Premature Rupture of Membranes at Term

How do you know your main bag of water breaks? You feel a pop & fluid bursts out of your vagina like a river, making a large ~ 2 1/2 - 3 cup puddle on the floor, or it totally saturates your clothes or where you were sitting/lying. You keep leaking fluid throughout the day that’s not pee, saturating your maxi pad like the first morning baby diaper, or your poured at least a few cups in it. It looks clear, blood tinged with white specs of vernix, or it’s brown/green color of baby’s first poop meconium (let your provider know). It does not look or smell like pee or semen (no history of recent sex). Your provider sees it flowing out of your vagina, pooling in your vagina on sterile speculum exam or on microscope, or simply + Amnisure test.

And it’s not the few tablespoons of fluid between the two membranes that can release before labor making ~ pancake size stain on your underwear, seat, sheets. It is important to know that as main membranous bag is intact. When in doubt discuss with your provider. They can confirm or rule it out. The test strip that turns blue with amniotic fluid is not diagnostic by itself as it can also turn blue with other things, like blood and even the fluid in between the membranes. It is important to be certain of the diagnosis of PROM. You do not want to be falsely diagnosed as “ruptured membranes” with all the possible unnecessary potentially treatment that entails.

PROM - premature rupture of membranes means when the main amnion bag of amniotic fluid breaks at term, before labor. It happens 8-10% of the time. It’s important to know for sure it’s not just a crack in the inner chorion membranous bag, leaving the main bag intact, so you’re not on the “clock” unnecessarily. Babies are double wrapped with a few tablespoons of fluid in between the two membranes - enough to make a pancake sized stain on your underwear or whatever you’re sitting on if outer bag tears, but then no further leakage. If in doubt, I advise wearing a maxi pad & walking around a few hrs. If it becomes saturated like an overnight diaper that’s the main inner bag with lots more fluid just > 1/2 liter; if it remains dry PROM is unlikely.
But is this “clock” evidence based? No. Recommending to induce to avoid risk of infection & stillbirth is based on outdated low quality studies from 1959s-1960s. According to newer quality research, as long as mom & baby are doing well & meet certain criteria, induction is just as much an evidenced based option as waiting for mama to go into labor on her own up to 48-72 hours later, without increased risk newborn health problems or death. 77-95% will go into labor anyway by 24 hours.

Many leading professional organizations like ACNM, RCOG, NICE, AOM, & RANZCOG recommend offering both options as acceptable as long as certain criteria are met - like single term uncomplicated pregnancy, clear fluid, no fever, no GBS, & normal fetal heart rate. ACOG says induce immediately but that if mom declines, waiting for labor to start on its own (expectant management) is acceptable. Waiting for labor to start on its own has very good outcomes for moms & babies. Induction of labor has strong consequences like the cascade of interventions, cesarean & birth trauma, & many opine it can not be justified as standard of care for a normal physiological occurrence in healthy term pregnancy.
It’s important to know your rights to autonomy, & be educated to make an informed decision if this happens. Do avoid or minimize internal exams or anything internal as it increases risk of infection.

If you are interested in more gentle ways of bringing on labor naturally refer to my Natural Birth Secrets book second edition.
Be informed, empowered & educated with my online course Guide to Pregnancy, Birth & Postpartum - sold separately or in a bundle.

'Overdue' Baby: What to Do If You’re Past Your Due Date

Although it’s totally normal to have an ‘overdue’ baby, it can be very frustrating. The ideal is to prevent it early on by knowing when you conceived and getting accurate pregnancy dates.

Try to keep busy past your due date by continuing to exercise as tolerated and planning some daily pleasurable activities to keep your morale upbeat and positive.

There is a five week time frame around the estimated due date, when babies are considered term, in which it is normal and most common for moms to go into labor.

In a well-nourished, healthy woman whose pregnancy has been accurately dated, the actual time of delivery often extends 1-2 weeks past the estimated 40-week due date. This is especially true with first-time moms.

Only a small percentage of women give birth on their due date, and most babies are indeed born at the perfect time for them.

A pregnancy is actually “postdates” when it exceeds the 42nd week of gestation. In this case, it’s still best to wait for labor to occur naturally, assuming:

• Your baby is still as active as usual

• The amount of amniotic fluid is adequate

• Your baby has a normal heart rate

• The size of your baby is estimated to be compatible with the characteristics of your pelvis

• You are healthy and there are no other pregnancy complications

Monitoring a Postdate Baby

There is an increased risk of complications associated with postdate pregnancies, mostly related to an aging placenta that ceases to function as well as it did earlier, or to a baby that continues to grow to an exceptionally large size. Therefore, there will be a need to monitor you and your baby more closely after 41 weeks. Rest assured, though, that the majority of postdate babies do just fine.

FETAL MOVEMENT COUNTS

Fetal movement demonstrates adequate nourishment and oxygen from a healthy placenta. A baby will significantly decrease its movement as the condition of the placenta deteriorates. With that in mind, a wonderful way you can monitor the continued well-being of your baby throughout the third trimester is to do daily fetal movement counts. 

Pick a time when your baby is usually most active, often this is after meals, when resting or at night when lying in bed. Make sure you count at least 10 distinct moves in 2 hours. If you notice less, the baby may be sleeping. Try again a little later after drinking 2 large glasses of fruit juice, a cup of coffee and eating a complex carbohydrate and natural sugar meal, such as peanut butter and jelly sandwich on whole grain bread. Lay down after 30-40 minutes and count the number of moves. If baby is not moving after this, or you still feel that the baby is moving less than usual in a 12 hour period, contact your practitioner right away. The baby needs to be evaluated, and if in trouble, will need to be delivered as soon as possible.

IN-OFFICE TESTING

Two tests commonly done in the office to monitor the condition of the placenta and baby’s well-being are the twice weekly NST (non-stress test) and the weekly BPP (biophysical profile sonogram).

The NST uses an external electronic fetal monitor to note the character of the baby’s heart rate and its response to fetal movement. A desired response is a fetal heart rate that varies from beat to beat within the normal range, and increases at least twice when the baby moves, 15 beats per minute for at least 15 seconds within 20 minutes. Out of hospital midwives are asked and can use a fetoscope or doppler to check fetal heart rate and record accelerations manually, but it is less accurate, without a recorded tracing, not the standard of care nor evidence based; it is also not supported by modern medicine, or most of the collaborative obstetricians midwives work with.

The BPP uses ultrasound to examine the fetus and its environment in utero by assessing a variety of parameters including the baby’s movements, muscle tone, the placenta and the amount of amniotic fluid. The ultrasound can also provide estimates on the baby’s growth and weight, but they are only estimates and not always accurate at this late stage of pregnancy. Try to schedule this test during a time the baby is usually active and moving the most. On the day of the test, make sure you are drinking your usual daily 8-10 glasses of water so the baby has plenty of amniotic fluid. 30-40 minutes before the test, make sure to have 2 large glasses of fruit juice and a natural sugar/carbohydrate meal or other foods that usually wake baby up and causes lots of movement. You can even have a cup of coffee or tea just in case the baby is still sleeping after the meal. The test is somewhat dependent on the baby moving, and we would not want a false report of no fetal movement indicative of fetal stress, when the baby was just sleeping healthfully.

Natural Measures to Help Prevent Problems Related to Postdates

These recommendations are especially helpful if you had complications from postdates in prior pregnancies, you are attempting a vaginal birth after a previous cesarean, or you have other complications such as diabetes or high blood pressure and it is not advisable to let the pregnancy extend past term. Research on natural induction methods is sparse, but growing. Sometimes one remedy or a combination of them does the trick, and all is well. Sometimes, no matter what we do, we can not get labor started. Nothing works consistently, including the medications used in hospitals. Ultimately, unless there is a scheduled cesarean birth, when a baby comes into the world is ultimately not in our human control.

KNOW YOUR STATUS

If you are planning a pregnancy, keep an accurate record of your cycle and know the first day of your last menstrual period. Or better yet, the day of conception around the time of ovulation. If there is a question about your dates (if you are breastfeeding, recently miscarried, went off the birth control pill, or have long  or irregular cycles), an early first trimester ultrasound can accurately date your pregnancy. This will prevent a lot of aggravation later on, like unnecessary testing, pressure to deliver and induction based on miscalculated dates.

EAT RIGHT FOR BABY

Maintain a healthy well balanced diet including lots of:

• Organic fresh fruits and vegetables

• Whole grains

• Seeds and seed products like tahina 

• Nuts and nut butters

• Beans

• Organic tofu and tempeh  

• Organic whole eggs

• Turkey or chicken

• Beef, lamb, or wild game

• Wild Alaskan salmon 

• Organic fresh raw whole dairy-ideally goat or sheep

Use healthy fats for cooking, such as organic cold pressed extra virgin olive oil, coconut oil or goat butter. Drink at least 64 ounces of filtered, spring or well water or herbal tea per day, at least 20-30 minutes before meals. Limit intake of fruit juice and refined white flour, sugary products, and refined vegetable oils or partially hydrogenated fat. Aside from being unhealthy and fattening, the refined sugars and starches grow big babies that are harder to push out.

Make sure to eat plenty of dates and pineapples - some swear by them to encourage labor. I am not convinced, but no harm trying.

Prepare Your Mind

Prepare for a deeply positive childbirth experience. It is very important to enter labor and birth with positive feelings, trusting your body and the whole birth process.

It is helpful to write a positive birth vision, what you wish your labor and birth to be like from start to finish, and include the role and involvement of all persons who will be there.

This is something you and your partner can think about and write together. You may write as little or as much as you like, but enjoy thinking about this special time in your life. 

There are a number of methods to help you get ready for the amazing experience to come:

• Childbirth classes

• Hypnosis for birth in adjunct 

• Gentle, Prenatal and Restorative Yoga 

• Breathwork, meditation, and progressive muscle relaxation techniques (yoga nidra)

• Watching positive birth movies

• Listening to inspiring podcasts and birth summits

• Books. Some of my favorites are:

  • Mindful Birthing by Nancy Bardacke

  • Orgasmic Birth by Elizabeth Davis and Debbie Pascale Bonaro

  • Ina May’s Guide to Childbirth by Ina May Gaskin 

  • Baby Catcher by Peggy Vincent 

  • Natural Birth Secrets by me, Anne Margolis! 

Accept and express feelings that might be holding you back, such as anxiety or fear about childbirth or becoming a mother, uncertainty about your changing role as a person or relationship with loved ones, and hesitation about giving up the special attention you’ve enjoyed while being pregnant. Do not hesitate to talk with a close friend, family member, childbirth educator, or therapist, as labor and birth is heavily influenced by your emotions. Often, simply sharing and releasing ambivalent or troubling feelings does wonders to help you open up, let go and give birth. When that does not help, try releasing it from your body with breathwork.

Practice the following thoughts daily while doing slow deep breathing in a quiet meditative space: 

Spend some time saying goodbye to your pregnancy and inviting your baby to come out. Tell yourself that you and your baby are ready for labor and birth to occur. Imagine your uterus contracting. Visualize your cervix softening and opening, and picture your baby descending through the birth canal so you can cradle your beautiful newborn child in your arms. Affirm that you will surrender, let yourself be relaxed and open so that your body will do what it was perfectly designed to do - give birth to a new human being.  

HERBAL SUPPORT

Most of the supplements and herbal remedies I recommend are available on my customized online holistic apothecary. Find the best supplements that have gone through my thorough screening process there. Look in the category for labor stimulation support or search them individually. My online dispensary is a convenient way for you to purchase my hand-picked, professional-grade, whole food supplements and other natural health products. Ordering is simple, and the products will be shipped directly to your home or work within a few days.

Drink fresh infused Red Raspberry leaf tea regularly. Among its many benefits, it encourages more effective uterine activity and thus an easier birth. It is optimal to make your own by adding a generous handful of the dried herb to 1 quart of water. Let it soak in a glass canning jar for approximately one hour, then strain. You can add honey, fresh mint leaves and/or lemon juice to taste and drink several times per day.

Dr. Christopher’s Birth Prep herbal formulation is designed to cause an increase in toning contractions in late pregnancy and prepare your body for labor and birth. It can be taken during the last 6 weeks of pregnancy under supervision by your provider. The recommended cycle is 1 capsule per day at week 34-36, 2 capsules per day at week 37, 2 capsules twice per day at week 38 onward, until you have your baby.

Make your own wonderful late pregnancy herbal tonic, to be used 37 weeks onward. Combine 1 dropperful each of red raspberry leaf, partridge berry, blue vervain and cramp bark with ¼ dropperful each of wild yam and motherwort in a separate tincture bottle and shake to mix well. Take 1/2 dropperful of the mixture a few times daily. You can double the dose in the last week before your due date. Other reputable herbal brands include Gaia, Wish Garden, Herb Pharm and Eclectic Institute.

You can take Evening Primrose oil capsules, 500 mg daily, as early as 36 weeks to help ripen the cervix. 

At 38 weeks gestation, start inserting 6-8 caps of Evening Primrose oil deep inside your vagina behind the cervix every 8-12 hours if:

• This is your first baby OR

• You have a history of post-term pregnancies

At 41 weeks gestation, start inserting Evening Primrose at the dose above if:

• Your cervix is still not ready for labor as measured by internal exam AND 

• Your bag of waters is intact

You should have a ripe cervix within a few days. At 41 weeks, you can also increase the oral 500 mg dose to three times daily. 

GET IN THE MOOD

As long as your bag of waters is still intact and you do not have a history of premature labor, engage in frequent sexual intercourse, especially after 36 weeks. Semen contains prostaglandins which can help ripen the cervix for labor, and reaching climax can bring on uterine contractions that may stimulate labor if the cervix is ripe and the baby is ready. The same energy that gets baby in, gets baby out, so turn up the sensual and make lots of love.

She is dancing to the music on her phone.

GET MOVING

Likewise, if you do not have a history of preterm labor, engage in regular moderate exercise like brisk walking, cycling, dancing, swimming or low impact aerobics for at least 30 minutes 5 days per week. As you get closer to term, moving around while upright uses gravity to help get the baby in an optimal position for birth, as well as press on the cervix and cause it to ripen and stimulate contractions.

As women get closer to the term, it is common to feel an increased frequency, length and intensity of Braxton Hicks contractions as the uterine muscle warms up for labor. These contractions are felt as occasional lower abdominal menstrual-like cramping in early pregnancy. But, as you get closer to term, you can actually feel your uterus ball up and harden, often from the top on downward before it softens again. They are usually brief, painless and irregular without pattern, increase with activity and resolve with rest. 

If you do not feel such uterine activity beginning at 39 weeks, you can do nipple stimulation every 10 minutes for an hour 3 times per day to stimulate contractions. To do this, roll the end of your nipple between your fingers and compress and pull slightly as a suckling baby would do. Alternately, you can, or use a breast pump, which will come in handy postpartum. 

Natural Ways to Bring on Labor

Only use the below methodologies if you have reached or passed your due date and you have discussed options with your practitioner.

Increase nipple stimulation to every five minutes for 2 hours, 4-5 times per day. It may take several hours, but with a little persistence, this can get labor going. Nipple stimulation causes release of your body’s own oxytocin, the hormone that ripens the cervix and stimulates uterine contractions. Don’t stop until labor is progressing on its own.

Take homeopathic Cimicifuga 30c, 4-5 pellets, alternating with Caulophyllum 30c, 4-5 pellets every hour for 12 hours. Repeat for two days. This gently stimulates your cervix to ripen and labor contractions to begin.

Massage your uterus with Castor oil until you get a contraction, and then repeat every 5 minutes until a labor pattern is established on its own.

If all else fails, you can try drinking Castor oil. This induces labor by stimulating your bowels, so be prepared for the possibility of diarrhea. Take 2 ounces of Castor oil in orange juice every hour for a total of 3 times. Two ounces of vodka, brandy or bourbon can be added to this mixture to loosen you up psychologically if needed. After each drink, go for a walk around your house (staying close to a bathroom!) and then take a hot shower, letting the water flow onto your nipples and persistently massage your belly with some of the Castor oil.

If still no labor, there are other things we can recommend like an enema, gently stretching your cervix open and stripping your membranes (separating the membranes from their attachment to the lower uterine wall), or as a last resort, breaking your water and/or medication if your baby needs to be born without delay.

If you need more personal guidance, schedule a consultation with me. I am happy to help!

Natural Induction Methods: The Evidence

Art by Catie Atkinson @spiritysol

Natural Induction Methods: An Unbiased Look at the Evidence

Natural methods of labor induction have been sought after for millennia by third trimester mothers for a variety of different reasons. In modern times, they're frequently a resort of mamas who might be facing a medical induction if they don't labor naturally soon.

There are myriad purported natural induction methods, but both the efficacy and safety of the methods in question are often under-studied and sometimes dubious. It's important to understand the difference between treatments that are largely safe and those that could negatively impact labor, birth, or your baby's health.

The majority of popular natural labor induction methods revolve around the consumption of plants or plant derivatives, such as castor oil and dates or pinapple, or herbal and homeopathic remedies. In the case of simple fruit consumption, there's little risk to mom beyond a stomach ache caused by an overzealous attempt. This can mislead pregnant women into thinking that all plant-based methods of attempting to naturally induce labor are safe, which is not true. In fact, some more potent plant derivatives have been shown to lead to labor complications.

The other category of natural induction methods involve forms of physical stimulus. Again, these have been attempted throughout the ages with varying degrees of success. Sexual intercourse, which is one of the most colloquially suggested methods of naturally triggering labor, has minimal risk unless a midwife or doctor has noted otherwise. Interestingly, despite its reputation, it has still been shown to be less effective at triggering labor than other forms of physical stimulus. Other stimulation methods include breast massage, acupuncture and acupressure, walking (most effective once actually in labor), uterine massage, and membrane stripping - to name just a few.

When you're attempting a natural labor induction, knowing what works and what doesn't is helpful; knowing what's healthy and what could harm your baby, however, is vital. We The Parents has compiled an infographic detailing nine of the most popular ways mothers attempt natural labor induction. For each method, the scientific evidence is examined. How much research has been done? And what do the results indicate about the efficacy and safety?

While this can help you to make an informed decision, it's also essential to get your treating physician, midwife, nurse practitioner, or other qualified health care provider’s go-ahead before trying any of these methods in order to avoid inadvertently harming yourself or your baby.

As a holistic midwife of just about 25 years, countless mamas have sought my guidance on how to bring on labor with natural modalities. I have experienced much success with a variety of methods - some not even mentioned here, but nothing has been consistent, and as with many natural remedies there is a paucity of research. As long as they are safe and sometimes effective, I will continue to recommend them, knowing that I am helping, and it is ultimately not in our control - babies prefer to come when they are ready. Many of the professional grade, top quality remedies I recommend and use often are available in my holistic online apothecary. Find the best supplements that have gone through my thorough screening process there. Look in the category for labor stimulation support or search them individually. My online dispensary is a convenient way for you to purchase my hand-picked, professional-grade, whole food supplements and other natural health products. Ordering is simple, and the products will be shipped directly to your home or work within a few days.

Also, even the powerful medicinal methods have significant risks we can not take lightly, as well as benefits when there are serious complications, and do not always work either.

A common reason women want to bring on labor naturally is the concern about being ‘too late’, the postdates testing and threat of hospital induction, along with the cascade of interventions associated with it. A key factor people often do not consider is prevention. When planning a pregnancy, I encourage women to take charge of their fertility, empower themselves with knowledge about their cycles, fertile signs and know when they conceived, so the due date is more accurate than if simply based on first day of last menstrual period alone. Read more about what you can do, covered more in depth in a previous blog. Women who do not know their cycles or the date they got pregnant can also consider an early first trimester sonogram, especially if they have a history of long or irregular cycles, or of being induced previously for carrying post-term babies; but a decision to do that should be an informed one, as there are also pros and cons of ultrasound to consider.

Knowing what you should do can seem daunting. I am here to help if you need more personalized guidance. You can also read my books, to prepare yourself for a healthy, joyful and calm pregnancy and childbirth, and for healing and enhanced well-being. For further inspiration, empowerment, and optimal health in pregnancy, birthing and postpartum, please make sure to click here to take my online Love Your Birth course, so you can ROCK your journey wherever and however you plan to give birth.

I have a holistic approach to life, including healing after pregnancy and birthing. Nothing replaces abdominal toning and exercise for restoring muscle strength and tone - which I encourage for all mamas as soon as they feel up to it postpartum. Nothing replaces touch, slow deep abdominal breathing, and a 'love your postpartum body' perspective that I promote.  

But I have found many mamas simply feel comforted by this support garment, especially early postpartum and temporarily as needed....to be used without forfeiting abdominal toning and strengthening exercise, breathing well and touch. I have found Bellefit supportive garments to help like they use belly binding around the world such as in Indonesia. They do aid in early postpartum healing and provide support many mamas feel comforted by.

I deal with human beings and the reality is many postpartum mom's struggle with body image, feel frustrated that getting back to themselves takes longer than expected. Being into holistic health and healing includes being sensitive to real human struggles - the mind, body, heart and soul of each person and their unique situation. 

Having helped countless women with these issues after having a baby as a midwife, I have found many still love that binding and feel better with this support, and ability to fit into their pre-pregnancy clothes comfortably and sooner than they would if they went through a C-section or natural childbirth recovery without it - especially when they have to dress up and fit into a certain favorite outfit for a special occasion or wedding not long after having a baby. For more info on the Bellefit girdle, check out my blog about it here. 

Have a Great Postpartum Recovery (with a little help from Bellefit)!