Premature Rupture of the Membranes (PROM) and Birth Injury

Premature Rupture of Membranes (PROM) occurs when the “water breaks.” The amniotic sac that holds the baby and the amniotic fluid may rupture before labor begins.

In most cases, this rupture prompts the onset of labor, but it usually requires medical intervention and monitoring. The amniotic fluid and sac serve as a protective layer for the baby. Losing that layer places the baby at risk for numerous health issues, such as:

• periventricular leukomalacia (PVL)
• hypoxic-ischemic encephalopathy (HIE)
• neonatal encephalopathy
• cerebral palsy
• developmental disabilities
• microcephaly
• sepsis or meningitis

When PROM occurs before 37 weeks, it is known as preterm premature rupture of membranes, or PPROM.

PPROM occurs in eight percent of all pregnancies. With prematurity accounting for roughly 11% of births, PPROM occurs in only three percent of pregnancies.

When PROM or PPROM occur, the mother must receive antibiotics to prevent infection. Normally, the amniotic fluid protects the baby against infection. C-sections are often necessary in cases of PROM and PPROM.

Physicians should make every effort to prevent PROM. Prompt diagnosis is essential. Medical staff should also treat infections such as chorioamnionitis and group B strep (GBS).

PROM/PPROM can occur naturally. However, frequent and unnecessary cervical exams late in pregnancy can trigger PROM/PPROM. Examinations can lead to infections after a rupture or during restricted bed rest in the hospital. These complications also may contribute to fetal distress and a possible C-section.

The causes of PROM/PPROM are sometimes unclear. But it is more likely to happen in women who have experienced (1,4):

• Prior PPROM: Women with a history of PPROM and preterm delivery have an increased chance of PPROM happening again. There is a 13.5% rate of recurrence in subsequent pregnancies.
• Prior preterm labor and delivery
• Genital tract infection: Genital tract infection is the most common risk factor for PPROM. Common infections include bacterial vaginosis, urinary tract infections, chorioamnionitis, and Group B strep.
• Antepartum bleeding: Bleeding in the first trimester can indicate a risk of PPROM.
• Cigarette smoking: smokers have a two to fourfold increased risk of developing PPROM compared to nonsmokers.
• Polyhydramnios: an excess of amniotic fluid
• Placental abruption
• Poor nutrition
• Previous cervical surgery, including cone biopsies or cerclage
• Overstretching of the uterus and amniotic sac, which sometimes occurs with multiple fetuses or too much amniotic fluid (hydramnios)

PROM and PPROM are associated with the following complications:

• Premature birth: The main risk of PPROM is premature birth, or birth before 37 weeks. This can lead to many serious neonatal complications.
• Fetal distress
• Respiratory distress syndrome (RSD)
• Infections: The fetus is at a higher risk of infection after the leaking of the amniotic fluid that surrounds and protects it.
• Loss of nutrients
• Sepsis
• Umbilical cord prolapse: a complication in which the umbilical cord comes out before or alongside the fetus and can be compressed. This can cause birth asphyxia, periventricular leukomalacia (PVL), and hypoxic-ischemic encephalopathy (HIE). Umbilical cord compression usually requires an emergency c-section.
• Placental abruption
• Chorioamnionitis: the inflammation of the fetal membrane
• Malpresentation
• Oligohydramnios
• Necrotizing enterocolitis (NEC)
• Intraventricular hemorrhage (IVH – brain bleeds)
• Periventricular leukomalacia (PVL). Although PVL can occur in term infants, it is most frequently found in premature babies.
• Hypoxic-ischemic encephalopathy (HIE). HIE usually occurs in term infants, but sometimes premature babies can develop it. HIE usually involves damage to the basal ganglia, cerebral cortex, and watershed regions of the brain and can sometimes also include PVL.
• Neonatal encephalopathy
• Permanent brain damage
• Seizure disorders
• Cerebral palsy (CP)
• Motor disorders
• Microcephaly
• Meningitis
• Fetal death

Water breaking

The most important symptom of PROM/PPROM is fluid leaking from the vagina. This is what is often referred to as “water breaking.” It usually feels like a sudden gush or a slow trickle of fluid from the vagina. The fluid is clear or pale yellow.

Many women describe the “water breaking” as a constant or intermittent leaking of smaller amounts of fluid, and others have observed it as a sensation of wetness.

If you think your water has broken, whether prematurely or during labor contractions, call your doctor immediately.

Signs of infection

Infection and PROM/PPROM can occur together. Thus, it is important to recognize the signs of infection. Signs of infection include the following:

• Contractions of the uterus
• Increased temperature and heart rate (in the mother)
• Tenderness of the uterus
• Foul-smelling vaginal discharge
• Increased white blood cell count or a change in the pattern of white blood cell type
• An increase in the baby’s heart rate

Physicians can diagnose PROM using a thorough history, a physical examination, and lab testing.

They can observe amniotic fluid that has pooled or is coming out of the cervical canal. They can also use a speculum to determine if fluid is leaking from the cervix. If the fluid isn’t immediately present, the patient may need to cough or push gently on the fundus to push some of the fluid out. Medical staff test the sample of fluid to verify that the fluid is amniotic.

An ultrasound can determine the amount of amniotic fluid around the baby. Roughly 50-70% of women with PPROM have low amniotic fluid volume in the first sonography.

If a medical professional failed to properly treat your condition during pregnancy or delivery and your child was harmed as a result, contact a knowledgeable birth injury lawyer to better understand your legal options.

When PROM and PPROM occur, medical staff should typically give antibiotic treatment to the mother. This treatment helps to avoid possible infection in the newborn. 

Infection can lead to:

• premature birth
• sepsis
• meningitis
• hypoxic-ischemic encephalopathy
• periventricular leukomalacia
• cerebral palsy
• intraventricular hemorrhages (IVH).

In a term pregnancy where PROM has occurred, spontaneous labor usually is permitted. Current care standards suggest that labor induction is beneficial at or after 24 weeks. However, many physicians induce labor immediately.

Research suggests that an induced labor is less likely to result in uterine infection. Usually, physicians give antibiotics to ensure that no infection spreads to the baby.

When PROM occurs after 37 weeks, your doctor will likely induce labor within 24 hours. Medical staff usually choose to induce labor if PROM occurs between 34 and 37 weeks, too. The risk of infection is greater than the risk of the baby being born a few weeks early.

If PROM occurs before 34 weeks, the situation is more complex. If there are no signs of infection, the physician may determine it’s too soon to deliver the baby safely. Medical staff will usually try to delay labor with medication.

Corticosteroids

Corticosteroids decrease perinatal morbidity and mortality when used to treat PROM. They are commonly used with babies likely to be born prematurely. Corticosteroids accelerate lung development within the womb. Before using this medication, the physician will test if the baby’s lungs are mature by collecting a sample of amniotic fluid.

When PPROM occurs before 32 weeks of pregnancy, it is best to delay delivery. Medical staff will give corticosteroids.

Research shows that steroid treatment reduces: 

• neonatal death
• respiratory distress syndrome
• intraventricular hemorrhages (IVH) or brain bleeds
• necrotizing enterocolitis
• duration of neonatal respiratory support 

The steroid treatment reduces the likelihood of these conditions without an increase in either maternal or neonatal infection. Babies delivered this early often have RDS, IVH, and intestinal problems (NEC).

The use of corticosteroids even after 32 weeks showed a number of benefits for the infant. These babies had lower rates of respiratory complications, and they needed surfactants less often. Surfactants are a medication applied to the lungs through a breathing tube. This can help stabilize a premature baby’s developing lungs. Babies whose mothers did not receive this treatment experienced more complications.

Antibiotics are also used to treat PROM because they can reduce neonatal infections. A study found that an antibiotic treatment reduced rates of chorioamnionitis and neonatal infection. Antibiotic use also coincided with fewer infants receiving oxygen therapy or having an abnormal head ultrasound.

Infection can be both a cause and a consequence of PPROM. Medical staff should administer antibiotics as a precautionary measure to prevent or treat infection as soon as possible. The goal of antibiotic therapy is to:

• decrease the frequency of maternal and fetal infection
• delay the onset of preterm labor
• minimize the risk of chorioamnionitis, cerebral palsy, and other known complications associated with infection.

A premature baby with an infection is much more worrisome than a premature baby without an infection. Ideally, the baby should be delivered before infection occurs. This is difficult to predict, so close monitoring is essential. Medical staff should rely on signs of infection or changes in the baby’s testing (even subtle ones).

After premature rupture of membranes, the baby’s delivery must happen as soon as possible. As more time passes, the risk of infection increases. The risk significantly increases if labor does not occur within 12 hours of the membranes rupturing.

The main goal is to keep the baby safe and protected from infection. Waiting for a natural delivery after PROM is dangerous. The delivery may not occur within a safe time frame.

Physicians may resort to risky options to force the delivery. Using equipment like forceps and vacuum extractors can cause traumatic birth injuries to the baby. Complications can come from using potentially dangerous drugs like Cytotec and Pitocin to speed up delivery. If your child was harmed by medical providers’ mistakes, you may be entitled to bring a medical malpractice claim to recover the financial compensation needed to provide for their care. Talk to a qualified birth injury lawyer today to learn more.

Many complications can occur with premature rupture of membranes. Physicians must closely monitor the mother and baby when PROM/PPROM takes place. Timing is crucial to prevent infection and to ensure that the baby’s lungs are mature at birth.

Medical negligence occurs when a physician or medical team fails to:

• follow medical guidelines
• meet standards of care
• properly monitor the infant
• perform a timely C-section when necessary.

If this negligence leads to injury of the mother or baby, it is medical malpractice, and medical professionals can be held responsible for the harm they cause.