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rosehips
02-01-2013, 02:09 AM
If a woman goes into premature labor (just over three weeks early) and her water breaks, what happens when she gets to the hospital?

I had my own son three weeks early, but my situation was different--I had preeclampsia, so they provoked. A few weeks before that I started having preterm labor, but they were able to stop it using I forget what drug. Of course, my water hadn't broken. In this situation, the woman goes into labor early and her water breaks, so it's my understanding that there's no going back. Would they put her on an IV? I had one because I had to have antibiotics and magnesium, but I know that's not standard. Are there other reasons to have an IV? Would they try to bring in an anesthesiologist? I'm guessing the nurse would do a pelvic exam to check how dilated she is?

The order of actions would be good to know. Thanks!

cornflake
02-01-2013, 02:29 AM
I don't think three weeks is considered premature?

Also, they like IVs because they may need to use them, but that's up to the patient, same as an anesthesiologist - if someone plans on having anesthesia vs. plans on not.

waylander
02-01-2013, 03:29 AM
Where is this happening?

rosehips
02-01-2013, 03:44 AM
Thanks for the responses! Way, it's in a large hospital in Sacramento.

This is actually another reason I need to ask, as my hospital was small, in a small town. :) So thanks for asking, Way.

ETA: Cornflake, my understanding is that three weeks is the cut-off. That's why they waited until I was three weeks away to provoke. My character is just over three weeks away, so it's technically premature. Plus, all the doctors I saw told me they really don't like to let a baby come early at all, even if it is only three weeks. But you're right, I don't think they would say the baby was premature. Maybe there's another word?

ULTRAGOTHA
02-01-2013, 04:53 AM
According to my wife, who was a postpartum nurse at a large hospital in Sacramento (back in 1994 so this may be oldish info), once the water breaks they'd deliver the baby (especially if it's only three weeks early). They'd either encourage the labor or do a c-section, depending on circumstances.

First, they'd run a test to make sure it's amniotic fluid and not something else. They would want to make sure it actually is the membranes rupturing and not something else.

Then they'd admit her and get her insurance information, name of her doctor, and have her sign all the consent forms.

Then do vital signs.

Then start an IV. Mostly just to keep a vein open but she says they might also add glucose because they won't let her eat any more in case they need to do a c-section. An IV would be strongly indicated in this circumstance and she'd have to really object to not get one.

While the IV is getting going, others would call her doctor (out of her hearing) to tell him she has broken membranes and give the Dr her vital signs and get her medical records.

At this point her Doctor would give orders to the hospital staff on what to do next.

They would limit pelvic exams as much as possible to limit infection. (This was a major cause of maternal death in pre-germ-theory days.)

They wouldn't bring in an anesthesiologist at this point. You're probably hours away from even needing an epidural, says Mrs. ULTRAGOTHA, RN. If the patient and Dr agree on an epidural or if a c-section is needed, at that point they'd call in an anesthesiologist.

Plains Pen
02-01-2013, 07:48 AM
A few more details. I delivered babies up until last year.
40 weeks is considered "term" or the due date. Any time 2 weeks before or after this is considered normal for delivery. In general, deliveries as early as 35 weeks are considered pretty routine, and are done in a small rural hospital like where I practice. Deliveries before that time get increasingly at higher risk with each week.

One thing to consider is that it is rarely known with precise certainty the day a pregnancy began, and so while there are ways to calculate and guess whether someone is at 37 weeks, it could be that the timing is off by one or two weeks (commonly) or even as much as 3-5 weeks (rarely). Because of this, deliveries around 37 weeks could actually be 34-35 weeks if the dates are off a bit. Even sonograms are not super-precise, unless they are done very early in the pregnancy.

So really long way of saying that at 37 weeks, your mother would receive exactly the same sort of care as she would at 40 weeks, but everyone would realize that she might be a little earlier than that, in which case after the baby was delivered, the baby might have a bit of prematurity, and might need more aggressive measures than the usual keeping warm/dry thing.

And I agree with everything ULTRAGOTHA posted above.

Fantasmac
02-01-2013, 08:35 AM
Ms. ULTRAGOTHA, RN pretty much nailed it. I'll add that the mother would be hooked up to a fetal heart monitor almost immediately. There are certain patterns you look for in the fetal heart rate to determine if it's doing well or in distress.

They wouldn't do a pelvic exam like you get at the gynecologist. But the doctor or nurse would examine the vagina with sterile gloved fingers to assess cervical dilation and fetal descent.

She would almost certainly have an IV, because it's better to have it and not need it. She might need a drug like pitocin to speed up the contractions or, depending on how early she is, corticosteroids for the baby's lungs (which are pretty much the last thing to develop in the fetus and a primary cause of preterm complications). She might also just get fluids (normal saline or lactated ringers). If she gets pain medication then she'll need fluids because epidural anesthesia is associated with drops in blood pressure.

I did my last OB rotation pretty recently. Let me know if you have anymore questions and I'll crack open the textbook.

*And I think you mean induce labor, not provoke. As far as I know making the vagina angry won't help anything ;)*

rosehips
02-01-2013, 09:37 AM
Thank you for these great responses!


First, they'd run a test to make sure it's amniotic fluid and not something else. They would want to make sure it actually is the membranes rupturing and not something else.What kind of test?


*And I think you mean induce labor, not provoke. As far as I know making the vagina angry won't help anything * LOL... yes, you're right! That was a Frenchism. In French you provoke labor--I speak to my mother in French and we had many conversations at the time, so that's the word that stuck in my head. :)

Fantasmac
02-01-2013, 11:09 AM
What kind of test?


They'd either test the pH or do a fern test. I've only seen the first one done because all you need is pH paper and it's quick. If the fluid is basic (about pH 5 and above) then it's probably amniotic fluid. But they can also do a fern test where they take a little bit of fluid and spread it on a glass slide. When amniotic fluid dries it forms a pretty distinct fern pattern.

There are other clues as well. You can measure the amount of amniotic fluid on ultrasound -- a marked decrease probably means her water broke. The doctor can also often feel if the amniotic sac is still intact through vaginal exam. All of the available information would be used to make a diagnosis.

Canotila
02-01-2013, 11:42 AM
IVs are pretty standard from what I understand. I have two children born in two different states, one in a hospital and one in a birth center. Both times they gave me an IV just in case. Sometimes things happen fast, and it's a lot easier in an emergency if you're not trying to get an IV in a vein in between contractions.

When I had my son there were a lot of complications. When the fetal heart monitor showed that he was in distress they brought a team of folks into the room, including an anesthesiologist. I was told that the anesthesiologist wasn't there for anything surgery related, but in case the baby needed resuscitating. Maybe they lied so I wouldn't freak out though, ha ha.

Lia_joy
02-02-2013, 01:11 AM
Another thing to consider: If her waters break, but she's not in active labor, they would likely want to induce labor by putting pitocin (synthetic oxytocin) in her IV.

Mrs. de Winter
02-02-2013, 07:51 AM
It has been a few years since I worked in labor and delivery so my memory is a little fuzzy, but they would test the fluid to see if it is amniotic fluid and not urine/vaginal secretions. They would do a cervical check and put her on the monitors for a little bit to see if she is contracting and check on the baby. If she is not in labor yet, they might encourage her to walk around or bounce on a big exercise ball to see if that helps labor get going. They would start an IV but may just leave a heplock in and not hook anything up yet. If nothing is happening after a few hours, they would start IV Pitocin. Once the water breaks, they usually want the baby delivered within 24 hours or so to avoid an infection. Some hospitals will "allow" clear fluids, especially if she is not in active labor, so they might bring her a Popsicle or broth. Sometimes amniotic fluid breaks are just little trickles and sometimes they are like Niagara Falls. There is enough variety in birth and different hospital practices that you can really tailor it to your creative needs.

Ravenheart
02-02-2013, 08:03 AM
I actually had my last child as a planned home water birth. Three weeks early is actually what my midwife said was the limit for home delivery (i.e. within normal range) otherwise she would refuse care and I would have to go to a hospital if it were any earlier. My second child was four weeks early. I had her in the hospital. She came out perfectly healthy but they did have me do something most parents don't have to. Since she was slightly premature they had me bring in the entire car seat, base and all, and monitored her vitals for an hour while strapped into it the day before we were supposed to go home to make sure she'd be okay. Also, since she was slightly premature she had a small issue with temperature regulation (staying warm) at first and they had me use an SNS with breastfeeding at first until my milk came in. Later she had a ventral (not sure if I'm spelling that right) hernia which at age four is still unresolved and she has a heart murmur but that could be unrelated to being premature. She was 6 pounds 6 ounces at birth, a nice healthy weight. Hope this helps...

Elizabeth Holloway
02-02-2013, 12:33 PM
You've received some great responses here. As a labor and delivery nurse who has worked in both a large city hospital and a small town hospital, I don't really have anything to add. But, if you have any more questions, you can PM me. I've been a perinatal nurse (labor, delivery, postpartum, and newborn nursery) for many years.

Petroglyph
02-02-2013, 07:21 PM
As with most things in birth, it depends.

At 37 weeks, we do not stop labor, especially if the water is broken.

What typically occurs in my practice is that the woman presents either to clinic or triage reporting that she thinks her water broke. Sometimes it's obvious (ie a towel between the legs) and sometimes it is not. If there is a ton of fluid coming out, a quick nitrazine check (small strip of paper to the fluid, ours turns bright blue) confirms. However if it is not obvious, we do a speculum exam, try to see the cervix, ask the woman to cough or bear down to see if fluid comes out of the cervix. I obtain the fluid on a q-tip, rub it on a microscope slide, let it dry and look under the microscope. Confirmation is ferning, and it looks like frost on a window.

Sometimes, women will go into labor on their own when their water breaks. Not always though so if 6 or 8 or 12 hrs pass, labor may be induced or augmented. Often with pitocin (medicine in the IV) or sometimes with a cervical ripening agent.

The initial cervical exam for dilation may be delayed to reduce the chance of infection. If it is not certain that the baby is head down, an ultrasound or a cervical exam can confirm presentation.

Typically there is an initial period of monitoring the contractions and fetal heart rate for 20 minutes or so. Further monitoring may also occur continuously or intermittently.

IV access may occur depending on mom's plan for pain management or other risk factors (antibiotics, hydration, any sort of risk).

Is there something you need to happen in a certain way for a story? All of this can be manipulated if you need something to happen or not happen.

akpeach
02-03-2013, 08:33 AM
The only thing I wanted to add is that if the mother had tested positive for Group B strep (a test they do earlier in your pregnancy) then the dr. would want to get iv antibiotics started as soon as possible, especially in the instance you're referring to because babies who are born before 37 weeks are more likely to contract it from a mother carrying it. So that's just something to consider. Not that the mother in your book necessarily would have tested positive for it, only that they would most likely ask her about it right when she was admitted.

McMich
02-03-2013, 05:01 PM
I wanted to add that if her water breaks and she is not immediatly at the hospital, she might be in active labor by the time she arrives (water breaking can really increase labor) My cousin had her water break at 6:30 in the morning, no labor pains at all, 36.5 weeks, and was at the hospital by 7:30 and had to go immediatly into pushing the baby out who arrived at 8:00. Very quick labor and techincally early. Within the time of going to the hospital and her water breaking, she arrived in full labor. She even said to her doc, remember those pain meds I was unsure about, I'll take them. And the doc said, oh sory hun, you're too far gone to do that, now let's push.

rosehips
02-04-2013, 04:07 AM
Thanks so much everyone! You've given me everything I need. I really appreciate it.

Debbie V
02-05-2013, 04:15 AM
When my water broke, I was not in labor. The doctor confirmed my water had broken via ultrasound. (He may have done an internal exam as well.)He also confirmed I was still producing fluid. If I had stopped producing fluid, I would have been sent straight to the hospital to induce labor. Since I was, I went in 24 hours after my water had broken. At this point they began to induce with pitocin and put me on IV antibiotics - the risk of infection increases over time. Skip 12 hours. Another pitocin suppository was used. I still hadn't dilated. They rolled me from one side to the other every half hour over night hoping to use gravity to assist dilation. Contractions became stronger at about three or four AM, but I wasn't dilated until around 10. My daughter was born very shortly thereafter. I did develop a low grade fever, but she was fine (APGAR 9, Then 10)

The story with my son was similar, but I was smarter. I didn't wait the 24 hours before going to the hospital. My body also reacted to the pitocin much more strongly.

shaldna
02-05-2013, 04:21 PM
If a woman goes into premature labor (just over three weeks early) and her water breaks, what happens when she gets to the hospital?

At only three weeks early, not much.

In fact, once you start labour not much tends to happen for a while.

On arriving at the hospital you will check in, then be seen by a midwife. If your labour isn't looking like it's going to go anywhere anytime soon, you may be sent home for a while - especially if the ward is busy.

Sometimes maternity wards have to close to admissions, so you'll be sent to another hospital nearby.

If it looks like you are going to go into proper labour soon then you will be admitted to a ward and possibly offered some mild pain relief - the maternity ward here will offer you cocodamol, or, if you are in real pain, gas and air. You won't be offered or given an epidural until your labour reaches a certain point as it can wear off.

After that, it's a waiting game. You'll be checked at routine intervals, and you may have a monitor attached to your stomach to montior the babies heart rate - this is quite tight and made me feel nauseous.

You'll possibly be given several internal examinations to determine what's going on, but if labour has started naturally you won't be given anything to advance it at that stage. Later on if labour isn't progressing any further you may be given something to help kick things up a gear.


In this situation, the woman goes into labor early and her water breaks, so it's my understanding that there's no going back.

No going back, but that doesn't necessarily mean that labour is imminent. My cousin had a soft break (ie. was leaking rather than gushing) for 8 days before she actually had her daughter.



Would they put her on an IV? I had one because I had to have antibiotics and magnesium, but I know that's not standard. Are there other reasons to have an IV?

They may. It depends on the individual labour - getting and IV in at the start when it looks like drugs might be needed is obviously easier than trying to get it in when labour is more advanced. Also, sometimes it's simply to keep fluid levels up - I know one woman who was physically sick wither her contractions and so they wanted to replace that lost fluid.


Would they try to bring in an anesthesiologist?

Only if she was going to have a section. That said, is it an anesthesiologist who administers an epidural? I didn't have one so I'm not sure, but others may be able to advise.

Mrs. de Winter
02-06-2013, 04:22 AM
At only three weeks early, not much.

In fact, once you start labour not much tends to happen for a while.

On arriving at the hospital you will check in, then be seen by a midwife. If your labour isn't looking like it's going to go anywhere anytime soon, you may be sent home for a while - especially if the ward is busy.

Sometimes maternity wards have to close to admissions, so you'll be sent to another hospital nearby.

If it looks like you are going to go into proper labour soon then you will be admitted to a ward and possibly offered some mild pain relief - the maternity ward here will offer you cocodamol, or, if you are in real pain, gas and air. You won't be offered or given an epidural until your labour reaches a certain point as it can wear off.

After that, it's a waiting game. You'll be checked at routine intervals, and you may have a monitor attached to your stomach to montior the babies heart rate - this is quite tight and made me feel nauseous.

You'll possibly be given several internal examinations to determine what's going on, but if labour has started naturally you won't be given anything to advance it at that stage. Later on if labour isn't progressing any further you may be given something to help kick things up a gear.



No going back, but that doesn't necessarily mean that labour is imminent. My cousin had a soft break (ie. was leaking rather than gushing) for 8 days before she actually had her daughter.




They may. It depends on the individual labour - getting and IV in at the start when it looks like drugs might be needed is obviously easier than trying to get it in when labour is more advanced. Also, sometimes it's simply to keep fluid levels up - I know one woman who was physically sick wither her contractions and so they wanted to replace that lost fluid.



Only if she was going to have a section. That said, is it an anesthesiologist who administers an epidural? I didn't have one so I'm not sure, but others may be able to advise.

Yep anesthesiologist does the epidural. They do both the initial procedure as well as any re-dosing/adjusting that might be needed.