Henci,

I am currently 39 weeks pregnant and at one of my recent visits I showed my doctor my birthing plan which stated that I do not want my water broken manually. She informed me that if when I come to the hospital that they will break my water if it hasn't broken already. Her reasoning was that they would want to test for meconium (a standard practice regardless of whether a women is past her due date).  Is it necessary for my doctor to do this? It's my thought that regardless of if my water breaks on it's own or manually they'd be able to tell if meconium was present. Not that i would want to be in labor for over 24 hours after my water breaks, I can't help but to think what if i do go over the time limit and they suddenly want to do a c section because I may go over the time limit. Because of all of this I am planning on staying home as long as I can, hoping my water breaks on it's own. But if I do go to the hospital when my contractions are 5 minutes apart am I really at a risk of being in labor for more than 24 hours anyway? What are the other risks and benefits of my water being broken manually if I'm already in labor? The meconium testing reason just isn't cutting it for me.

Thanks,

Mandie from Michigan

Hi Mandie.

I'm responding on Henci's behalf.  I'm a nurse-midwife and also the administrator of this Forum.

Your instincts are right. Checking for meconium is no reason to artificially rupture membranes. This is primarily because there is nothing your doctor would or should do differently if meconium is present. If it doesn't change the care plan, there is no reason for it.  In the past, doctors suctioned the baby's nose and mouth after the head was born but before the rest of the body was born when there was meconium in the amniotic fluid. However, a very large study done a few years ago showed that this practice didn't improve outcomes for the babies.  Since suctioning can cause a vagal response (which can slow the baby's heartrate) and may interfere with breastfeeding, the practice of "intrapartum suctioning" is now not recommended.  The only recommendation related to meconium that remains is to suction a baby's airway if there is meconium and the baby is not breathing when it is born.  Clearly, you don't need rupture membranes early in labor in order to carry out that recommendation.  (Your doctor may say that s/he wants to have extra staff present for the birth or have suctioning equipment set up if there is meconium.  However, this doesn't mean that you have to have your water broken as soon as you get to the hospital - it can certainly be postponed until closer to the time of birth. Though there's no good evidence that doing it late in labor is useful, either.) 

There are many reasons you might not want your membranes ruptured artificially by your doctor.  The fluid provides extra cushioning for the baby and lowers the risk of the umbilical cord getting compressed by the force of your contractions.  Babies are well equipped to deal with brief compression of the cord in labor, but there is no reason to stress them out with more compression than is necessary or natural.  That argument is even more compelling when you consider that meconium itself can indicate that the baby has experienced or is experiencing stress.  Why take away the cushion for a baby that already might be compromised?  (Most babies with meconium are NOT compromised.)  Ironically, some doctors rupture membranes to see if there is meconium, and then when they find meconium, they perform an "amnioinfusion" which is a procedure to put fluid BACK into the uterus to cushion the baby - a good example of performing an intervention that creates a problem and then needing another intervention to fix the problem.

You mention your concern about time limits.  It is very unlikely if your membranes rupture while you are in active labor that you will still be in labor 24 hours later.  However, the risk of infection goes up as long as your membranes are ruptured, especially if your provider does frequent vaginal exams. There is nothing magic about 24 hours.  However, common sense says that the shorter the time from membrane rupture to birth, the less chance an infection will reach the baby or the inside of your uterus.  It's also important for you to know that having ruptured membranes for any particular amount of time isn't in and of itself a reason to do cesarean surgery.  Surgery raises the mother's risk of infection.  So it doesn't stand to reason that you should do surgery to prevent infection. 

You had another instinct that should serve you well - you are right to plan to stay home as long as possible.  Especially with a provider that is so eager to intervene, you stand the best chance of having a healthy vaginal birth if you stay home until you are in a well established active labor pattern.

Best wishes to you and enjoy these last days or weeks of your pregnancy.

Sincerely,

Amy Romano

Kind of on a side note, I saw this recent article in the New York Times about a new study which showed that AROM (Artificial Rupture of Membranes) might not speed delivery after all.

Here's a link to the article:

http://www.nytimes.com/2007/10/30/health/research/30chil.html?_r=3&adxnnl=1&oref=slogin&ref=health&pagewanted=print&adxnnlx=1194552095-VJQknGDdK2I+dt4l0036DQ

And here's a link to the report

http://www.cochrane.org/reviews/en/ab006167.html

This is a new systematic review in the Cochrane Database of Systematic Reviews. A systematic review is a "study of studies." The reviewers collect all the studies on a particular topic according to predetermined criteria and systematically present their data. Most SRs are of randomized controlled trials, although this is not a requirement. If the studies are sufficiently similar, data from them can be pooled using a special statistical technique called meta-analysis. A SR allows stronger conclusions to be drawn because you are looking at the entire body of research. SRs differ from the more common narrative review in that in narrative reviews, the authors support their arguments by selecting bits of data from studies that make their point.

Systematic reviews have their potential flaws and weaknesses. One obvious one: the review is only as good as the component studies, aka "garbage in, garbage out." Another, not so obvious one: systematic reviews are as subject to bias as any other study type. Example: A few years ago, Childbirth Connection sponsored a seminar on pain management in labor. It commissioned two SRs of epidurals, one headed up by an epidemiologist and the other by an anesthesiologist. You will not be surprised to hear that despite a high degree of overlap in the component studies, the epidemiologist found far more areas of concern and areas with insufficient data to relieve concern than the anesthesiologist. That being said, I've got the new review on rupturing membranes, though, and I think it's a good one. 

-- Henci