My wife wore a serious expression as she entered our living room. “I think my water just broke,” she said. My heart skipped, half in excitement and half in concern. Her due date had arrived, so it was time for the baby to come. But she wasn’t yet in labor, and contractions are supposed to be well underway before the gush that signals the rupturing of the amniotic sac.
Events, in other words, were out of order. Her nearly textbook-perfect pregnancy had taken an unexpected last-minute turn.
(JULIETTE BORDA FOR THE WASHINGTON POST)
The medical dilemma we would soon face is far from rare. As many as one pregnancy in 10 — about 400,000 annually in the United States — are complicated by the expectant mother’s water breaking before labor begins. Doctors call it PROM, for prelabor (or premature) rupture of the membranes. (The condition has nothing to do with premature birth.) While it’s unclear why PROM happens to some women and not others, studies suggest that women who experience PROM once are likely to have it happen again.
Despite how common PROM is, there’s no universally accepted way to care for women who experience it. Childbirth professionals disagree, and practices can vary from one hospital to the next.
If the pregnancy is at term, as my wife’s was, obstetricians typically recommend prompt induction of labor, in which drugs are used to bring on contractions and hasten delivery. Any delay, they say, poses an unacceptable risk of infection. That’s because bacteria in the lower genital tract can migrate upward and enter the uterus, potentially threatening both mother and fetus, which is no longer sealed inside the amniotic sac’s protective envelope.
But other professionals, including many midwives, argue against universally inducing. In their view, induction can increase the need for subsequent interventions, potentially culminating in a Caesarean section. They maintain that many women with PROM can safely stay at home and wait for labor to begin naturally.
My wife and I had been oblivious to the simmering debate, but we didn’t remain that way for long. Two phone calls later, we’d learned that our obstetrician wanted us in the hospital as soon as we could make it, while the midwife-in-training we’d hired to be our doula, or personal birth assistant, urged us to stay put.
I’m a medical journalist. My wife is a doctor. Through our work, we have greater access than most people to the sprawling library of medical evidence that doctors use to guide their decisions. That August night in 2009 we felt sure that close examination of relevant studies would tell us the right move. So we pulled up trustworthy medical sites, punched in passwords, downloaded studies and guidelines, and began reading. But a definitive answer remained elusive.
Sometimes, medical science can’t address — or, at least, hasn’t addressed — the pressing questions patients can find themselves facing. What to do when PROM occurs at full term, we realized, was one such instance.
When obstetrician Aaron B. Caughey moved from Boston to California years ago, he was stunned that his new colleagues’ approach to PROM was diametrically at odds with the one familiar to him. In Boston, women who experienced PROM at term were routinely admitted to the hospital and induced. In San Francisco, they were often sent home to wait for labor to begin spontaneously.
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