Babies puncture, Membranes rupture

June 8th, 2010 § 0 comments

Why is it sometimes difficult to determine if a mother’s water bag (amniotic sac) is intact, or broken (“ruptured”)?

If a client has a big “pop” or “splash”, and gets all wet and soaked, then her water is broken, especially if she keeps leaking, right? If those things don’t happen, then it’s not.

If only it were so simple…here are a few case studies to demonstrate my meaning.

Case Study #1
A client is laboring in hands-and-knees, and is in active labor. Her midwife is with her. During a contraction, she suddenly says that her water broke. It soaks through her clothes, and she proceeds to keep leaking. Obviously her water is broken.

A few hours later, her midwife checks her to see what progress she has made, and discovers a bulgy bag of water—the membranes are still very much intact. What happened?

Case Study #2
A client comes in saying her water broke at home, and it made a puddle on the floor, smelled clean and fresh, and took a few towels to clean it up. She kept leaking for several hours, and then stopped. Her midwife checked her a few hours later—membranes are still intact. What happened?

Case Study #3
A client says she thinks her water is broken, but she’s not sure. It broke with a pretty obvious sound, but she didn’t keep leaking afterwards. She got pretty wet at the time, though. Her midwife did a Nitrazine test (pH paper to test for the highly alkaline amniotic fluid) that was pretty positive, and they decided to give her all night to see if she would go into labor on her own. Nothing much happened. Her midwife repeated the Nitrazine test in the morning, and it was negative. They did a sterile exam, and there was a very thin membrane in front of the baby’s head, and when the mother had a Braxton Hicks contraction, it bulged slightly. Intact membranes! How did that happen?

When the membranes rupture or the “water breaks”, there are a couple ways that can happen. First, there is the classic “water breaking” with the water bag breaking at the cervix with a pop or gush, and a large quantity of fluid gushing out. Second, is the “slow leak”, where there is a break in the bag of waters (usually up high) that causes slow leaking and little gushes with fetal movement or contractions. The third main way it can break (but rarely), is for fluid to leak between the two layers (the amnion and the chorion) and for only the chorion, the outer layer, to rupture—this causes the fluid trapped between the two layers to leak out. Usually with this last kind of rupture, the mother won’t continue to leak once the fluid leaks out initially.

So it can be trickier than you would think. 🙂 Why is it so important to determine for sure whether or not a mother’s membranes are intact?

If a mother’s water is truly broken, there is a risk of infection (Varney’s Midwifery says from 1.6-29% risk of infection depending on a lot of different factors) that isn’t a problem with the membranes are intact. An intact amniotic sack, for the most part, seals the baby in a sterile environment which protects the baby and the mother from infection.Also, if the membranes are broken, you really don’t want to do any vaginal exams until active labor has begun, because the risk of infection goes up by a good amount 24 hours after the first vaginal exam. Additionally, there is a greater chance of infection if the mother is GBS positive, but that’s a discussion and topic for another day…

Basically, I realized through the last few times I’ve faced having to determine the status of membranes, I’ve learned that it’s not nearly as straightforward as I thought it was!

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