Evidence Based Medicine Re: Your Membranes Releasing Prior to Labor Beginning

What does this mean?  The internet offers these definitions:

Definitions of Evidence-based medicine on the Web:

It would benefit you in asking the question of “Why must it be done this way? What would happen if we did it differently? What do the studies indicate regarding this procedure? What if I want something different?”

Today I received an email from a mom whose practice told her in her previous pregnancythat they wanted her come in within two hours of her water breaking. She was full term and GBS-. When she spoke to them about why- they told her their rational was: she was not contracting and had no signs of labor.  Because they only give you 24 hours from your water breaking to have a baby vaginally, they knew she needed to come in and start medication to induce labor. When she came to the hospital, she still showed no signs of contracting and hadn’t dilated so the

decision was made to start Cervidil and then later, Pitocin.

I wonder where the “they only give you 24 hours to have the baby” came from…She asked me if that made sense. I told it it was not evidenced based. There are several practices that go with this protocol: “ Some believe that labor should start within 24 hours or the risk of infection outweighs the risks of induction of labor.

Others feel that the risk of infection remains low for the next 72 hours and waiting gives the benefit of avoiding the ‘cascade of intervention’ that may occur with induction of labour – by this time, most women will have gone into labour, anyway. In either case, the risk to the baby is very small and either way to go is reasonable.”
Another website stated,”When the membranes rupture prior to labor, after 37 weeks of pregnancy, most women will go into labor spontaneously.

86% of women will labor within 12-23 hours
91% will labor within 24-47 hours
94% will labor within 48-95 hours
6% of women will not be in spontaneous labor within 96 hours of PROM.

Most maternity units therefore practice what is called ‘expectant management’. The mother is asked to wait either at home or in the unit for 24-48 hours to ‘see what happens’, knowing that the majority of women will start to labor without any further intervention. During this time they will be asked to report back if the color of the fluid changes or they feel unwell.

After this time most units would encourage induction of labor as the longer the time interval of ruptured membranes, the higher the risk of infection.

In addition to this most maternity units also encourage antibiotics for prolonged rupture of membranes, after varying lengths of time, depending upon research evidence and local policies. These are usually given orally before labor and intravenously during labor, to reduce the risk of infection.

Some units also give the mother the choice of immediate induction of labor after SROM. Whilst this is done to reduce the risks of infection, it is important to acknowledge the risks of intervention and failed induction which could result in Caesarean section.”

Medscape states this: “Most patients (90%) enter spontaneous labor within 24 hours when they experience ROM at term. The major question regarding management of these patients is whether to allow them to enter labor spontaneously or to induce labor. In large part, the management of these patients depends on their desires; however, the major maternal risk at this gestational age is intrauterine infection. The risk of intrauterine infection increases with the duration of ROM. Evidence supports the idea that induction of labor, as opposed to expectant management, decreases the risk of chorioamnionitis without increasing the cesarean delivery rate.4,5

Hannah et al studied 5041 women with PROM who were randomly assigned to induction of labor with intravenous oxytocin or vaginal prostaglandin E2 gel versus expectant management for as many as 4 days with induction of labor for complications.6 They concluded that, in women with PROM, induction of labor and expectant management resulted in similar rates of cesarean delivery and neonatal infection. However, induction with oxytocin resulted in a lower risk of maternal infection (endometritis) when compared with expectant management. Additionally, the women in the study viewed induction of labor more favorably than expectant management.
Other smaller studies have shown results with higher cesarean and/or operative delivery rates when the cervix was unfavorable.
At term, infection remains the most serious complication associated with PROM for the mother and the neonate. The risk of chorioamnionitis with term PROM has been reported to be less than 10% and to increase to 40% after 24 hours of PROM.7 This points out the importance of appropriate management strategies for PROM at term.
Since risk of infection at term with ROM is small during the first 24 hours, expectant management and waiting for spontaneous labor may be considered in selected patients for the first 12-24 hours if a patient desires expectant management. The use of expectant management after the first 24 hours is questionable.
Digital vaginal examinations should be avoided until labor is initiated; however, fetal presentation should be documented to avoid discovering malpresentation of the fetus long after admission for ROM. All patients with ROM should be asked to come to the hospital to ensure fetal well being.”
So, it appears rushing to the hospital within two hours of your water releasing and then being induced- it is considered induction if you are not dilated to at least 3cm- is a bit over zealous on a woman who is not GBS+ and is full term. Especially since this mom wanted a low or non interventive labor and planned to go without medication for pain. (She did go without pain medication by the way!)So, given this information, one might consider asking, “How about letting me wait and be given an expectant management of labor- and given at least 12 hours to see if things start on their own?”