“She’s contracting every seven minutes and liquid is coming out.” It was a Sunday morning in early March, and I was the doctor on call for family practice and pregnancy-related matters. This call from a concerned father-to-be would have seemed ordinary except that Ronnie, the laboring mother, had a May due date.
“You need to take her to the hospital right away; it looks like she’s going to have her baby early,” I told him. “Have you registered at the hospital already?”
“Then go straight to the third floor. I’ll call them and let them know you’re coming.” I did so and asked the nurse to monitor the baby, perform a sterile speculum examination to confirm that she had ruptured her membranes (her bag of waters), and to do a vaginal culture for a particular bacterium, the Group B streptococcus.
Ronnie’s baby had an estimated gestational age of 31 weeks and 2 days; 8 weeks and 5 days remained before he would reach his due date at 40 weeks’ gestational age. Women can go into labor this early for many reasons, most of which involve infections of either the urinary tract, the vagina, or the uterine contents. If the membranes remain intact and labor hasn’t yet reached the active stage, with the cervix dilated four centimeters or more, we can often delay or stop labor with medications, treat the underlying cause of the preterm labor, and give the baby’s organs, particularly the lungs, a chance to mature. We can use medicines to hasten lung maturity when we think we will not be able to keep the baby from delivering before 34 weeks’ gestational age.
When the membranes rupture, things get more complicated. Ruptured membranes stimulate labor, and almost all babies, no matter what the gestational age, deliver within ten days after rupture of membranes. Leaking membranes also give vaginal bacteria free access to the amniotic fluid, facilitating infection of the fluid and membranes if they weren’t infected already. If the mother develops a fever, foul-smelling fluid, pus in her fluid, or other definite signs of infection, it becomes too dangerous to keep the baby inside, so we treat with antibiotics and allow labor to progress on to delivery. Because of all this, definitive determination of the membranes’ status is an important part of these patients’ initial evaluation.
As I gulped down my lunch in preparation for a trip to the hospital, Kathy, the triage nurse, paged me to say Ronnie’s uterus was contracting with moderate strength every two to four minutes. I asked if the membranes were ruptured, and she said they weren’t, a pleasant surprise given that Ronnie had told me she was leaking. I ordered Kathy to give Ronnie a subcutaneous injection of terbutaline, which usually slows or stops the contractions of early labor, and I drove to the hospital.
I entered the triage area through the door just to the left of the labor and delivery area’s main desk, passed the curtains closed around the patients undergoing evaluation, two on each side of the central walkway, and proceeded to the triage desk, tucked in a corner on the right. As the fetal monitors broadcast their rapid thumps as though dueling for recognition, Kathy brought me Ronnie’s prenatal record and the news that she was still contracting every four to seven minutes. “I have the setup for the sterile speculum exam,” she informed me, “except that I haven’t found a place to plug in the light source.”
This didn’t make sense to me. I had ordered the exam to be done upon Ronnie’s arrival, so when Kathy had told me that the membranes were not ruptured, I assumed she knew this because she had done the exam.
I processed this information as I squeezed through the curtain and around the metal-tray table holding the speculum and other instruments to arrive at Ronnie’s right side. The 32-year-old African-American’s hands and legs trembled, not from fear but from terbutaline, one dose of which can make you feel like you’ve had about ten cups of coffee. She and her husband listened to me explain the exam and why I needed to do it. She consented. Kathy found a light with a long enough cord to reach the outlet across the room, so I gloved up and placed the sterile speculum between my hands, a more symbolic than effective gesture that tells my patient that I am trying to avoid putting an ice-cold speculum in her vagina.
I asked about the fluid, “When did you first notice you were leaking?”
“Friday night. I thought I was losing control of my bladder. It slowed down a lot yesterday, so I wasn’t as worried, but today the contractions came harder and I was leaking more, so we called you.” So she might have had ruptured membranes for over 36 hours, plenty of time to develop an infection. But she felt well, and she didn’t have a fever yet.
After about 15 seconds of attempting to impart some warmth to the cold metal instrument, I advanced it slowly into her vagina. Despite our attempts to be gentle, this exam is painful for many pregnant women, and Ronnie was one of those women. It didn’t help that I needed to get a good look at her cervix and therefore had to exert additional downward pressure to position the instrument, a move that brought tears to her eyes. I didn’t want to have to check her cervix with my gloved fingers because each cervical check increases the infection risk.
As I opened the speculum, a pool of clear fluid flashed into view, and I had my answer. I stuck a piece of yellow nitrazine paper in the fluid, and it instantly turned deep blue, confirming that this was amniotic fluid. Using a Q-Tip, I then swabbed some fluid onto a slide, removed the speculum, and took the slide over to the microscope. Under magnification, I could see the delicate characteristic “ferning” patterns that look like broken crystal snowflakes and complete the identification of amniotic fluid. This baby was coming very early, and I therefore needed a specialist, a perinatologist, to take over at this point, so I summoned Mickey, the on-call perinatologist. I had never met her and it was, in fact, her first day on the job at our hospital. Her short, curly hair made her look younger than her probable late-30s age, and we had a pleasant introduction and case discussion.