What Does It Mean When Your Waters Break and Labour Doesn't Start?

About 8-10% of women and birthing people will experience prelabour rupture of membranes - this is when your waters break, but there are no immediate signs of labour e.g. contractions. In terms of when most women will go into labour after waters breaking, the figures differ depending on where you look. NICE says approximately 60% of women will go into labour within 24 hours of their waters breaking. This Cochrane review references research saying that 79% of women will go into labour within 12 hours and 95% by 24 hours. A clinical guideline from Wales suggests that 94% of women will have gone into labour by 96 hours (4 days). Whatever figures you look at, you can at least see that most women will go into labour within 24 hours of their waters breaking.

What Is Prolonged Rupture of Membranes? (PROM)

Prolonged rupture of membranes, or PROM, is defined as your waters having been broken for 24+ hours. For the purpose of this blog we’ll be talking about when your pregnancy has reached full term, so >37 weeks as the advice for pre-term rupture of membranes is different.

PROM can feel like you’ve been thrown a bit of a curveball when it comes to your birth plan, because the maternity system very much starts the clock on your labour and birth at this point - which we’ll explore more later on. We always recommend thinking about what you might do in this scenario during pregnancy so that if your waters break before labour starts, you’ve already thought about your options.

What’s the Advice When Your Waters Have Been Broken for 24 Hours?

What Does NICE Guidance Say?

The NICE guidelines advise that when your waters break but there are no other signs of labour you should be offered:

1. Induction of labour immediately (or as soon as the hospital has capacity e.g. staff and/or a bed for you).
2. Induction of labour approximately 24 hours after your waters have broken.
3. Immediate induction of labour or caesarean if you’ve ever tested positive for GBS in your pregnancy.

NICE recommends induction of labour due to an increased risk of neonatal infection after 24 hours of your waters being broken. Interestingly Rachel Reed has highlighted in her blog that this infection risk relates to babies that were induced and those that were not. So, it may not be truly representative of the infection risk for babies in women who choose to await labour instead of being induced. NICE also recommends that your decision to not be induced at 24 hours should also be respected - we would add that you should be informed of signs of infection and/or other potentially concerning signs and advised to attend the hospital if you have any concerns about yours or your baby’s wellbeing.

The Infection Risk - What Are the Real Numbers?

You Might Be Told The Risk Of Infection To Your Baby Doubles.

This is factually correct, but it’s important to know that it doubles from 0.5% to 1%. What this means is that it is far more likely that your baby won’t get an infection. Whilst the risk isn't 0%, it can be quite alarming if all you’re told is the risk doubles without knowing the actual numbers. It’s also important to note that this increased risk of neonatal infection might feel too much for you, but someone else might feel comfortable with it.

How Do You End Up Being Induced Without Anyone Really Asking You?

Coercion is unfortunately rife in maternity care. That’s not to say that we believe midwives and doctors working in the NHS are actively and consciously coercing women, but rather it can be a case of ‘hospital policy says x, y, z’ without looking at the whole picture of giving women all the information. What this can then look like is women not really being given a choice, or not having all their options explained to them. It can look like being told, ‘you have to come back for an induction’.

The 24-Hour Deadline and the Induction Pathway

You will be ‘offered’ to return to hospital approximately 24 hours after your waters have broken to have your labour induced if there are no signs of contractions. We say offered, but the reality can sometimes be that you get told your induction has been booked and you should return at a certain time, which isn’t an offer but instead an assumption that induction of labour is what you want. We have also heard of people being told to come into hospital at the 24 hour mark for an antenatal assessment and when they do they find themselves being admitted and prepared for an induction of labour. One person told us she felt like she’d been trapped by the hospital as she thought she was just coming in for an antenatal assessment.

It’s interesting to note that in other countries, and in previous decades in the UK, there used to be a longer timeframe between the waters breaking and induction being offered. Some countries only offer induction between 24 and 72 hours after waters break (in the absence of any other concerning signs).

Antibiotics Are Offered By Some Hospitals, But Not Others

Some hospitals will offer everyone antibiotics if they have PROM, even if there aren’t any signs of infection. Other hospitals await any signs of infection before offering antibiotics. A Cochrane review concluded the following:

“This updated review demonstrates no convincing evidence of benefit for mothers or neonates from the routine use of antibiotics for PROM at or near term. We are unable to adequately assess the risk of short‐ and long‐term harms from the use of antibiotics due to the unavailability of data. Given the unmeasured potential adverse effects of antibiotic use, the potential for the development of resistant organisms, and the low risk of maternal infection in the control group, the routine use of antibiotics for PROM at or near term in the absence of confirmed maternal infection should be avoided.”

If you give birth in a hospital that has a policy to offer antibiotics in the event of PROM, it’s always still your choice whether or not to have them. Antibiotics work wonders in the presence of actual infections, but as the Cochrane review highlights, their overuse can lead to antibiotic resistance - which is bad news for all of us!

What Are the Real Risks of Induction Nobody Mentions?

What we have found frequently missing from the conversation around induction of labour is the risks of induction of labour. The focus tends to be heavily on the risk of neonatal infection, with little attention given to the arguably more significant risks of induction to both women and babies. It’s not possible to make an informed decision without having all the information and we simply don’t believe that the majority of women are being given all the information.

Risks of Induction for You: Caesarean, Instrumental Birth, Episiotomy and More

Hannah Dahlen and colleagues published a research paper looking at induction outcomes for women and babies in Australia. It looked at both short and long term outcomes, the latter of which is often missing from maternity research.

Dahlen et al. found that women who had an induction of labour were more likely to experience interventions or complications than those who did not have an induction of labour. The difference in outcomes was more noticeable in women giving birth for the first time, however increases were also noted for women who had given birth before - with the exception of caesarean birth.

The study found that for women having their first baby when compared to spontaneous labour, induction of labour increased the chance of:

• Caesarean section in labour (29.3% vs. 13.8%)
• Instrumental assisted birth (28% vs. 23.9%)
• Epidural (71% vs. 41.3%)
• Episiotomy (41.2% vs. 30.5%)
• Postpartum haemorrhage (2.4% vs. 1.5%)

Another thing to consider with induction of labour for PROM is that the aim is to reduce neonatal infection risk, yet inductions generally require several vaginal examinations to either assess the cervix or sometimes to insert the induction medication and then most likely regular examinations in labour to ‘assess progress’. Research has shown that having 5 or more vaginal examinations in labour increases the chance of getting an infection in labour.

This is important information for you to know, so you can really weigh up the pros and cons of having an induction of labour if you have PROM - or indeed in any other scenario where you may be offered an induction.

Risks of Induction for Your Baby

The research paper we mention above also highlighted that induction of labour carries risks for babies. The authors found that where labour was induced, there was a higher chance of short term neonatal complications, including admission to a neonatal unit (NICU), birth trauma, baby needing resuscitation at birth, asphyxia (oxygen deprivation) and respiratory disorders when compared to spontaneous labour.

This study also looked at long term outcomes for babies and found that induced labour increased the chances of them being hospitalised for infections (e.g. ear, nose, throat and respiratory infections) compared to spontaneous labour.

Are there any benefits to induction of labour for PROM?

This wouldn’t be a very good blog if we didn’t discuss any potential benefits there might be to having your labour induced with PROM. This Cochrane review found the following:

“There is low quality evidence to suggest that planned early birth (with induction methods such as oxytocin or prostaglandins) reduces the risk of maternal infectious morbidity compared with expectant management for PROM at 37 weeks' gestation or later, without an apparent increased risk of caesarean section.”

Note the previously mentioned Dahlen study actually found a higher incidence of caesarean birth following induction for women having their first baby.

This guideline from Wales states that there women are 5% less likely to have an infection after birth and their babies are 1% less likely to receive antibiotics after birth (most likely for suspected infection) if they choose to have an early induction of labour (before the 24 hour mark).

How Can You Make an Informed Choice If You Don't Have All the Information?

If you don’t have all the information you can’t make an informed decision about what to do when you experience PROM. We believe you need to know about the following to make an informed choice:

• The risk of neonatal infection with PROM
• The risks and benefits of awaiting labour
• The risks and benefits of induction labour

It might sound like a lot of information, and that’s why we’d recommend exploring the potential scenario of PROM during pregnancy. You might be someone who already knows they’d await events - but if you’ve never given it any thought it can be easy to be pressured into going with the flow and accepting an induction of labour you didn’t want, with all the potential risks that carries. The BRAINS decision tool can be really helpful to logically go through your options and it’s something that can be used throughout your pregnancy, birth and postnatal journey.

What Does Genuine Informed Consent Look Like in Maternity Care?

We bang on about this because genuine informed consent is missing from many aspects of maternity care. You need to know all of the pros and cons to make a decision and therefore give your informed consent for anything that’s offered to you in maternity care. This can feel quite overwhelming depending on the decision needing to be made. For example, it probably feels easy to give your consent to have your blood pressure checked at antenatal appointments - but making a decision around induction of labour can feel difficult, especially if you aren’t being given balanced information or have been told you’re putting your baby at risk.

You have the right to accept or decline anything that’s offered to you in maternity care. Literally anything. Your healthcare provider doesn’t have to agree with your decision. Birthrights has excellent information about your rights in pregnancy and they’re an excellent resource if you’re struggling to feel heard or are feeling pressured by your midwife or doctor.

Supporting Your Right to Choose - Independent Midwifery Care in Kent and East Sussex.

We Do Things Differently at Juno Midwives

Having worked in the NHS for over a decade each, we understand how the maternity system works and are familiar with both NICE guidelines and our local hospital policy. We know what the recommendations are when it comes to PROM but also what the evidence is. PROM is one of the things we discuss with you during your pregnancy and encourage you to think about what you might want to do in that scenario. We’ll support you if you choose to await labour and we’ll support you if you choose to have an induction of labour. The choice is yours to make, our job is to make sure you have all the information to make that decision.

If you decide to await events, we offer an assessment at home 24 hours post your waters breaking. It’s an opportunity to check in to see how you're feeling and to find out if you're happy with your baby’s wellbeing. We offer an antenatal check, which includes your observations (blood pressure, pulse, temperature), an abdominal palpation and we can listen to your baby’s heartbeat. It’s always your choice if you want to have this check or just parts of it, what it can be helpful for is monitoring for any signs of infection (e.g. raised pulse or temperature). At this point you might feel happy to keep waiting or you might decide it’s time to go to hospital if you are considering an induction of labour. All of this generally happens in an unhurried and calm way, with midwives you know - which means you can make the decisions that feel right for you.

If you’re looking for pregnancy, birth and postnatal care where you are supported and respected the whole way, we’re the midwives for you. Book your free intro chat to find out more.