Pre-labour Rupture of Membranes (prom) Management at Term



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CHHS17/165




Canberra Hospital and Health Services

Clinical Guideline

Pre-labour Rupture of Membranes (PROM) Management at Term

Contents





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




Introduction

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)



Scope

The Clinical GuidelinePre-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

Background

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.



Purpose

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.



Section 1: Review of the evidence

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:

  • 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 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

Back to Table of Contents

Section 2: Care of the Woman with Prelabour Ruptured Membranes (PROM) at Term




Procedure


Each 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 Assessment


Woman 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 birth


Women 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

No history of cervical suture

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
PRACTICE NOTE:

Notify obstetric registrar or specialist obstetrician of:



  • temperature elevated above 37.5C

  • maternal tachycardia e.g. ≥ 100

  • maternal hypotension (systolic<90mmHg or a ≥ 40mmHg drop from usual)

  • abdominal pain/tenderness

  • offensive liquor

  • abnormal CTG trace

  • meconium stained liquor



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.

Spontaneous onset of labour:


consider whether intravenous prophylactic antibiotics are recommended

document all care, observations, medications and interventions required.



Intra-partum Intravenous Antibiotic Prophylaxis


All 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)
Benzylpenicillin is preferred over ampicillin because of its narrower spectrum of activity.
If a woman has sensitivity to, but not anaphylaxis to, penicillin then the recommendation is to use cephazolin. If there is a history of anaphylactic reaction to penicillin then the recommendation is to use clindamycin.
Table 1: Medication doses (CDC recommendations: https://www.cdc.gov/mmwr/pdf/rr/rr5910.pdf)


MEDICATION

DOSE

ROUTE

FREQUENCY

DURATION

Benzylpenicillin

3g stat then 1.8g

Intravenous

4 hourly

intrapartum

Cephazolin (if non immediate hypersensitivity)


2 grams stat

then 1 g



Intravenous

8 hourly

intrapartum


Clindamycin

(if anaphylaxis

to penicillin)


900mg in 100mls


Intravenous

8 hourly

intrapartum

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

Section 3: Observation and Care of the Newborn and Woman Post-partum



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.


PRACTICE NOTE:

A baby with any symptom of possible sepsis, or born to a woman who has evidence of chorioamnionitis, should immediately be referred to the neonatology team.





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

Implementation

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

Related Policies, Procedures, Guidelines and Legislation



Guidelines

  • Induction of Labour

  • Meconium Stained Liquor

  • Early Onset Group B Streptococcal Disease

  • Labour care: first second and third stage

  • Fetal surveillance

  • Neonatal Early Warning Score (NEWS)

  • Maternal Early Warning Score (MEWS)


Back to Table of Contents

References



  1. Saccone G, Berghella V. Antibiotic prophylaxis for term or near-term premature rupture of membranes: metaanalysis of randomized trials. Am J Obstet Gynecol 2015;212(5):627.e1-9.

  2. Wojcieszek AM, Stock OM, Flenady V. Antibiotics for prelabour rupture of membranes at or near term. Cochrane Database of Systematic Reviews 2014, Issue 10. Art. No.: CD001807. DOI: 10.1002/14651858.CD001807.pub2. 2014.

  3. Nabhan AF, Elhelaly A, Elkadi M. Antibiotic prophylaxis in prelabor spontaneous rupture of fetal membranes at or beyond 36 weeks of pregnancy. Int J Gynaecol Obstet 2014;124(1):59-62.

  4. Dare MR, Middleton P, Crowther CA, et al. Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database Syst Rev 2006; CD005302. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005302.pub3/full

  5. Duff, P 2007 Preterm premature rupture of membranes, Up-To-Date (16.1)

  6. King Edward Memorial Hospital: 2.8 Prelabour rupture of membranes at Term August 2016

  7. Maternity Care in SA Preterm Prelabour Rupture of the Membranes 21 March 2011

  8. NICE Clinical guideline: Intrapartum care of healthy women and their babies during childbirth. July 2008.

  9. Prevention of Perinatal Group B Streptococcal Disease Revised Guidelines from CDC, 2010. https://www.cdc.gov/mmwr/pdf/rr/rr5910.pdf

  10. Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Term prelabour rupture of membranes (Term PROM) C-Obs 36 March 2014

  11. Royal College of Obstetricians and Gynaecologists guideline 2004, guideline no. 7, antenatal corticosteroids to prevent respiratory distress syndrome.

  12. Royal College of Obstetricians and Gynaecologists Guideline 2006, no.44,Maternal Perinatal Clinical Trials Unit http://www.health.adelaide.edu.au/og/research/mpctu.html#pprompt

  13. Royal College of Obstetricians and Gynaecologists Guideline October 2010, guideline no. 7, antenatal corticosteroids to prevent respiratory distress syndrome.

  14. The Women’s (the Royal Women’s Hospital, Victoria. Rupture of the membranes: preterm premature (PPROM). https://thewomens.r.worldssl.net/images/uploads/downloadable-records/clinical-guidelines/rupture-of-membranes-preterm-premature-pprom_160517.pdf

  15. William E Scorza, MD. Management of premature rupture of the fetal membranes at or near term. UptoDate 2017.

  16. Royal Cornwell Hospitals NHS Trust. 18th June 2012. Clinical Guideline for the Management Of The Prelabour Rupture of Membranes at Term (Term PROM).


Back to Table of Contents

Definition of Terms



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

Search Terms

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.


Date Amended

Section Amended

Approved By

Eg: 17 August 2014

Section 1

ED/CHHSPC Chair













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



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