pPROM Essentials

What do you do when your water breaks too early?

Whether your water just broke, or it’s been awhile, here are some essential tips to help you.  (borrowed from kanalen.org/prom)  It is a long list, but take a deep breath and proceed mindfully.  You are working toward the best outcome for your baby.

Don’t give up hope.

Your health care team may know little about PROM and may tell you that your baby’s chance for survival is so grim that it isn’t worth trying to save him or her. Although you may have different specifics of your situation, there are many stories on kanalen.org/prom of babies who have survived despite PROM. Know that miracles happen.

Follow your instincts.

If something doesn’t feel or sound right, ask for a clarification or an explanation. Ask more than once. Even if you think you understand the information, allow extra time for it to sink in, and to act on what you are told.

PROM is a pregnancy crisis and the shock of the trauma may make it difficult to think and express yourself clearly, absorb new information, and – most importantly – make decisions. Don’t feel pressured to make any decision immediately, and don’t just “go along” with what your health care team is recommending if you aren’t completely sure that it’s right for you and your family.

If you are uncertain about a procedure or diagnosis, wait before acting and get another opinion. Find out what the range of options is. You are entitled to get a second, third, or fourth opinion. Don’t be shy about searching for other doctors who specialize in pregnancy complications to consult about your situation. University hospitals are often a good source for maternal/fetal specialists with advanced training.  If you feel a different course of action is more appropriate for you, discuss with your health care team whether it is possible to take the alternative course.

Be your baby’s advocate with your OB/Health care provider

PROM can leave you feeling completely helpless. However, you may find empowerment in the fact that you are your baby’s advocate. Be as active as you can in the decision-making process. If you are uncomfortable making requests or asking for another opinion, remind yourself that you are doing this for your baby, and that your baby’s health is the most important thing.

• Keep asking questions if you don’t understand something or don’t have all the information you need. Wait until you feel that you have all the information you need before you make a decision. Unless your health care team tells you that your health or safety are in immediate danger, don’t make decisions quickly or hastily.
• Don’t worry that you are being a pest by asking the hospital staff to monitor you closely.
• Insist on being seen any time you feel that something is not right, even if you have left the hospital. If your health care practitioner will not schedule an appointment, go to the emergency room.
• To the extent possible, keep a written log of what you are told, by whom, and the date and time you received the information. A written log is also useful for keeping track of your medications, fluid intake, bathroom visits, and pad changes (if applicable), as well as the names of the members of your health care team.

Be informed about PROM

• Get a laptop and research PROM on the web.
• Join the PROM list on kanalen.org/prom for information and support.
• Read the PROM stories to find out what has helped others who have experienced PROM. Print out stories of babies who have survived to educate your health care team about the possibilities and options. Many health care practitioners don’t know or don’t believe that babies survive despite PROM.

PROM: the first 12 to 24 hours

Get the facts

• Confirm that you have ruptured. Do not rely on the “fern” test. Insist on an abdominal ultrasound (not trans-vaginal ultrasound) to confirm that you are losing or have lost fluid.
• Write down your baseline amniotic fluid index (AFI). Use this as a reference to gauge whether fluid is reaccumulating.
• Test for and treat an infection. In particular, look for:
  • Group B Streptococcus (GBS) – your health care practitioner will almost certainly treat GBS if it is present in your urine; discuss whether to treat if it is only present in your vaginal flora.
  • Urinary tract infections (UTIs)
  • Bacterial vaginosis/gardnerella
  • Citrobacter freundii – treatable with gentomicin-family antibiotics
  • Yeast infection
• Learn the signs of cord prolapse. Ask your health care team to describe the signs indicating that your baby’s cord has prolapsed. If you believe the cord has prolapsed, get in a position on your hands and knees with your hips in the air and shoulders down to help take the pressure off the cord until you can get medical attention. If you don’t have someone to take you to the hospital immediately, call an ambulance.

Explore immediate treatment options

• Ask whether you will remain in the hospital, or go home on bed rest. If you will go home, ask about home monitoring for preterm labor.
• Ask if you are a candidate for corrective procedures such as amnioinfusion, fibrin injections, or the amniopatch. You may need a different hospital and/or a different doctor for the procedure.
• Ask to start antibiotics immediately. Some members of the PROM list have reported starting antibiotics immediately after they PROM’d, even though no infection was present. Although some health care practitioners will not prescribe antibiotics because they worry that antibiotics will “mask” an infection, several recent studies have shown antibiotics increase the possibility of a positive outcome.

• Ask if/when you can receive steroid shots to help your baby’s lung development. Members of the PROM list have reported receiving steroid shots as early as 23.5 weeks.
• Ask for tocolytic drugs if you are having preterm labor. Members of the PROM list have reported receiving magnesium sulfate and/or terbutaline as early as 17 weeks.
• Consult with doctors in other specialties before your baby is delivered, if applicable. For example, if you are 24 weeks or beyond, you should meet with a neonatologist to talk about what to expect if your baby is delivered preterm.

If you are being told to induce labor or terminate your pregnancy

• If you are NOT showing any signs of infection or active labor and your baby is not in distress, but your health care team is still recommending that you induce labor or terminate your pregnancy, find out how much time you have to decide whether to follow their recommendation. Find out the consequences of not inducing labor or terminating your pregnancy. Take as much time as you need to feel comfortable with your decision.
• If your health care practitioner has already told you that you have no choice but to induce labor or terminate your pregnancy and you know that your baby will not survive long after birth, visit kanalen.org/prom for guidelines on what to consider before you begin the procedure.
• If your baby will be taken to the NICU immediately after birth, read as much as you can about preemie care.  There is information on kanalen.org/prom and I highly recommend The Premature Baby Book by Dr Sears.
• Discuss options for delivery (vaginal or c-section) and pros, cons, and risks of each. Find out whether your health care practitioner or someone else will be attending the delivery, and express your preference for who you would or would not like to have attending you.
• Begin working on your birth plan.

Monitor for complications

• Ask what to expect or watch out for in the first 24-72 hours after PROM. For example, more fluid leakage, bleeding, cramping, or fever.
• Learn the signs of infection. Signs of infection include fever, abdominal tenderness, foul-smelling discharge, and elevated white blood cell count. Ask your health care team for more details on each of these signs. Keep in mind that women on the PROM list have reported discovering infections after delivery, even though they were asymptomatic before delivery.
• Limit exposure to infection. Insist on sterile speculum exams rather than internal vaginal exams. If your health care practitioner believes an internal vaginal exam is necessary to determine the texture of your cervix, insist that the exam be done only with sterile gloves (these come in a sealed package, and not out of a big box of gloves).
• Some research indicates that daily vaginal disinfection with povidone iodine may prolong the period before delivery. Discuss with your practitioner if this is right for you.
• Establish your options if infection develops, and how much time you will have to make decisions if you begin to develop an infection.
• Ask for hospital bedrest if you feel that it is appropriate for you. Hospital bedrest is usually available after 24 weeks. Some hospitals will admit you earlier, especially if your hospital is a long way from your home.
• Monitor for preterm labor. Talk to your practitioner about home uterine activity monitoring and self-palpation.

Increase your fluid intake

Staying well hydrated is one of the most important things you can do for your baby. It helps keep your temperature down and fight infection.

Staying hydrated will also help replenish amniotic fluid, because the more you drink, the more urine your baby will produce. By 27 weeks gestation, your baby produces about 500 ml of urine into the amniotic sac each day. While much of this fluid may leak out again, pockets of fluid may accumulate and help with lung development.

• Drink ten 8-ounce glasses of water per day. Drink more than that, if you can.
• Drink milk and cranberry juice to help ward off infection.
• Drink chamomile tea if you are having preterm labor. Don’t drink more than 3 cups per day, and wait 3 hours between cups. Drink the tea around the times that you are having the most contractions. Talk to your health care practitioner if you are unsure whether you should drink herbal tea.

Lie low

• Remain in a position where you leak the least. This may be sitting instead of lying down.
• Lie on your left side if you are lying down, rather than on your back. If you are uncomfortable lying fully on your left side, lie on your back with a pillow propped up under your right side.
• Aim for strict bedrest, staying horizontal or in the minimum-leak position as much as possible. Get up only for bathroom breaks or quick showers.
• In the shower, avoid letting hot water run on your breasts because it stimulates the uterus. Also, sit down if you can (use a plastic lawn chair if you don’t have a seat in your shower).
• If you are on hospital bedrest, insist on frequent monitoring for cord compression if your AFI is low (AFI<3).
• If you are on hospital bedrest, consider using a bedpan or bedside commode instead of walking to the bathroom.
• If you are on home bedrest and you have small children, follow these guidelines as best you can!

Ward off infection

Because your health care practitioner will almost certainly require you to end your pregnancy if you develop an infection, here are some ideas that might help prevent infection. Be sure to do your research about dosage and safety of any supplements.

• Eat yogurt. Dairy or soy yogurt are both fine as long as they have live cultures. If you don’t like yogurt, take acidophilus or probiotic supplements (Garden of Life Primal Defense is amazing.) If you are taking antibiotics, take them at least one hour, preferably two, before OR after you have the yogurt or acidophilus (otherwise, the antibiotic will kill off all the good bacteria you are trying to build up).
• Drink unsweetened or fruit-juice sweetened cranberry juice to discourage urinary tract infections. Avoid cranberry juice that is sweetened with high-fructose corn syrup as it may actually encourage the growth of bacteria. Try diluting unsweetened cranberry juice with water or sparkling water. As an alternative, take cranberry capsules with a big glass of water.
• Avoid caffeine (including chocolate).
• Use anti-bacterial wet wipes after using the toilet. Remember to wipe front to back.
• Take Vitamin E, Vitamin C, and zinc supplements. Talk to your health care practitioner about dosage.  Don’t be surprised if your doctor has no recommendations on supplements.  A good start is 800 iu of E and 3-5 grams of esterized C with bioflavinoids per day.
• Don´t wear underwear. If you are leaking or spotting, lie on a towel or chuck pad.
• Avoid sex.  This means no vaginal penetration of any sort and includes orgasm, as it can trigger contractions.

Above all, research, research, research.  Network with other women who have experienced pPROM, find out what they did and what the results were.  Read all of the stories on kanalen.org/prom, not just the ones with happy endings (make sure you’re emotionally ready to handle it, though.)  All of the stories provide insight into how to handle this extreme pregnancy complication.