When Your Water Breaks: It's Not Like the Movies

Phoebe's water breaks in Friends.

It’s a classic scene. A pregnant woman gasps dramatically as a large puddle of clear water forms at her feet. Someone says, “It’s time,” and then everyone rushes into action to get her to the hospital as she goes into active labor within minutes. There’s probably a speeding car involved, likely an inconvenient traffic jam that requires some heroic act from a stranger, all while the pregnant woman is dramatically groaning and moaning with rapidly progressing contractions. In the end, of course, they make it to the hospital in the knick of time, the baby just slips right out, and then there are smiles, and maybe a few tears, all around. It’s perfect for the screen: dramatic, snappy, and too often centered on the actions of all those but the pregnant person. 

In reality, of course, it would be difficult, if not nearly impossible, to find someone with a birth story that comes anywhere close to the one that is repeated in countless TV shows and movies. Yet it’s through scenes like this that the media has managed to sneak its way into many of our collective assumptions and expectations for birth. Almost every one of these scenes begins with water breaking, so it’s no wonder that we might assume that this is how labor starts. However, most of the time, water breaks well into labor. It occurs in only 8-10% of births, or approximately 1 in 10 people, before labor begins. And it might not look like it does in the movies. 

So what does it mean when “water breaks”? 

Water breakage, as it’s commonly known, is the rupture, or tearing, of fetal membranes. These membranes make up the amniotic sac that contains the amniotic fluid, which protects and cushions the growing fetus — this is the “water” that leaks out. This rupture usually occurs naturally due to several factors, primarily the physical stress on the membranes as pregnancy progresses and labor begins. The contractions that occur during labor increase the pressure and can contribute to water breakage, which usually occurs at a weakened spot near the cervix. You can think of it like a water balloon, as it expands, the balloon thins out and pressure builds, and eventually, it pops. But unlike a water balloon, the walls of the amniotic sac are much stronger, more like fabric, so although it tears, the amniotic sac largely stays intact.

The rupture of these membranes is a natural and important step in labor. The amniotic fluid contains prostaglandins, which are a kind of lipid (fat) that acts as a hormone (chemical messenger), which increase throughout pregnancy and spike before the start of labor. When water breaks, this prostaglandin-filled amniotic fluid comes in contact with the cervix, and it helps to thin, soften, and dilate the cervix and encourage contractions in the uterine muscle. 

What can you expect? 

When your water breaks, it might be obvious: many experience a sort of bursting or popping sensation followed by a large gush of liquid. But sometimes, it might just be a subtle wetness or trickle of liquid, and it can be hard to distinguish from urine or vaginal discharge. The fluid will be thin and watery, and it won’t be controllable; you won't be able to "hold it in." It may continue to leak out as labor progresses and the baby moves around. Sometimes the baby’s head can act as a plug at the opening of the cervix, which is why not all the fluid will leak out at once. 

Amniotic fluid is usually clear or yellowish and odorless. Brown or greenish fluid may indicate the presence of meconium (a baby's first poop), which might just show that your baby has healthy bowels, but most medical providers will likely recommend monitoring you and your baby in case it becomes evidence of some fetal distress.

What happens when water breaks BEFORE labor? 

For 90% of birthing people, the rupture of membranes will occur during labor, when contractions have already begun, but some experience “PROM” or the premature rupture of membranes. In most cases, this is “term PROM,” which means water breaks at 37 or more weeks, just before labor begins. Some midwives and other birth workers will say that a full sac (water that hasn’t yet broken) is more ideal because it allows the baby to shift positions during labor and provide lubrication as it moves through the pelvis, but those who experience PROM can still have successful vaginal births. Amniotic fluid is also constantly being replenished throughout pregnancy and even after the water breaks, so even though some fluid is lost, the baby is never without some fluid. This does mean that it is even more important for the pregnant person to stay hydrated once water has broken.

A common misconception that persists to this day is the concept of the “24-hour clock” or the idea that once water breaks, birth must occur within 24 hours. This was popularized by doctors in the 1950s and 60s when babies were seemingly increasingly likely to be stillborn or die prematurely the longer they were born after PROM occurred. However, this was a time when infant death was high in general, and antibiotics were not yet popularized. Most evidence today suggests that waiting 48-72 hours after water breaks to give birth does not increase the risk of infection or death for babies. 

Although the 24-hour clock has been disproven, many who experience PROM may still feel pressured by health care providers to induce, rather than wait it out. But even without induction, studies have shown that up to 95% will go into labor within 24 hours. Countless studies have demonstrated that the rates of infection and death in newborns are not affected by waiting longer for labor to begin rather than inducing. 

Still, one factor that may influence a decision to induce is that birthing people who experience PROM are more at risk for infection themselves. Yet it is important to note that it is not the time, but the number of vaginal or cervical exams that is the most important factor increasing one’s risk of infection. Even if a provider is wearing sterile gloves, they may be unintentionally pushing bacteria from outside the vagina up to the cervix. In fact, vaginal exams have been shown to double the number of types of bacteria present on the cervix. 

Currently, the American College of Obstetrics and Gynecology still recommends induction of labor at term for those who experience PROM, but they give an option for “expectant management” (or waiting for labor rather than inducing) for 12-24 hours if the patient is counseled on the risks and the “clinical and fetal conditions are reassuring.” The American College of Nurse Midwives recommends that expectant management is safe if it is a term and uncomplicated pregnancy, the amniotic fluid is clear, and there are no infections or fever. They advise skipping a baseline vaginal exam and keeping all exams to a minimum to reduce infection risk. Most research suggests that, as long as the pregnant person and baby are doing well, and without major risk factors (such as gestational diabetes, hypertension, etc.), waiting 2-3 days for labor to begin spontaneously after water breaks is safe and highly evidence-based.

What is preterm PROM?

Preterm PROM (or PPROM) is when water breaks before 37 weeks, which occurs in 3% of pregnancies and a third of preterm births. PPROM can happen before the fetus is viable outside the womb, far from term, or near term. Typical treatment includes allowing the fetus to continue developing, with antibiotics to prevent infection. For near-term PPROM pregnancies, induction is typically recommended, but like PROM pregnancies, expectant management is thought to be safe for uncomplicated pregnancies without risk factors. Risk for PPROM is associated with infection, smoking, vascular disease, uterine distention from a multiple pregnancy or polyhydramnios (too much amniotic fluid), or low collagen levels. Rates of PPROM are higher in U.S.-born Black birthing people, which most research suggests is due to a combination of factors, most prominently racism that contributes to chronic stress and a lack of quality prenatal and birth care. However, community-informed and racially aware midwifery-led care and doula services can be successful interventions.

Conclusions

This post is not intended to provide any medical advice. It's only a brief overview of water breakage to get you started, but you should do your research and speak with your medical provider. Ask them what they would recommend if your water broke before labor began, and make a plan for expectant management or induction based on your health, risk factors, and preferences.

Sources:

https://evidencebasedbirth.com/evidence-inducing-labor-water-breaks-term/ 

https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/water-breaking/art-20044142 

https://my.clevelandclinic.org/health/symptoms/24382-water-breaking