Pre-labour Rupture of Membranes (prom) Management at Term
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- Bu səhifədəki naviqasiya:
- Section 1: Review of the evidence
- Section 2: Care of the Woman with Prelabour Ruptured Membranes (PROM) at Term
- Expectant management versus expediting birth
- Spontaneous onset of labour
- Section 3: Observation and Care of the Newborn and Woman Post-partum
- Postnatal Care for the woman with PROM
- Related Policies, Procedures, Guidelines and Legislation
CHHS17/165 Canberra Hospital and Health Services Clinical Guideline Pre-labour Rupture of Membranes (PROM) Management at Term
Contents 1 Introduction 2 Scope 2 Background 2 Purpose 2 Section 1: Review of the evidence 2 Section 2: Care of the Woman with Prelabour Ruptured Membranes (PROM) at Term 3 Procedure 3 Initial Assessment 3 Expectant management versus expediting birth 4 Expectant Management: 4 Expediting birth: 5 Spontaneous onset of labour: 5 Intra-partum Intravenous Antibiotic Prophylaxis 5 Section 3: Observation and Care of the Newborn and Woman Post-partum 6 Postnatal Care for the woman with PROM: 7 Implementation 7 Related Policies, Procedures, Guidelines and Legislation 7 References 8 Definition of Terms 8 Search Terms 9
The purpose of this Clinical Guideline: Pre-labour Rupture of Membranes Management is to outline the safe and effective management for the care of the pregnant woman with pre-labour ruptured membranes at term (PROM) (≥37.0 weeks)
The Clinical Guideline – Pre-labour Rupture of Membranes Management pertains to: Medical Officers Midwives and nurses who are working within their scope of practice (Refer to Midwifery and Nursing Continuing Competence Policy http://inhealth/PPR/Pages/PPRSearchResults.aspx?k=nursing) Student midwives and nurses working under direct supervision
Rupture of membranes is associated with maternal and neonatal morbidity and mortality. This includes the complications of maternal and neonatal infection (chorioamnionitis, neonatal sepsis and wound infection). This guideline will aim to reduce the incidence of maternal and neonatal morbidity and mortality.
The purpose of this guideline is to provide guidance regarding the management and care of women with Pre-labour Rupture Of Membranes (PROM) at term.
Routine antibiotic administration is not recommended for women with PROM at or near term prior to the onset of labour There is no difference in incidence of early onset neonatal sepsis, maternal or neonatal infectious morbidity, mortality or stillbirth when routine use of antibiotics is compared with placebo or no antibiotics (N= 2639, 4 studies) for PROM at or near term Reduced infectious morbidity has been reported when labour is established and intravenous antibiotic prophylaxis administered for term PROM greater than 12 hours duration Irrespective of Group B Streptococcus (GBS) status, when labour establishes (not before) commence intravenous antibiotic prophylaxis if:
If known positive GBS status or there are other risk factors, recommend induction of labour (IOL) as soon as is practicable with IV oxytocin and intravenous antibiotic prophylaxis If known negative GBS status and no other risk factors, offer expectant management and arrange IOL within 24 hours or as soon as is practicable with IV oxytocin and intravenous antibiotic prophylaxis If unknown GBS status offer lower vaginal swab for GBS culture
ProcedureEach woman is to have an initial assessment to confirm rupture of membranes (ROM), and to have a clinically appropriate individualised management plan. It should be ensured that the woman is fully aware of the clinical situation and verbal consent is obtained for the proposed management. There should be clear documentation of a management plan. If the selection criteria are met, the woman should be given the options of induction of labour or expectant management (at home or in hospital). On initial telephone contact with the woman a history should be taken, including the date and time of the suspected ruptured membranes. Irrespective of planned place of birth, the woman should be advised to attend MAU or Birthing for assessment as soon as feasible if she reports any of the following: vaginal bleeding green or offensive liquor feeling unwell or has a raised temperature decreased fetal movements fetal presentation was not cephalic at the last antenatal visit history of GBS carriage in this pregnancy or has a past history of a neonate affected by GBS history of previous Caesarean Section multiple pregnancy.
Initial AssessmentWoman should have an initial assessment as soon as practical after potential ROM. At this assessment inform obstetric registrar Perform initial assessment of the women including: temperature, pulse, blood pressure, respiratory rate and an abdominal palpation (confirming presentation, position and engagement), a urinalysis and cardiotocography (CTG) to assess fetal wellbeing. Confirm ruptured membrane by either a convincing history and positive AmniSure® or liquor seen by sterile speculum examination after the woman has been lying in left lateral position for 30 minutes. Document findings including detailed history A bedside ultrasound scan may be helpful in determining the amount of amniotic fluid in-utero and thus assist in ongoing management plan, especially if initial assessment is inconclusive. Avoid vaginal examination unless in established labour If a cervical suture is present, there is a very high risk of sepsis. The suture should be removed as soon as possible and prompt delivery must be considered If there is no evidence of PROM and no other risk factors the woman can be discharged home. Advise her to re present if further symptoms arise or recur. Expectant management versus expediting birthWomen who have confirmed ruptured membranes at term should be advised of the following: 70% of women with PROM will spontaneously labour and birth in the first 24 hours 85% within 48 hours and 95% within 72 hours. the risk of serious neonatal infection is increased from 0.5% to 1% compared to intact membranes. There is no significant increase in neonatal infection with expectant management up to 24 hours the increased risk of chorioamnionitis and endometritis with expectant management.(Clinical chorioamnionitis with Induction of Labour 4% versus 8.6%with expectant management – (RANZCOG)) that should initial expectant management occur, IOL is offered after 18 hours of ruptured membranes there is no evidence supporting expectant management beyond 96 hours. If the woman is known to be GBS positive IOL should be recommended as soon as possible refer to Clinical Practice Guideline ‘Early Onset Group B Streptococcal Disease (EOGBSD)’ If the woman has meconium stained liquor refer to relevant clinical practice guidelines, available on the policy register (http://inhealth/PPR/default.aspx) for further information: Meconium Stained Liquor Induction of Labour Fetal Surveillance Prevention of Early Onset Group B Streptococcal Disease
Expectant Management:Up to 24 hours of expectant management, in selected cases may be considered at the patient’s or clinician’s discretion. Criteria for expectant management include: Term PROM Fixed cephalic presentation GBS negative No signs of infection (maternal tachycardia, fever, uterine tenderness). No digital examination Normal CTG If the woman chooses expectant management the following are advised: daily CTG check maternal observations as per MEWS or more often if clinically indicated monitor PV loss and liquor for volume, colour and odour monitor for signs and symptoms of labour including presence, frequency, strength and duration of contractions. do NOT perform a vaginal examination unless indicated (e.g. woman is in labour). midwife to document all assessments attended at home or in hospital provide and discuss fact sheet on “Advice for going home now your membranes have ruptured” confirm the woman is comfortable with staying or going home and that she is aware of the signs and symptoms of chorioamnionitis discuss the woman’s ongoing plan of care with her and document the plan in her maternity record including when to attend hospital for assessment
Notify obstetric registrar or specialist obstetrician of:
Expediting birth:prepare the woman for possible induction of labour or augmentation with oxytocin if required (see Induction of Labour guideline, available on the policy register (http://inhealth/PPR/default.aspx)) consider whether intravenous prophylactic antibiotics are recommended document all care, observations, medications and interventions required.
document all care, observations, medications and interventions required. Intra-partum Intravenous Antibiotic ProphylaxisAll women with risk factors for GBS or with GBS positive screening should be recommended intravenous antibiotic prophylaxis, this is defined as: antibiotics ≥ 4 hours prior to birth. Irrespective of GBS status, when labour establishes (not before) commence intravenous prophylactic antibiotics if: Duration of confirmed PROM is greater than or equal to 18 hours at the onset of established labour During established labour, the duration of ROM reaches or exceeds 14 hours and birth is unlikely before duration of ROM equals 18 hours (i.e. do not wait for duration of ROM to equal 18 hours before commencing intravenous antibiotic prophylaxis)
If there is evidence of infection in the woman (e.g. temperature >38°C or > 37.5 twice or more within a 4 hour period), women should be advised to have intra-partum intravenous antibiotics after cultures are taken including FBC, Blood cultures and urine Microscopy, Culture and Sensitivity (MC& S). If there is evidence of chorioamnionitis or systemic infection the following antibiotic regime is recommended: Ampicillin (or amoxycillin) 2g IV 6 hourly, plus Gentamicin 4-6 mg/kg (booking weight) IV daily Metronidazole 500 mg IV 12 hourly Women allergic to penicillin to be given clindamycin 900 mg IV 8 hourly Back to Table of Contents
The asymptomatic baby born to a woman with PROM (>24 hours) and who is GBS negative): should remain in hospital for the first 24 hours of life and be observed as per the Neonatal Early Warning score (NEWS) chart. babies born to women with PROM and who are GBS positive –follow the GBS protocol for newborn observations Women should be asked to inform their healthcare professionals immediately of any concerns they have about their baby’s wellbeing in the first 5 days following birth, particularly in the first 12 hours when the risk of infection is greatest.
Postnatal Care for the woman with PROM:requires 4 hourly observations as per the Maternity MEWS If the woman has been febrile in labour continue IV antibiotics for at least 24 hours, followed by a full course of oral antibiotics. Back to Table of Contents
This guideline will be: discussed at maternity multidisciplinary education; distributed to maternity staff available via the ACT health intranet: Policies and Clinical Guideline Back to Table of Contents
Guidelines
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PROM Prelabour Ruptured Membranes LMP Last menstrual period UTI Urinary tract infection CTG cardiotochograph FHR Fetal heart rate FMU Fetal Medicine unit PV Per vagina MAU Maternity Assessment Unit LVS Low vaginal swab GBS Group B streptococcus ROM rupture of membranes IOL Induction of labour Back to Table of Contents
Rupture of membranes, PROM, ROM, SROM, Prolonged, Prelabour, Tocolytics Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
Doc Number Version Issued Review Date Area Responsible Page CHHS17/165 1 21/06/2017 01/07/2020 WY&C – Women and Babies of
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register Yüklə 58,72 Kb. Dostları ilə paylaş:
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