7 things you should know about having your waters broken

You hear it all the time – ‘I had to have my waters broken’; ‘My midwife said it was the bulging bag of waters that was holding me back’; ‘The midwife thought I’d have the baby really fast if she just broke my waters’.  Sounds entirely benign, doesn’t it?  Sometimes fully informed consent isn’t sought for the artificial rupture of the membranes (ARM); you may hear ‘I’ll just give your waters a nick’ as a vaginal examination is being performed.  So it couldn’t be a big deal, right?

Here are 7 things you should know about ARM. If you prefer not to have it, include birth preferences refusing it as a routine procedure.

1. It doesn’t always do what it says on the tin
It’s sold to you as making labour quicker: “We’ll just nick the waters there and you’ll have your baby soon”.  Yes, sometimes ARM speeds up labour but sometimes it does nothing or even slows the process down.  A review of the evidence says that ARM hasn’t been shown to speed labour up – it’s not evidence based. Why would it slow it down? Well, sometimes when the waters underneath the baby’s head gush out, the baby’s head can come down in a less then ideal position, meaning direct pressure is no longer being put on the cervix to cause it to dilate. You then have to work to get baby to move into a better position and with the waters gone, this is made more difficult.  Sometimes your dilation can even go backwards  after ARM – if it was the bulging bag of waters that was pushing the cervix open.

2. It may increase your chances of a Caesarean delivery
Were you told this when staff offered to release your waters artificially? Evidence shows that having ARM goes hand in hand with increased likelihood of a Caesarean. The water bag is protective and cushions the cord – once that cushioning is gone, there can be times when the cord becomes compressed and this can cause a drop in the baby’s heartrate, ultimately leading to a diagnosis of foetal distress and a Caesarean birth.

3. We don’t know if it’s safe
The amniotic sac, placenta and umbilical cord are something of a mystery. There can be variations in how the umbilical cord inserts into the placenta. One of these variations is known as velamentous cord insertion (VCI). Normally, the blood vessels connecting baby to the placenta are wrapped in a substance called Wharton’s jelly and protected by this and an enclosing membrane. With a VCI, the blood vessels are not protected at the placental end and are inserting separately into the placental membranes rather than the placenta itself. They are often entwined in the foetal membranes ie. the water bag. The major risk is that one of the blood vessels could be near the cervix (this is known as vasa praevia), and therefore could be ruptured if an ARM is performed. VCI is not very common, approximately 1 in 100 pregnancies, but it’s usually undiagnosed – I didn’t find out that I had a VCI until after my daughter was born. My waters had released themselves at 10cm – clever body!

4. It can speed labour up and make it unmanageable
Yes, I said earlier that it doesn’t always speed up labour, but sometimes it does, and your labour takes off like a rocket.  It can be very tempting if you are plateauing at 4cm dilation for a couple of hours to consent to an ARM in order to get things going. However, you might find yourself going suddenly from coping well with your surges to not coping, as sometimes ARM can accelerate labour and make surges longer, stronger and closer together very, very quickly. This means that you have not had the opportunity to build up endorphins in your system to deal with the sensations of the surges, nor have you gotten into the labour groove with coping mechanisms. Many women opt for an epidural after an ARM because they feel they cannot manage the intensity of labour – the epidural may then have the effect of slowing labour down! Cue the syntocinon drip to speed it up again…a classic cascade of intervention.

5. Meconium in the waters can change the course of your labour
Some babies poo before they are born – this is known as meconium. It is more common with babies who are over 40 weeks gestation and is indicative of a mature gut rather than distress, if baby’s heart rate is normal and all is well otherwise.

When meconium is found in your waters, it is generally hospital policy to use continuous monitoring, or cardiotocography (ctg), to check your baby’s heart rate from then on. However, ctg has a notoriously high rate of false positive for foetal distress, and so your chances of a Caesarean increase by around 30% once it goes on. Your movement is also somewhat limited, although you can work around this if necessary (it is not necessary to be on your back in bed if you are on ctg – you can be on your knees on the bed or floor or sitting on a birth ball, for example).

You will also be on a clock, as staff will not want a delay in delivering baby with meconium present – the time limit for labour may now be reduced.

This fascinating article looks at  what happens if meconium is found in your waters, if you would like to know more.

Bottom line – if there is meconium in your waters, it is safer for baby and more desirable for your labour experience that your waters remain intact for as long as possible.

6. The water bag protects baby from infection
You may or may not have heard of Group B Strep (GBS). This is a bacteria which up to one in four of all women carry in the vagina.  It doesn’t require any treatment and, for the non pregnant population, isn’t a problem. For most pregnant women, it still won’t be a problem, but in some cases, baby can become very sick if infected.  Policy in some maternity units for managing labouring women with GBS is that there should be no ARM routinely – so if you don’t know your GBS status, it makes sense to leave the waters intact.  You can find out more about GBS at this very informative website.

7. We just don’t know what’s going to happen next
We can’t predict what will happen after an ARM – maybe labour will fly and we’ll be holding our baby 2 hours later.  Or maybe our baby will be born by c section, after going into distress following the ARM. All interventions carry risk – and ARM can lead to a number of obstetric emergencies.  Our best chance at a vaginal birth is always to avoid any unnecessary intervention.

 

Labour is unpredictable and sometimes we depart from our birth preferences.  On the day, you may feel, all things considered, that ARM is worth a throw of the dice. As long as we make informed choices and are in the driving seat, birth can be a positive experience, whatever path it takes. Guidelines from the Royal College of Midwives state that ARM should not be routine and should only be carried out after a discussion with the woman – and that this discussion should not take place just before or during a vaginal examination. When making choices, always take the time to ask any questions you have and, if you feel you need to, you can ask staff to step outside the room while you discuss your options with your birth partner. It is difficult to get into the headspace to make an informed decision when someone has their fingers inside your cervix!

For further reading, check out:

http://midwifethinking.com/2010/08/20/in-defence-of-the-amniotic-sac/
https://www.rcm.org.uk/sites/default/files/Rupturing%20Membranes.pdf
http://42weeks.ie/2013/10/02/may-i-break-your-waters-information-on-artificial-rupture-of-membranes/

Day 2 of the Your Birth GentleBirth workshop looks at standard hospital policies and procedures and birth preferences.  Find out more about our workshops here.