Evidence-Based Practice: Supporting Expectant Management After Spontaneous Rupture Of Membranes At Term

A Case for Patient-Centered Care Grounded in Current Research

For decades, the immediate response to spontaneous rupture of membranes (SROM) at term has been to initiate induction of labor as quickly as possible. This approach, rooted in concerns about infection risk, has become standard practice in many institutions.

However, emerging evidence from recent peer-reviewed studies and updated clinical guidelines challenges this one-size-fits-all approach, demonstrating that expectant management for up to 72 hours can be both safe and effective for low-risk pregnancies.

Understanding the Natural Process

When membranes rupture spontaneously at term, the body often initiates labor on its own without medical intervention. Research shows that in more than 60% of cases involving prelabor rupture of membranes (PROM), spontaneous labor begins within 24 hours.

Even more remarkably, 95% of individuals will enter labor spontaneously within 72 hours of membrane rupture (Kittelmann et al., 2025). This natural progression suggests that immediate intervention may not be necessary for most low-risk pregnancies.

What the Research Shows

Recent studies have provided compelling evidence that expectant management—the practice of waiting for labor to begin naturally while monitoring for signs of complications—is a safe alternative to immediate induction for appropriately selected patients.

A 2025 study published in the Journal of Perinatal Medicine examined outpatient management following PROM and found encouraging results. Importantly, outpatient observation was associated with no increase in maternal or neonatal infections compared to immediate hospital-based induction (Kittelmann et al., 2025). This finding challenges the assumption that immediate intervention is always safer and suggests that carefully selected patients can safely await spontaneous labor in the comfort of their own homes.

Similarly, research published in the American Journal of Perinatology in 2021 compared outcomes between women managed expectantly at home and those who received immediate intervention. Women who were managed expectantly had significantly longer intervals between rupture of membranes and delivery, yet there were no significant differences in important clinical outcomes.

Rates of chorioamnionitis (infection of the fetal membranes) and cesarean delivery were comparable between groups, leading researchers to conclude that home management may be considered safe and effective for select patients (Chacón et al., 2021).

Updated Clinical Guidelines

Professional organizations have also updated their recommendations to reflect this evolving evidence base. The American College of Obstetricians and Gynecologists (ACOG) published Practice Bulletin No. 217 in 2020, addressing prelabor rupture of membranes at term. This bulletin makes several important recommendations that support expectant management.

First, ACOG explicitly advises that digital cervical examinations should be avoided unless the patient is in active labor or delivery is imminent (American College of Obstetricians and Gynecologists [ACOG], 2020). This recommendation is significant because frequent vaginal exams have been associated with increased infection risk, and avoiding them is a key component of safe expectant management.

Second, the bulletin acknowledges that expectant management is an acceptable approach at term if the patient declines immediate induction. This represents a shift toward patient autonomy and shared decision-making in maternity care. The guidelines note that while most women will enter labor within 24 to 48 hours, waiting up to 72 hours may be acceptable for appropriately selected patients (ACOG, 2020).

Clinical Implications for Practice

These findings have important implications for how maternity care providers approach SROM at term. Expectant management aligns with the midwifery model of care, which respects physiologic labor processes and supports the body's natural ability to initiate and progress through labor. By allowing time for spontaneous labor to begin, providers honor the biological wisdom of the birthing process.

Minimizing digital vaginal examinations is a crucial component of safe expectant management. Each exam introduces bacteria from the vaginal environment into the sterile uterine cavity, potentially increasing infection risk. By avoiding unnecessary exams, providers can support optimal maternal and fetal outcomes while still monitoring for signs of complications.

Perhaps most importantly, current evidence supports shared decision-making between patients and providers. Expectant management is not appropriate for everyone, and some individuals may prefer immediate induction for personal or medical reasons. However, for low-risk pregnancies, patients should be fully informed about the safety and effectiveness of waiting for spontaneous labor and empowered to participate in decisions about their care.

Moving Forward: Policy Should Reflect Evidence

Institutional policies regarding SROM management should reflect current evidence rather than outdated protocols based primarily on risk aversion. A standard that allows up to 72 hours of expectant management following SROM in low-risk pregnancies is supported by peer-reviewed research and endorsed by leading professional organizations.

Of course, appropriate safeguards must be in place. Patients choosing expectant management should receive thorough counseling about warning signs of infection or fetal distress, clear instructions about when to seek immediate care, and appropriate monitoring protocols. Regular assessment for signs of infection, fetal well-being monitoring, and open communication between patients and providers are essential components of safe expectant management.

The evidence is clear: for carefully selected, low-risk pregnancies, expectant management for up to 72 hours following spontaneous rupture of membranes is a safe, effective, and patient-centered approach that respects physiologic birth processes while maintaining excellent maternal and neonatal outcomes. It is time for institutional policies to reflect this evidence and support informed choice in maternity care.

References

1. American College of Obstetricians and Gynecologists. (2020). ACOG Practice Bulletin No. 217: Prelabor rupture of membranes. Obstetrics & Gynecology, 135(3), e80-e97. https://doi.org/10.1097/AOG.0000000000004142

2. Chacón, S. S., Bryant, A. S., Clapp, M. A., Cohen, B., Emerson, J., Burris, H. H., & Little, S. E. (2021). Association between home prelabor rupture of membranes management and maternal and neonatal outcomes. American Journal of Perinatology, 38(5), 513-518. https://doi.org/10.1055/s-0039-3400997

3. Kittelmann, A., Muehlbacher, T., Goletzke, J., Waker, L., Mense, L., Hecher, K., & Mautner, E. (2025). Management of prelabor rupture of membranes at term: A survey of current practice patterns in Germany. Journal of Perinatal Medicine, 53(1), 12-19. https://doi.org/10.1515/jpm-2024-0604

   
   

   Marie-Celine Farver 10.6.2025

Marie-Celine Farver