“Going to the PROM with Dr. Caroline Friedman”

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right, Dr. Caroline Friedman, welcome back to the podcast. How are you doing?

Dr. Friedman: Hi. Thank you. Great. How are you?

Dr. Fox: Good. So we’re going to the prom.

Dr. Friedman: Wow.

Dr. Fox: Excellent. You asked me if I ever went to a prom.

Dr. Friedman: Yeah.

Dr. Fox: So, they don’t really have proms in Jewish day schools so much. We had events that were prom-like, meaning we had like a formal that people got dressed up for, and people did, not everybody, but frequently people did like pair up as a date and go, but a lot of people didn’t. But there wasn’t any formal couple events. There was no dancing or anything. There was no prom king and queen. It was basically just like a formal dinner with like, you know, some sort of entertainment. What about you?

Dr. Friedman: There’s no dancing. Was there music?

Dr. Fox: So, the Jewish schools are not big on the mixed dancing. It’s a big taboo in the religious Jewish circles. And so, they didn’t have it. Sometimes there was rogue dance events afterwards that caused some strife between the students and the faculty. But, you know, it’s all part of growing up. So, I guess sort of yes, sort of no. What about you?

Dr. Friedman: Yeah, I went to a prom or a few.

Dr. Fox: Nice. Corsage, the whole thing? We had corsages for ours.

Dr. Friedman: Yeah. We had junior prom, we had senior prom. My senior prom was actually on one of those princess cruise lines around the city.

Dr. Fox: Oh my God.

Dr. Friedman: I know.

Dr. Fox: I don’t ever wanna go on those because you’re trapped.

Dr. Friedman: But that was the point.

Dr. Fox: You can’t get out.

Dr. Friedman: They were trying to trap us so kids couldn’t get into trouble.

Dr. Fox: Oh. Was that before the day of pre-gaming?

Dr. Friedman: I don’t know. I wasn’t drinking then. Other people were, I’m sure.

Dr. Fox: Yeah. You seem to be like a rule follower.

Dr. Friedman: We’re a school in New Jersey. So, we were… Yes, I was a rule follower. Mom, are you listening?

Dr. Fox: I was definitely a rule follower.

Dr. Friedman: I think probably most of us were. That’s why we’re doing what we’re doing now.

Dr. Fox: Yeah. Yes, we are lame. Okay.

Dr. Friedman: We’ll take it. It was fun though. Good music.

Dr. Fox: All right. That’s cool. Very nice. Yeah, similar thing. My kids saying they go to schools and there’s not supposed to be a prom. There’s sometimes a rogue prom or there’s again a prom where it’s like supervised prom. It’s an interesting world that we have.

Dr. Friedman: Yeah, it’s okay.

Dr. Fox: But that’s not the kind of prom we’re talking about.

Dr. Friedman: No.

Dr. Fox: That’s a preamble.

Dr. Friedman: This is our new PROM that we deal with.

Dr. Fox: Right. Our PROM is a nice acronym for premature rupture of membranes. So, what does that mean?

Dr. Friedman: Yeah. So basically, when you break your water, that’s the colloquial term for rupture of membranes. So we talk about membranes being basically the bag that’s holding all the fluid around the baby inside the uterus. And when people say, “Oh, their water broke,” basically that means that a hole has developed in this sack or this bag and now the amniotic fluid is leaking out of the uterus.

Dr. Fox: Right. So that’s the rupture of membrane’s part. That’s the ROM. So what does the P indicate? Premature. People get confused because they think it means before 37 weeks, but no.

Dr. Friedman: It’s not. No, we have to make everything as confusing as possible.

Dr. Fox: Yes. That’s another consequence, yeah. We’re kinda lame when it comes to drinking, but we’re also kind of annoying when it comes to making complicated things more complicated.

Dr. Friedman: So basically, in this term, premature means that the water breaks before the onset of labor or before you’re contracting and your cervix is already in the process of dilating usually. And so it’s what happens a lot of times in the movies when people are just out shopping and doing whatever they’re doing, and all of a sudden, you know, they look very comfortable, they’re not contracting, they don’t seem to be in labor, but all of a sudden their water breaks.

Dr. Fox: Right. And then to really complicate things, when that happens before 37 weeks, we call it PPROM. Two Ps, preterm premature rupture of membranes. And for those of you who are in this world, the reason that’s so confusing is because premature almost always in our lexicon means before 37 weeks. But this is the one instance when it doesn’t, yet it happens before 37 weeks. And so it’s just weird.

Dr. Friedman: Yeah, don’t worry about it too much.

Dr. Fox: Yeah. Sorry. So, you’ll hear PPROM, you’ll hear PROM, but when we…in our own world, we’ll usually say term PROM, just to sort of like clarify again, we’re talking about someone who’s full term 37 plus weeks whose water breaks. Now, you are 100% correct. It’s like people describe in the movies, and I would say pretty much everyone in the movies, that’s what happens. The first thing that happens is their water breaks and then sometime thereafter, usually three seconds, they go into labor very, very strong labor, you know, and the babies come out, you know, four minutes later. But in reality, PROM is the exception, right?

Dr. Friedman: Yeah, it only happens about 10% of the time, I think. Most of the time people start by contracting or something else starts first.

Dr. Fox: Yeah. I tell people that 90% of the time your labor’s gonna start with contractions that build up, get more painful, get more regular. You’ll show up to the hospital, your water bag is still intact, and either it’s gonna break on its own when you’re six, seven, or eight centimeters, or we’re gonna break it for you. And that’s a whole other question about whether it’s better or worse, whatever, but that’s what’s gonna happen. But only about 10% of the time are you gonna, again, have what you say, either wake up and your water’s broken, or be at Nordstrom and your water breaks, or whatever it is in some…

Dr. Friedman: Right, wherever you are.

Dr. Fox: Yeah, some real embarrassing place and your water breaks all over the place. And once the water breaks, it’s quite variable when you’re gonna go into labor, right?

Dr. Friedman: And the other thing you just said too about going everywhere, it’s not always such a big, huge mess. That’s the other thing the movies make it seem like.

Dr. Fox: Yeah, my example is always Phoebe from “Friends” with the triplets. You know, water breaks and then she’s in booming labor and then they all come out like an hour later with a doctor who’s funny. Yeah, vaginally. Vaginal birth of triplets for Phoebe. Good job. Yeah, so there’s a lot of things that can differ. And so, one of the first things that people wanna know about is how would they know if their water’s broken?

Dr. Friedman: Yeah. Most of the time people will feel some sort of wetness, for lack of a better term. You know, sometimes it is that big gush. Sometimes people even say they feel a pop. And then all of a sudden there’s water going down their legs, and their pants are wet and it goes through their jeans and their dress and it’s on their chair or their bed or whatever. You know, sometimes they describe it as just more of like a trickle or they feel like, you know, the discharge is more watery than usual and they change their underwear and it happens again and again. But usually, it’s described as sort of more than discharge, clear, watery, and usually at least good amount.

Dr. Fox: Yeah. And it keeps coming.

Dr. Friedman: Right, it keeps coming. Sometimes people say they think they peed their self, but it wasn’t yellow, and it kept coming even when they stopped going to the bathroom and whatnot.

Dr. Fox: Yeah. And similarly, I tell people just like how, you know, 9 out of 10 times you’re gonna have contractions before it happens, meaning 1 out of 10 times it’s gonna happen. Probably about 9 out of 10 times it’s obvious. Meaning if I’m on call and someone calls me at 2 in the morning and tells me their story, most of the time it’s like, yeah, your water’s broken. Like, you know it, I know it, everyone knows it. Come on in. But 1 out of 10 times, it’s a little bit trickle, it’s a little more than usual. I’m not sure. Maybe I peed a little bit, which happens in their pregnancy because the baby’s sitting on your bladder, you know, a little bit of urine can come out, that wouldn’t normally happen. And so in those times that it’s confusing and it’s not obvious, what would you do? So it’s 2 in the morning, someone calls you and it’s sort of not clear what’s going on. How could someone maybe determine at home?

Dr. Friedman: At home I would say, you know, assuming everything else is fine, you’re not bleeding, you’re feeling the baby moving, all those good things. I would say put on a pad, you know, in your underwear, stand up, walk around, do a few laps around your house, your apartment, wherever you are, and see if the pad gets wet and if you’re noticing continued trickling. And if you don’t have, you know, another drop of anything, go back to bed and we’ll see you in the morning, or call back if anything changes. But most of the time if the water’s really broken, then they’ll call back and say, “Oh yeah. It happened again.” At that point I say, “Come on in. Something’s going on.”

Dr. Fox: We’re gonna talk about why we tell people to come on in. But before that, if someone is unsure that their water’s broken and we’re unsure that the water’s broken, what can we do, not over the phone like you just mentioned, but in person, either in the office or in the hospital to really get a sense of whether someone’s water’s broken or not?

Dr. Friedman: Yeah. Basically on exam, we have to do, you know, a vaginal exam with one of those lovely speculums that we use. We can look with our eyeballs, and a lot of times we can just see the amniotic fluid sitting in the top of the vagina. Sometimes we might ask you to cough or bear down a little bit so we can see it coming out. And it looks very different than regular discharge, you know, what was normally there. And we do this all the time, so it’s pretty clear to us. Amniotic fluid also has a different pH than what is typically in the vagina. So we can do a pH test called the nitrazine test, which will tell us. We can spread some of the fluid on a slide and look under the microscope and see certain characteristics or features that we would expect to see in amniotic fluid as opposed to normal vaginal secretions or discharge.

Dr. Fox: Yeah. It’s interesting. The first one where you see it in the back of the vagina, we call that the pool test.

Dr. Friedman: Yeah, the pool test.

Dr. Fox: Because it’s pooling in there so that you’ll…some… I mean, the listener may not, but we hear like the students and residents say, you know, there’s pooling or positive pool or something like that. So that’s pretty clear. The second one we call nitrazine because that’s the name of the substance that, you know, changes color based on the pH of the fluid. And then the third, which is really, it’s such a nice thing to show a med student, you know, at 3 in the morning, we call it the fern test. Because when it dries and crystallizes, it looks like these fern trees. It’s actually very pretty.

Dr. Friedman: Yeah, it is pretty.

Dr. Fox: It’s beautiful. Yeah.

Dr. Friedman: It’s interesting.

Dr. Fox: It crystallizes. And so those things we use, and it’s rare that I need to do all three tests to figure out if someone’s water’s broken. Sometimes…and again, when you’re training at residency, you always do all three because you’re learning and you’re trying to like be 100%. But usually, you know, before the exam, but then if you have to do it, it’s pretty clear what’s going on. There is a commercial test out there called AmniSure, which is basically like an antibody test or something that’s just an amniotic fluid. Interesting fact. I know the guy who developed that company sold it for a boatload of money.

Dr. Friedman: I’m sure.

Dr. Fox: Great job. We don’t use that as much full-term. It’s much more useful like preterm when the stakes are really high in terms of figuring this out. It can be used at term, but it’s not…

Dr. Friedman: It’s not actually necessary.

Dr. Fox: It’s not a routine test. We don’t personally routinely use it. I don’t know if they are commercially available or they might become commercially available where people can check at home. And I think it’s using this technology. I’ve never seen anyone use it or use it myself. I have no idea what the availability is of that product. But that’s what we do in the hospital. Okay, so let’s say we’re highly confident someone broke their water on the phone, or they come to the office, go to the hospital, and we think their water is broken. You mentioned before we’re gonna have you come in, right? So I agree with that. That’s what I do as well. But let’s talk about that.

So, there’s two options, and people ask a lot. You know, why am I doing this versus this? And one option is if the water’s broken, we consider it like labor, come to the hospital and we’re going to evaluate you. And sort of if you’re not by then in labor, push you into labor. Whether you call that an induction or an augmentation is semantics. It’s not truly an induction because a process has started. Okay? Versus stay at home, wait until you go into labor. And then once you’re in labor, or again, if something changes, you start bleeding, you have a fever, whatever, come in then. So those are the two options. Why do you prefer, let’s bring ’em in?

Dr. Friedman: Yeah. I think that there’s pretty good data to support that doing the first thing where we bring ’em in and push labor along has much better outcomes, specifically in regards to infection and other potential, you know, bad outcomes. We know that, you know, risk of C-section or anything like that is not increased. And so if we have nothing to lose and a lot to gain, why not just come in and get this process started in a safe, monitored place where we’re watching the baby, we’re watching you, we’re making sure, you know, no signs of infection, and if so, we can treat the infection and things like that.

Dr. Fox: Yeah. And this is one where there are differing practices out there and some of that is more based on, I would say like, the experience of the woman in labor more so than the data. Meaning the data is very strong. This has been studied. I mean, people have done very big studies where they take, you know, term PROM, no infection, no nothing, and half the women they induce, the other half they send home for up to three days or whatever it is. And ultimately, there is no difference in the rate of C-section. Meaning coming in and getting Pitocin or whatever it’s induced does not increase the risk of C-section compared to going home and wait until you go into labor. That’s been studied extensively. So that’s not a risk. And the risk of infection to the mother and baby is higher if you go home.

Now, I don’t say that to scare people because it does not tend to be the type of infection that’s life-threatening to mother or baby. Meaning it doesn’t increase the risk of like, something horrible happening to the baby. But, you know, if you get an infection, the baby gets an infection. They need antibiotics, they go to the NICU. You know, it’s unpleasant in that sense. And so when you hear that, right, if you’re just looking at the data, it would say, well, come in. Like really no downside. And there’s an upside of lowering the risk of infection.

But some people look at the same data and say, all right, I still would rather stay at home just because that’s the labor I want. That’s the experience I want. And that’s considered reasonable. We don’t do it in our practice, but like if you have a midwife or doctor who has recommended that, it does not mean they’re outside the pale. Like, it is considered reasonable, but you have to understand that coming in does not increase your risk of C-section and it does decrease the risk of infection. There are some people who differentiate if you’re group B strep positive or negative. There’s also how fast is your labor? You know, if this is not your first, sometimes the labor can be quick.

Most people, I think 70% will be in labor within 24 hours and 95% within 3 days. So, there’s a lot. Some people say, you know, wait at home for X amount of hours. I basically tell people, as long as everything’s okay, you have time to grab your bag, take a shower, you know, have something to eat, and then head at me. You don’t have to call an ambulance to come in necessarily. But I tell people I prefer you don’t, you know, just wait till labor happens because I prefer not dealing with the infection. And that’s…I would say the general practice in the U.S. is to have people come in, but like I said, not uniform. Do you get a lot of pushback on that in your own practice?

Dr. Friedman: I don’t think so. Not usually.

Dr. Fox: I guess in our practice, not so much. Every now and again, but not so much. And there’s, again, some people, if they’re going places where they routinely have ’em wait at home, then maybe it would be a little bit different if someone came in.

Okay. So someone is coming into the hospital and their water’s broken. You’ve already evaluated them, so you’re confident their water’s broken. What do you do then?

Dr. Friedman: Yep. So basically, you know, once we’re ready to go, we try to get the contractions going. So, sometimes patients will choose to get an epidural before we start anything. But really, you know, the options for bringing on contractions are to start something called Pitocin, which is, you know, the same hormone that your body releases to make you contract, but we just give it through the IV in a very controlled fashion. Or if the cervix isn’t very dilated and you wanna… You know, some providers will use what we call cervical ripening agents, one’s called misoprostol, one’s called Cervidil. Those are also options as well. But most of the time, we’ll sort of just start with the Pitocin because the outcomes are just as good and it’s usually the easiest with the least risk for infection.

Dr. Fox: Yeah. It’s interesting because, you know, like I sort of mentioned before, I don’t consider this an induction. Meaning if someone’s coming in for an induction of labor, they’re not already in labor, and their water’s not broken, and we’re trying to like jumpstart them. Put ’em into labor. And that, as we said in the induction podcast, takes a fair amount of time, especially if it’s your first baby, requires a lot of patience, or often we have to do something like a balloon or a cervical ripening agent before we do Pitocin. And that’s all true for induction. But as someone whose water’s broken, that process is much quicker. Meaning…

Dr. Friedman: Usually.

Dr. Fox: Yeah. No, not always, on average. Meaning you don’t typically need something like the balloon or the cervical ripening agent. The data is that if you just start Pitocin, it’ll happen at the same speed, which is not the case if you’re inducing someone’s labor out of nowhere, right? Starting Pitocin will work, but it’ll take a lot, lot longer. And so it typically goes faster. It typically doesn’t matter which agent you use, again, if someone’s water’s broken. And there are people, it’s more common that it’s gonna be fast, right? Every now and again, you know, you start and their cervix is closed, and then they’re two centimeters, and then like three hours later they’re pushing, and even with the first babies. Because there’s something about people when the water’s broken, either it’s because a process has already started, or it does initiate a process. Like part of our induction protocol is to break someone’s water for that exact reason.

Dr. Friedman: Exactly.

Dr. Fox: Yeah. So for those of you who, when your water breaks, again, you may not feel like you’re in labor, but there is a process that has started. And so it’s a lot easier to sort of push that along if we want to. Do you have any concerns about someone as their water breaks at home? Are there any circumstances where that’s more concerning to you? Like, let’s say they’ve had a very high amount of fluid beforehand or something like that. Is there something where you again, would have more concern for someone?

Dr. Friedman: Yeah, I think if they had a lot of fluid and there’s…you know, especially if the baby maybe isn’t head down, you want the patient to come in right away so we can see what’s going on. Basically, if the baby’s not head down, you know, when the water breaks, we are concerned that another body part of the baby might come down like a foot or an umbilical cord or something that we really, really don’t want coming out of the vagina. So, the sooner you can get in, the better.

Dr. Fox: Yeah. I mean, generally, the times when we tell people to come in like rapido if their water breaks is, again, if they had high fluid, the baby wasn’t head down. If the fluid is like an odd color like green or it smells bad or there’s bleeding, or you have a fever and you feel like you’re infected. So those are things where it’s more concerning, not that the water broke, but sort of what’s going on as well. But usually, if it’s clear fluid and you otherwise feel okay, it’s okay, like we said, to wait a little bit. And then when someone’s already in labor and things are looking fine, do you think much differently about them if their water has been broken for a while before?

Dr. Friedman: You know, in the back of my head I’m always looking at, you know, wondering maybe they’re gonna show signs of an infection sooner than they might have otherwise. But as long as mom and baby and everything are looking stable, not really.

Dr. Fox: Yes. Nowadays, I mean this is for a long time, we test routinely for group B strep. So, if the group B strep is negative, we don’t worry about X amount of hours with ruptured membranes. People have this thought that…and this comes up a lot. Well, once my water’s broken, the clock starts, and the baby has to be out within 24 hours. I have no idea who invented that clock or…

Dr. Friedman: Me neither.

Dr. Fox: …whose clock that is. That clock does not exist in like medical literature. So yeah, there’s nothing about your water being broken for a long time. It increases the risk of an infection, but it’s not something that means you have an infection and we have to do anything about, we just sort of watch and wait. Now, if someone has a history of it happening in last pregnancy, and they ask you, “Is it gonna happen to me again in this next pregnancy?” What would you say? You know, pregnancy number two.

Dr. Friedman: I don’t think so. Ten percent chance.

Dr. Fox: Yeah. I see just as many people who it does happen to again, as it doesn’t. I don’t know what the data is on that, whether there is a higher risk of it happening, or it happened to my mother every time, it happens to my sister. I don’t think so. I think we don’t really understand why labor starts or why someone’s water breaks usually. It does not seem to be from activity or for anything like that. We just don’t know. There’s so much we don’t know.

Dr. Friedman: No, I know.

Dr. Fox: It’s very sad.

Dr. Friedman: Frustrating. I know.

Dr. Fox: All right. Good stuff. All right. Term PROM. That was a brief podcast…

Dr. Friedman: Your first prom.

Dr. Fox: …but an important one. Yeah, this was my first prom. Thanks for letting me take you to the prom, or thanks for taking me to the prom, I guess.

Dr. Friedman: My pleasure. Anytime.

Dr. Fox: Good times. Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day. The information discussed in “Healthful Woman” is intended for educational uses only and does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.