Disclaimer – While this post is based on established evidence based midwifery protocols, it is not medical advice, as I do not know your specific circumstances.
Contrary to modern film and TV, labor does not generally begin with a big gush of amniotic fluid, followed by transition like contractions and a frantic rush to the hospital in a taxi. Most labors, in the absence of interference, will start with mild contractions that gradually become stronger, longer, and closer together, and the membranes will rupture spontaneously (as opposed to the artificial rupture of membranes (AROM) by a careprovider with an amnihook or amnicot) during the pushing stage. However, sometimes the bag of waters breaks prior to labor, sometimes hours or days before labor.
If you experience a gush of fluid at term (37 weeks or more), the first step is to determine if it is indeed amniotic fluid. Women tend to have lots of vaginal mucus towards the end of pregnancy, and this can be mistaken for amniotic fluid. Due to the pressure of the baby, weight of the uterus, and the muscle relaxing properties of progesterone, women very often leak urine in the third trimester and mistakenly believe that their waters have released. Anne Frye (a well known midwife and author of midwifery textbooks) has noted that some women release up to a cup of fluid at term that is NOT amniotic fluid. Other fluids that are sometimes confused with SROM include sweat, semen, and female ejaculation. Additionally, there are two layers of the bag of waters… the chorion (outer layer) and the amnion (inner layer, closest to the baby). Sometimes in early development when the membranes are forming, amniotic fluid can get trapped between the layers, and later be released when the chorion breaks or gets a hole. While this is amniotic fluid, the baby is still sealed inside the amnion.
There are a few ways to determine if your water has broken. First, smell the fluid. Amniotic fluid smells slightly sweet or like chlorine (similar to semen). Then, put on a clean pad. If the pad keeps getting wet, particularly when you change position, you have probably experienced SROM. Third, sometime close to term, request a amnicator from your careprovider. With an amnicator, you can run it along your panties, bed, floor, or wherever you believe fluid has leaked, and if it is amniotic fluid, it will turn a dark green or blue color.
If it is amniotic fluid, you will want to remember the acronym TACO. TACO stands for Time, Amount, Color, and Odor. Most importantly, you want to be aware of your baby’s movements and make sure baby is still moving often. You may want to consider calling your careprovider; however, be aware that most doctors/hospitals have a 24 hour (or less!) time limit to birth after your water has broken, and you may be subject to induction and infection risk (more on this later) if you go to the hospital immediately. Some women choose to “forget” what time their water breaks and give the hospital a different time if this is the case. The color should be clear, perhaps with a little pink (blood) and/or flecks of white (vernix) and the fluid should not have a strong or foul odor. If the fluid is yellow or light green, the baby has probably passed some meconium in the past few days or weeks (which is generally not an issue in the absence of other problems), but if the fluid is dark green or has chunks of meconium in it (this is referred to as “pea soup” or thick, particulate meconium) or baby stops moving, you need to call your careprovider (or go to the hospital) immediately. If you feel anything in your vagina (but do not check “just in case”), or see anything hanging out (such as a cord, arm, or leg), assume a knee chest position and call 911. Cord prolapse is extremely rare.
The first rule of SROM is NOTHING IN THE VAGINA. No tampons, no sex, no douching, and no vaginal exams (this includes careproviders! If the concern is checking for cord prolapse, fetal heart tones will indicate distress without introducing bacteria). There is no such thing as a sterile vaginal exam, and once you start introducing bacteria into the vagina and cervix, you really are on a time clock before infection sets in (hence the common hospital 24 hour rule… because the first thing they do is check the cervix). Practice impeccable hygiene, wiping front to back (preferably just blotting or drip dry though), change your pad every hour or two, and shower often (careproviders differ on the safety of baths after SROM prior to established labor). Eat nutritious foods with lots of protein and hydrate very well. You may also consider taking vitamin C (500 mg every 2 hours to bowel tolerance, and then back off slightly) and echinacea (follow directions on bottle, generally you want to be taking this 3 times a day. It is very difficult to overdose on echinacea with short-term use). You will want to take your temperature and pulse at least every 4 hours. If either of these begins to spike (although a spike in either can also signal dehydration, so make sure you are well hydrated), you need to call your careprovider. Studies show that there is no additional risk of infection for 72 hours (or more), as long as no bacteria are introduced into the vagina (as it is with a vaginal exam). (See this article with tons of studies referenced for more information)
SROM prior to labor is associated with malpositioned babies. Usually, they are posterior (OP), but they can also be asynclitic, have nuchal hands, etc. This is why doing optimal fetal positioning is SO important during pregnancy! It is considerably more difficult to change a baby’s position once the membranes have ruptured, but it is possible with time and patience. My advice is to treat baby as posterior, even if you think baby is not. Doing things to turn a posterior baby anterior is not going to turn an anterior baby posterior. If you can, go to a Webster certified pregnancy chiropractor as soon as possible (hopefully you have been doing this during pregnancy anyway!). Sometimes this alone will turn a baby and labor will begin soon after. In the meantime, avoid reclining positions and try to stay in forward leaning positions (such as sitting on the ball, hands and knees, etc). Knee chest (on your knees with your head on the floor or bed, not on your elbows) is particularly good for posterior/asynclitic babies. Have your partner learn how to use a rebozo during pregnancy… it is not complicated and it feels so good! It also is fabulous at turning OP babies and correcting malpositions. Zumba style dancing, with quick movements and lots of hip action is very effective and fun – it’s ok to be sexy in labor! You’ll also want to do fast circles sitting on a ball, the abdominal lift and tuck during early contractions, and the “banana” position (i.e. Walcher’s trochanter roll). The banana position (named because of the curve of the pregnant belly in this position) is also fabulous once labor has started if baby is still OP. We stack up a few pillows on the edge of the bed, have mom put her bottom on them, on her back with her legs hanging off the bed, for at least 3 contractions. It arches mom’s back, and since baby’s back is against mom’s back if baby is OP, it makes baby uncomfortable and forces him/her to flip over. You can also use homeopathy for OP babies… pulsatilla and/or kali carbonicum; homeopathy will work before or during labor and has no side effects. The worst thing that will happen is nothing will happen.
So, once your membranes are ruptured, you have a few options. First (and what I recommend, at least for 12-24 hours), is to wait and see. Labor will generally start on its own. Amniotic fluid actually helps to ripen the cervix. After that time, you may choose to wait some more, walk, work on getting baby into a good position, do nipple stimulation or use a breast pump (I like 30 minutes of pumping, 30 minutes of walking, repeat), or induce with herbs (such as black and blue cohosh, Tri-Light’s Start It UP, Mountain Meadow Herbs Master Gland, or other herbs), homeopathy (cimicifuga and caulophyllum… which are homeopathic black and blue cohosh), or drugs (including castor oil and medical inductions). Be aware that if you choose to medically induce (with pitocin, cytotec, etc) that you are more likely to choose an epidural during labor, and epidurals increase the likelihood of persistent posterior babies, which increased the likelihood that labor will end in a cesarean. Epidurals are also associated with maternal fever, which may cause baby to be given unnecessary prophylactic IV antibiotics (because of the fear that the fever was caused by infection), stay in the NICU, and be poked repeatedly for blood work (and possibly a spinal tap).
One last piece of advice… Relax! When you are stressed, your body is producing adrenaline. Adrenaline inhibits oxytocin, which is what you need your body to make in order to get the baby out. While you may not have planned on labor starting this way, your baby decided to start things with a bang (or a pop, as the case may be). You are going to have a great birth!
