c-section rate & medication rate is about one-third what the hospital average is.

- Linda B. Jenkins,RN, BSN, PHN, ACCE jenxl@aol.com http://www.birthprep.com

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Reminder: CIMS Workshop

Learn more about mother-friendly care at this year's ACNM Annual Meeting in Orlando, Florida. On Saturday May 29 from 12:45 to 4:30 p.m. participants in an interactive workshop titled Making Mother Friendly Care a Reality:

Birth Professionals as Agents of Change will receive in depth education on the development of the document, the scientific evidence for each of the ten steps, options for utilization of the document in specific work settings, an overview on the dynamics of change theory and an opportunity to interact and network with other birthing professionals. Cost of the workshop is $45. For more information or to receive a registration form, contact: Donna Haegele at dhaegele@acnm.org or call 202-728-9860.

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Midwifery Today E-News is not staffed to handle requests from people who are trying to find a midwife. However, Online Birth Center News, a free birth activist newsletter, has a Looking for Midwife section. Send your request to djz@efn.org, with OBCNEWS ITEM in the subject. If you'd like to subscribe to the OBCNEWS, write to the same address and ask to be added to the subscription list.

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8) How I Became a Midwife

I am almost a midwife, in my final year of study as a direct-entry midwife (DEM) in New Zealand and will, by the end of the year, have a Bachelor of Health Science Midwifery. At thirty-seven years old I decided to have my third child with midwifery-only care at home in Australia. I had to pay $1,000 for it but it was worth every dollar to be able to have my son born at home. He was a breech birth, weighed 8 lb. 4 oz and there were no complications! At that time Jane, my midwife, said "you'd make a lovely midwife." The seed was sown, and would bloom when I returned to New Zealand. A few years later, with midwifery autonomy and the DEM degrees, my dream has been realised.

I am looking forward to working with women and their families and being able to be a part of the movement to normalise the childbirth experience.

- Maryanne V.

Write and tell us how you became a birth practitioner! Send your submission to to mtensubmit@midwiferytoday.com

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9) Midwifery Today Conferences 2000

Philadelphia, Pennsylvania USA will be the setting for a domestic conference slated for March 23-27, 2000. One of the highlights will be an entire day focused on midwifery education, with intensives for educators, interactive discussion on the goals of midwifery education, assessing competence, key issues in education, apprenticeship, mentorship, and inquiry-based learning.

A Midwifery Today international conference has been scheduled for Sept. 28-Oct. 2, 2000 in Aachen, Germany. Plan to meet midwives from all over Europe as we come together to heal our fears and carry midwifery and birthing powerfully into the next century. In addition, we will plan how to keep midwifery an independent and autonomous profession worldwide.
In order to learn from the most experienced teachers, Midwifery Today is searching the world over to find highly experienced midwives who will share their decades of knowledge with you. If you would like to recommend one of these world treasures, please let us know.

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10) Coming E-News Themes

Coming issues of Midwifery Today E-News will carry the following themes.

You are enthusiastically invited to write articles, make comments, tell stories, send techniques, ask questions, write letters or news items related to these themes:

- doulas (May 28)
- induction (June 4)
- educating the public (June 11)
- episiotomy (June 18)
- Group B Strep (July 9)
- epidurals
- breastfeeding
- waterbirth
- breech birth
- nutrition
- homebirth

We look forward to hearing from you very soon! Send your submissions to mtensubmit@midwiferytoday.com. Some themes will be duplicated over time, so your submission may be filed for later use.


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