The Possibility of Infection
Tick tock. Tick tock.
That is the sound of the clock ticking after a woman’s water breaks.
Tick tock, better start contracting! Tick tock, let’s get that baby delivered!
The Rules
After a woman’s amniotic sac breaks and fluid leaks, most moms are told they need to have a baby within 24 hours because of the possibility of infection. This is because once the amniotic sac/barrier is gone, bacteria can be pushed up past the cervix and that bacteria can sometimes cause infection in mama. However, I have something very important to tell you.
Edit this
The research we will discuss shows that with proper care, waiting for up to 48-72 hours after the water breaks does not increase the risk of infection or death to babies who are born to those birthing people who meet certain criteria.* However, waiting up to 48 to 72 hours for labor to start means that birthing person may have a higher chance of experiencing infection themselves (Hannah et al. 1996; Pintucci et al. 2014).
So the “24-hour clock” rule is no longer valid today.
Vaginal Exams
The number of vaginal exams that someone with PROM has after their water breaks is possibly the most important factor that increases the risk of whether someone with term PROM will develop chorioamnionitis.
In the Term PROM study, a higher percentage of people in the waiting for labor groups (56%) had four or more vaginal exams compared to people in the immediate induction groups (49%).
Seaward and colleagues found that in the Term PROM study, a person’s risk of chorioamnionitis increased as the number of vaginal exams that they received increased (Seaward et al. 1997).
Compared to those who had fewer than three vaginal exams:
- 3-4 vaginal exams lead to 2 times the odds of having chorioamnionitis
- 5-6 vaginal exams lead to 2.6 times the odds of having chorioamnionitis
- 7-8 vaginal exams lead to 3.8 times the odds of having chorioamnionitis
- >8 vaginal exams lead to 5 times the odds of having chorioamnionitis
The strong link between the number of vaginal exams and the risk of chorioamnionitis has been confirmed in many other studies. For example, in 2004, Ezra et al. found that seven or more vaginal exams were an important risk factor for infection in women whose water had broken (Ezra et al. 2004).
The reason vaginal exams can lead to infection is because even though care providers use sterile gloves, their fingers are pushing bacteria from the outside of the vagina up to the cervix as they conduct the exam. In fact, vaginal exams have been shown to nearly double the number of types of bacteria at the cervix (Imseis et al. 1999).
There is some evidence that a “sterile speculum exam” does not introduce extra bacteria to the cervix. In one small research study, five women had two sterile speculum exams, and their cervixes were swabbed to check for bacteria after each exam. There was no increase in bacteria on the cervix after the second speculum exam (Imseis et al. 1999).
In the Term PROM study, about two in five people (40%) received a vaginal exam (with sterile gloved hands) when they entered into the study. This is important because those people who were in the waiting groups took longer to give birth than those people who were induced with oxytocin. In other words, those in the waiting groups likely had an increased risk of infection due to the initial vaginal exam (Seaward et al. 1997).
https://evidencebasedbirth.com/evidence-inducing-labor-water-breaks-term
Your Vagina is Not a Vacuum Cleaner
I repeat, your vagina is not a vacuum cleaner. Your vagina is not sucking up bacteria. Actually, fluid and mucus is coming down and out of your vagina.
So, you might wonder, how exactly does this bacteria climb up past the cervix?
Vaginal Exams
Vaginal exams are given to moms upon admission to the hospital, birth center, or when a midwife arrives for a homebirth. Care providers want to see if the signs of labor a woman is experiencing has put her in labor and if so, how much progress she has made.
Vaginal exams are given to moms periodically during labor to see how they are progressing (dilating). Also, vaginal exams are given when a mom feels like she needs to push to make sure she is fully dilated (10 cm).
If you recall my previous post, you will remember that vaginal exams do not predict the future, they just show what your body has already done.
Reduce the Risk of Infection During Labor
- If your care provider says it’s ok, stay home after your water breaks. You will have zero vaginal checks when you are in your own home.
- Get into a good labor pattern at home. The more “in labor” a woman is when she checks into the hospital the less interventions and vaginal checks she will receive.
- If needed, use natural labor stimulation methods to get contractions going (nipple stimulation, etc.).
- After your water has broken don’t have sex or insert anything into the vagina.
- Eat nutritious foods and drink plenty of water.
- Drink Emergen-C and eat foods rich in vitamin C to give your immune system a boost.
- Rest. The more rested you are the stronger your immune system will be.
- Refuse or limit vaginal checks, especially if your water has broken.
- Instead of vaginal exams use methods such as: observation of mamas vocalizations and mood to determine labor progression.
Undisturbed Birth
A woman’s body is wise. Her vagina is not a vacuum cleaner, trying to suck up bacteria and infect itself. Excessive vaginal exams can cause infection during labor.
Therefore, allowing a woman to labor and birth undisturbed as much as possible is wise.
Want More?
If you found this post interesting, you might be interested in this post called your vagina is not a crystal ball. Another gem is your vagina is not a steel pipe.
cervixwithasmile
Saturday 8th of April 2017
Great advice overall. Physicians and nurses are taught simultaneously that vag exams are both standard practice and unreliable in predicting labor progress, and yet, few of us really embrace the second part of that teaching.
A few exceptions I'd give to staying home after your water breaks (assuming you're not giving birth at home. If you are, then please notify your midwife if):
1) If you're not having your first baby, and even if your first labor was 48 hours long, please at least start heading for the hospital or notify your provider that your water has broken. Pay attention to your contractions. Are they getting harder? Closer together? Longer? Sometimes those second, third, fourth etc, kiddos come fast, especially after your water breaks!
2) If you're GBS positive, head straight for the hospital. If you test positive for GBS (Group Beta Strep), a naturally occurring bacteria, you have a certain window of time to receive antibiotics and protect your baby. While this bacteria poses no threat to you, a baby passing through a vagina can pick this bacteria up in her eyes, her respiratory tract, etc., and this can put baby at risk for lifelong consequences (blindness and life-threatening infection are the two possible consequences that come immediately to my mind).
3) If you notice a greenish color or strange smell to the amniotic fluid, please head for care immediately. This is a likely indicator that baby has taken his or her first poop on the inside. The medical profession calls this meconium staining. Not only can meconium staining result in infection on its own, but it can also cause issues with baby, even in utero, and verifying fetal well-being is important at this point.
4) If you feel like something is coming out/hanging out of you after your water breaks, call 911. Rarely, the cord will come out first or baby's limb will come through the vagina. If the cord comes out first (called cord prolapse), baby's life is in danger as baby's head (or presenting part--possibly legs or butt if you've got a breech kiddo in there) can compress the cord and cut off blood flow to the baby. If baby's presenting part is an arm or leg, birth is going to be a bit trickier than if baby was coming out head-first and you will need to get to the hospital to make sure baby is able to safely descend.
Mary
Tuesday 28th of March 2017
Great advice. With my first, my water broke before contractions started (although looking back, I think I was in early labor all day, it just wasn't very painful). I went to the birth center 6 hours later and then started pushing not long after I got there. I got to labor at home for the majority of the time which was good, but I am pretty sure I was in transition in the car! Yikes.
Lindsey Morrow
Friday 31st of March 2017
Thank you!
Kasey Keown
Friday 17th of February 2017
My water broke before I started feeling contractions. I was helping my hubby install the car seat and, when I pulled the strap, my water just broke. I showered off and put on clean-dry- pants then sat on my yoga ball for 30-45 mins until I started having regular contractions. My dad begged me to go to the hospital b/c my water had broken and that's what you're "supposed to do". The nurse did minimal exams because of the risk of infection. One when I got there and one when I felt the need to push. I actually dilated and progressed way faster than they expected I guess because she was shocked I was at 10 cm. They brought in pitocin to give me right after I got there because of the "risk of infection" and I refused. I remember thinking "I am in the hospital so unless your sheets here are dirty... what is the risk???" I mean they already said they weren't doing multiple vag exams. Long story short, I did not get an infection, I delivered within 5 hours, and I was so glad I did not get that pitocin because my contractions were definitely doing their job!
Vw
Sunday 17th of January 2016
This is an interesting (and certainly valid) point with regard to how bacteria is introduced. I did acquire infection during labor, and a six day NICU stay for my almost 41 week term baby. I *thought* I had waited a pretty long time before going to the hospital, after contracting for 15-16 hours (or more, as they woke me in the wee hours), but perhaps it was still earlier than would have led to a more ideal birth. It's hard to say on retrospect if it was or was not the right choice. When I went through my initial check, my blood pressure was sky high, and I underwent all the "usual" interventions in attempting to move things along, ending nearly 30 hours later in a Cesarean after fever spiked and last ditch attempts to get baby out failed. I had lots of time with hands "up there" through all of this.
Lindsey Morrow
Sunday 17th of January 2016
Hi there. It sounds like you went through a lot, you and your baby. Looking back at our births it's hard to not analyze them, wondering ehat we should have done differently or better. I know you probably wanted things do go a different way. However, I'm going to encourage you to say this one thing to yourself every time those thoughts come up, "I did the best I could do. I did my best. I'm a good mom." Be kind to yourself. ❤️
Anna
Monday 7th of December 2015
I just found your blog through Pinterest and am enjoying going through some of the articles as I am 35 weeks with #2. I have to say though, isn't it very unadvisable to stay home once your water has broken? Forget infection, that water breaking means that baby is trying to get out! I myself went STRAIGHT to the hospital when my water broke the first time, I was already a 6 upon arrival and dilated to a 9 within 2-3 hours with no pit. My body did end up stalling at 9 for a bit, but what if it hadn't? Had I stayed home for any amount of time I could have potentially had a paramedic delivering my baby instead of a doctor! And I know two different women who delivered within 2 hours of their water breaking. Both my first baby and this baby have been low almost from the get-go, and I fully believe my labor could likely be even shorter than my first already fairly short one. I know this isn't the case for some women, as they have to endure long labors even after the water breaks, but if its your first you don't know which type you'll be! Better safe than sorry!
Beth
Saturday 8th of July 2023
@Anna, YOU Deliver your babies, not a doctor, not a paramedic, not even a midwife. They are only there to help YOU deliver YOUR baby if an unusual, unlikely pathology occurs. So: what is the problem with "not making it to the hospital"? If you are birthing so well without the help that it isn't there "in time", then you didn't need it! People, undisturbed birth is so rarely problematic!!! Indeed, better safe than sorry. Better safe at home from unnecessary interventions than rushing to the hospital early enough in labor that their barrage of questions and decisions will pull you out of the sphincter-opening relaxed state and stall your labor, sending you down a slippery slide of protocol-induced interventions that often conclude with a c section.
Lindsey Morrow
Monday 7th of December 2015
Hey Anna! I'm so glad you found my blog... WELCOME! And congratulations on baby #2! I suppose the answer to your question would vary from care provider to care provider. BUT it sounds like you listened to your body and things worked out very well for you, which I think is very important. One thing we talk about in my childbirth class is the hormonal blueprint of labor. If you go to the hospital too soon, you can absolutely disrupt the flow of labor hormones, slowing things down. SO there's a lot to consider, when going to the hospital. And yes, I think many first time moms go to the hospital too soon, which can potentially cause unwanted interventions. Ultimately, I think excellent prenatal education AND a great relationship with a care provider AND listening to your body will facilitate the best of outcomes. Keep me posted on this new little one!