Do I look stupid to you?

Spontaneous rupture of membranes (aka SROM, aka water breaking) is a great reason for doctors to actively intervene in a pregnant patient’s care.  If the pregnancy is at term, it’s a good time to induce or augment labor in order to facilitate childbirth.  If it’s preterm, it’s a good time to attempt to stop or prevent labor, at least temporarily, to help prepare the mother and baby for delivery.  If, on the other hand, the water has not broken but the mother tells us it has (either because she really thinks her water broke or because she’s just tired of being pregnant), it’s important that we not promote labor and delivery, largely for the benefit of the child.  Either way, if a woman tells us her water has broken, it’s important for us to determine whether or not that’s really the case.

There are, of course, ways for the OBs to tell if a patient’s SROM is legit.  Typically, they perform three tests: speculum exam, ferning test, and nitrazine test.  The speculum exam involves using a speculum (what else?) to look for pooling of amniotic fluid the patient’s cervical vault.  The ferning test is done by putting a sample of the presumptive amniotic fluid on a microscope slide and looking for a characteristic crystallization pattern.  And the nitrazine test is done by exposing a sample of presumptive amniotic fluid to nitrazine and watching for a distinctive, characteristic color change.  If more than one of these tests are positive, it’s more likely that the patient did indeed experience SROM.

Despite modern medicine, however, some TOBPs think they can fake out their OBs.  "Hmm," they think, "I'll bet if I sit on a gurney and get the Chux pad under my butt wet, the doctors will think my water broke."  And what's the easiest way for them to get that pad wet?  Why, urinating on it, of course!

Which brings us to the patient.  She was a young woman, maybe 25 years old, who presented to the L&D deck one night while I was covering the night OB anesthesia service.  She arrived with a large water bottle in hand (really a 32 oz. mug full of water), which she was quite attached to.  She was complaining of regular, severe contractions, despite appearing to be quite comfortable.  The L&D nurses set her up in a triage room and took her vital signs, then she was seen by an OB resident.

The OB resident emerged from the patient's room several minutes later, shaking her head.  "That patient is gross," she said.

"What happened?" I asked.

"I was getting ready to do a spec exam, and I had my back turned to her, and she peed all over the Chux!" was the disgusted reply.

"Wait, what?!"

"She peed!  I had my back turned, and I was putting on gloves, and she got all excited and said, 'What was that?!  What was that?!  My water just broke!"

"OK..." I prompted.

"The Chux pad under her was wet, and her urine was really dilute from all the water she's drinking, but I could smell it and there wasn't much fluid in her vagina.  She peed on the Chux to try to make me think she SROMed."

"Wow..." I muttered, shaking my head.

"Anyway, I got what sample I could, and now I have to check nitrazine and ferning.  See you."

With that, the resident left and I returned to my reading.  I had all but forgotten about the incident when the OB resident returned and tapped my shoulder.

"OK, Matt, get this: you know how sperm makes the nitrazine test have a false positive?" she asked.

"You're asking me to cast my mind back to the dark days of med school, but yeah," I answered.

"Her nitrazine turned blue, but I could see swimmers on the slide.  So I went back in and asked her when the last time was that she had sex."

"OK..."

"And her husband said, 'Oh, it's been more than a week,' but she got really quiet and wouldn't look at me."

I looked over at the resident.  "You don't think..."

"Yes, I do think.  This lady is some piece of work.  I think I'm not the only one she's lying to this evening."

I shook my head in disbelief.  "I guess I'd rather be in your shoes than her husband's.  You think he'll put two and two together, and figure out why you asked when they had sex?"

"Maybe," she answered.

And there you have it.  Sometimes, the answers you get are a bit more than you bargained for.  And as irritating as it is when patients think their doctors are gullible fools, there are certainly worse things.