Waiting for labour to start is one of the most challenging experiences for pregnant mothers. There are so many unknowns and questions – “Is it today?”, “Is this a contraction?”, “When do I call someone?” And, of course, THE MILLION DOLLAR QUESTION: “Did my water break or did I just pee?” and “How can I tell the difference!?”
Setting the facts straight.
Contrary to what we see in the movies and on television, most women's "water" does not spontaneously break (AKA "ruptured membranes") until they are in well established labour--it actually most commonly happens between 7 and 10 cms dilated. This means your chances of experiencing this potentially awkward situation without any other signs of labour is around 10-14%. So the good news is that you don’t have to feel trapped in your house and avoid public places for fear of your membranes rupturing! The probability is low it will happen in the grocery store!
When your water breaks or membranes rupture, it means that a hole has been made in the bag of fluid (AKA "amniotic sac") that surrounds your baby while she is growing in your womb. The amount of fluid that leaks out can range from a tablespoon that leaves your underwear damp--thus the question: Did I just Pee?--to cups of fluid that gush out, running down your legs and leaving no question as to what is going on. How much fluid you lose depends on a variety of factors including the amount of fluid you have surrounding your baby (everybody is different), where the hole in the sac occurs and how deeply your baby’s head is engaged in the pelvis.
Having a lot of fluid usually means more escapes when your water breaks. Also, if the hole is right in front of the baby’s head more fluid will come out in a gush and conversely only an occasional trickle may escape if the hole is higher up. A deeply engaged head will act as a plug, so if your baby's head is deep in your pelvis you may experience a slow trickle that can be very confusing, making it hard to know for sure what is going on, while a head that is floating higher up in the pelvis can be the stage for a big gush!
As you get closer to term, your body releases enzymes whose job it is to weaken the amniotic sac. Ideally the enzyme release is timed so that the rupture occurs during labour. Pressure on the bag in front of the head increases with the increasing intensity of the contractions. This allows the fluid-filled bag in front of the head to act as a wedge, assisting in thinning and opening your cervix. When enough pressure is exerted on the membranes, they will rupture and a hole will have formed in the sac. Essentially, your water will have broken and there is no turning back--your baby is on his way!
Until the water breaks, the amniotic sac has acted as a protective barrier between the sterile womb and the outside world. Therefore having a hole in the bag represents a breach in the security system – creating an opportunity for bacteria to creep up into the uterus and an increased risk of infection for both mother and baby over time.
If you are one of the 10-14% of women who rupture their membranes before labouring, it may mean you will begin labour soon. Research shows between 77% and 95% of term women will go into labour spontaneously within 24 hours. However labour doesn't always start right away and if it doesn't, it means there can be an increased risk of infection. The number of vaginal exams a woman receives during this period can contribute to an increase in infection rates and so exams are not recommended until after the labour starts. Other recommendations include not introducing anything into the vagina like tampons, not having sex and not taking baths until labour starts.
Given the potential risk, if your water has broken, or you think it might have, it is very important to contact your care provider to assist in correctly identifying the fluid and discuss your options for care. Depending on your gestational age, Group B streptococci (GBS) status and risk of infection, your care provider may suggest “expectant management” or “induction of labour.”
When a mother’s water breaks at term, prior to labour, it is referred to as Premature Rupture of Membranes or PROM. If the waters break prior to 37 weeks this is called Preterm Prolonged Rupture of Membranes or PPROM. The causes of both PROM and PPROM are thought to be associated with infections or inflammation of the membranes causes by yeast or bacteria like GBS. Risks of PROM and PPROM also include a history of preterm labour, smoking, or vaginal bleeding in pregnancy. It is also associated with urinary tract infections and vaginal infections. Active babies in unusual presentations such as breech, or posterior positions can also cause your water to break.
Women describe the sensation of their water breaking as an obvious gush of fluid with or without a “popping” sensation. Or sometimes it is a slow leak that trickles out and only moistens your underwear. Even more perplexing is the fact that other body fluids such as urine, vaginal discharge, semen or even bath water can mimic the sensations of your water breaking.
So how do you know the difference?
The time, the amount of fluid, the colour and the odour of the fluid are all important in assessing ruptured membranes.
Amount: First, if you think your water broke take a minute to ask some questions.
One of the hallmarks of ruptured membranes is that the flow of water is uncontrollable and will continue to leak despite your best Kegel attempt! If there is a gush or trickle of warm fluid that continues to leak when you move or change positions, it is most likely your amniotic fluid and your waters have broken. If you are not sure, make your way to the bathroom and put a fresh pad or panty liner on to collect fluid for further testing. Then lie down on your couch or bed to do a “pooling” test. If your waters have broken, amniotic fluid will collect and pool inside your vagina. Lie quietly for a half hour before getting up. The pooled fluid will escape as you stand and can be captured for further examination and testing. If your pad is dry it was most likely another source of wetness such as urine, vaginal discharge, semen or water.
Odour: If your pad is wet, it still might not be your amniotic fluid.
It is very easy to confuse ruptured membranes with a moment of urinary incontinence. Your growing baby puts extraordinary pressure on your confined bladder. A cough, sneeze, or even a shift in the baby’s head can cause the bladder to release some urine unexpectedly. Most people can identify the acidic smell of ammonia in urine. If the fluid smells like urine, it probably is – amniotic fluid is often described as being more sweet and musky.
Colour: Amniotic fluid is often described as “clear” in colour. However, I often describe it as looking like coconut water. It is clear but not clean as there can be flecks of vernix (the white protective coating on the baby that protects the baby’s skin) that can be floating in the waters. Maturity and stress can cause the baby to have a bowel movement releasing meconium into the fluid. Depending on the amount of fluid to dilute the meconium, the fluid colour can range from green staining, like green tea, to green-yellow thicker consistencies, and from particulates to pea soup. Your care provider will need to determine whether the baby has experienced some stress. If the fluid on your pad is green it’s especially important that you communicate that information to your care provider.
Time: Make a note of the time when you experienced the gush or trickle of fluid.
Remember important decisions will be made about your labour based on the length of time your membranes have been ruptured. It is important the source of leaking is identified as soon as possible. If you have experienced some leaking and you are still not sure what it is, call your care provider to do further testing at the clinic or hospital. Bring your wet clothing or pad to use Nitrazine or PH paper on. Swabbing the fluid can help diagnose amniotic fluid as it is a different ph than other bodily fluids. When it is very unclear, sometimes a speculum exam is required to actually visualise fluid coming from the cervix and to do what is called a “ferning” test. Dried amniotic fluid has a very distinctive pattern that looks like a fern leaf. When this pattern is seen we finally know we are dealing with ruptured membranes and not a leaky bladder!
In summary, assessing ruptured membranes is tricky business. Thankfully it is not very likely to happen prior to labour starting, however if you think your membranes have ruptured it is important that you contact your care provider.