Women better off waiting than being induced if their waters break early, Lancet study finds

Rachel Dale with sons Nathanael, Micah and Elijah in their Sydney home.
Rachel Dale with sons Nathanael, Micah and Elijah in their Sydney home.  Photo: Louise Kennerley

Rachel Dale took it for granted after the birth of her first son that, next time, she would also travel home from hospital with a baby snuggled in her arms.

But her next two babies were hurried into the world after her waters broke early, and when she went home she left them behind in their plastic cradles, returning daily to the neonatal intensive care unit with bottles of expressed milk.

She expected to follow the same pattern with her number four.

Bed rest after waters broke: Rachel Dale with her baby, Micah.
Bed rest after waters broke: Rachel Dale with her baby, Micah. Photo: Louise Kennerley

This time her waters broke even earlier, and she was placed on bed rest in hospital until she went into labour spontaneously five weeks later.

By the time her baby arrived at 35 weeks' gestation, he was ready to go home.

"It was wonderful," Ms Dale said. "I had him in the room with me the whole time after he was born, and then I got to take him home with me."

The membranes surrounding the amniotic sac rupture before the mother goes into labour in about 20 per cent of all births and 40 per cent of preterm births.

When this occurs before 34 weeks, the women are not generally induced as the complications of prematurity outweigh the risks to the baby of infection, and by 37 weeks the infant is considered to have reached full term.

But medical opinion has been split on whether women whose waters break between 34 and 37 weeks should give birth immediately or wait until the baby is more mature.


Most recently it has been solidifying in favour of inducing labour because the care in neonatal intensive care units is high quality, and the consequences of an infection – including cerebral palsy – are so grave.

However, a game-changing study by the Kolling Institute at the University of Sydney has now determined that babies are better off waiting in utero through this twilight period, rather than being induced immediately.

The randomised controlled trial, published in the medical journal The Lancet, found babies whose mothers were placed on "expectant management" had significantly lower chances of respiratory distress and no difference in the rate of infection compared with those who were induced immediately.

Lead author Jonathan Morris said there had not previously been any studies to support the case for immediate induction, despite UK guidelines being updated in 2010 to recommend the practice and US guidelines in 2013.

"We usually want to do things rather than not do things – and this is suggesting that maybe we shouldn't be doing things," Professor Morris said.

"Over the last 15 years there's been a remarkable shift towards earlier and earlier birth and what's become apparent is these last few weeks are really critical."

About 8 per cent of babies are born prematurely in Australia each year, and even those born between 34 and 37 weeks have higher chances of metabolic disease, cardiovascular disease, obesity, decreased respiratory function and impaired learning, Professor Morris said.

Following the study, Monash Medical Centre has changed its policy in favour of expectant management for women whose waters break between 34 and 37 weeks.

Obstetrics director Euan Wallace said the two wards in the centre used to have opposing policies, but he has now conceded that his practice of immediate delivery was wrong-headed.

"Our practice used to be delivery at 34 weeks and the reason for that was concerns about infection causing problems to the baby," Professor Wallace said.

"When the results came out, it was better for the baby if you just sat tight and let the pregnancy go a bit further.

"The perceived risks that we were worried about, don't actually exist in reality."