Premature rupture of membranes (PROM) at term is rupture of membranes prior to the onset of labor at or beyond 37 weeks' gestation. PROM occurs in approximately 10% of pregnancies. Patients with PROM present with leakage of fluid, vaginal discharge, vaginal bleeding, and pelvic pressure, but they are not having contractions. Show
ROM is diagnosed by speculum vaginal examination of the cervix and vaginal cavity. Pooling of fluid in the vagina or leakage of fluid from the cervix, ferning of the dried fluid under microscopic examination, and alkalinity of the fluid as determined by Nitrazine paper confirm the diagnosis. Blood contamination of the Nitrazine paper and ferning of cervical mucus may produce false-positive results. Pooling of fluid is by far the most accurate for diagnosis of ROM. If all fluid has leaked out as in early PROM, an ultrasonographic examination may then show absence of or very low amounts of amniotic fluid in the uterine cavity. New evidence suggests that the use of biochemical markers to diagnose ROM in uncertain cases may be appropriate and cost effective. Echebiri et al reported cost effectiveness compared to standard methods of diagnoses between 34 and 37 weeks. [5] Ng et al reported placental alpha-microglobulin-1 levels have a 95.7% sensitivity, 100% specificity, 100% positive predictive value, and 75% negative predictive value. [6] In select cases when the diagnoses or ROM is not clear, placental alpha-microglobulin-1 should be used to provide additional information for appropriate management. Given the importance of making the correct diagnoses, the associated morbidity with hospitalization and delivery prior to term in PROM reaching 34 weeks and beyond, and the potential neonatal morbidity resulting from prematurity in cases of incorrect diagnoses of PROM, it is mandatory to confirm the diagnosis of PROM with pooling of amniotic fluid with some evidence of decreased or absence of amniotic fluid in all cases of suspected PROM. Most patients (90%) enter spontaneous labor within 24 hours when they experience ROM at term. The major question regarding management of these patients is whether to allow them to enter labor spontaneously or to induce labor. In large part, the management of these patients depends on their desires; however, the major maternal risk at this gestational age is intrauterine infection. The risk of intrauterine infection increases with the duration of ROM. Evidence supports the idea that induction of labor, as opposed to expectant management, decreases the risk of chorioamnionitis without increasing the cesarean delivery rate. [7, 8, 9] Hannah et al studied 5041 women with PROM who were randomly assigned to induction of labor with intravenous oxytocin or vaginal prostaglandin E2 gel versus expectant management for as many as 4 days with induction of labor for complications. [10] They concluded that, in women with PROM, induction of labor and expectant management resulted in similar rates of cesarean delivery and neonatal infection. However, induction with oxytocin resulted in a lower risk of maternal infection (endometritis) when compared with expectant management. Additionally, the women in the study viewed induction of labor more favorably than expectant management. Other smaller studies have shown results with higher cesarean and/or operative delivery rates when the cervix was unfavorable. At term, infection remains the most serious complication associated with PROM for the mother and the neonate. The risk of chorioamnionitis with term PROM has been reported to be less than 10% and to increase to 40% after 24 hours of PROM. [11] This points out the importance of appropriate management strategies for PROM at term. Since risk of infection at term with ROM is small during the first 24 hours, expectant management and waiting for spontaneous labor may be considered in selected patients for the first 12-24 hours if a patient desires expectant management. The use of expectant management after the first 24 hours is questionable. Digital vaginal examinations should be avoided until labor is initiated; however, fetal presentation should be documented to avoid discovering malpresentation of the fetus long after admission for ROM. All patients with ROM should be asked to come to the hospital to ensure fetal well being. The neonatal risks of expectant management of PROM include infection, placental abruption, fetal distress, fetal restriction deformities and pulmonary hypoplasia, and fetal/neonatal death. Fetal death does occur in approximately 1% of patients with PROM after viability who have been expectantly managed [1] and in about 1:1000 term PROM. [12] The primary determinant of neonatal morbidity and mortality is gestational age at delivery, again stressing the importance of conservative management when possible. (See the Gestational Age from Estimated Date of Delivery calculator.) In general, prognosis is good after 32 weeks' gestation as long as no other complicating factor, such as congenital malformation or pulmonary hypoplasia, exists.
First do Rapid assessment and management B3-B7. Then use this chart to assess the woman's and fetal status and decide stage of labour. View in own window
Next: Perform vaginal examination and decide stage of labour View in own window
Next: Respond to obstetrical problems on admission. Use this chart if abnormal findings on assessing pregnancy and fetal status D2-D3. View in own window
Next: Give supportive care throughout labour Use this chart to provide a supportive, encouraging atmosphere for birth, respectful of the woman's wishes. Communication
Cleanliness
Mobility
Urination
Eating, drinking
Breathing technique
Pain and discomfort relief
Birth companion
Use this chart for care of the woman when NOT IN ACTIVE LABOUR, when cervix dilated 0-3 cm and contractions are weak, less than 2 in 10 minutes. View in own window
View in own window
Use this chart when the woman is IN ACTIVE LABOUR, when cervix dilated 4 cm or more. View in own window
View in own window
Use this chart when cervix dilated 10 cm or bulging thin perineum and head visible. View in own window
View in own window
Use this chart for care of the woman between birth of the baby and delivery of placenta. View in own window
View in own window
View in own window
Next: If prolapsed cord The cord is visible outside the vagina or can be felt in the vagina below the presenting part. View in own window
Next: If breech presentation View in own window
Next: If stuck shoulders View in own window
Next: If multiple births View in own window
Next: Care of the mother and newborn within first hour of delivery of placenta Use this chart for woman and newborn during the first hour after complete delivery of placenta. View in own window
View in own window
Use this chart for continuous care of the mother until discharge. See J10 for care of the baby. View in own window
View in own window
After an uncomplicated vaginal birth in a health facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth. Use this chart to examine the mother the first time after delivery (at 1 hour after delivery or later) and for discharge. For examining the newborn use the chart on J2-J8. View in own window
Next: Respond to problems immediately postpartum If no problems, go to page D25. View in own window
Next: If elevated diastolic blood pressure IF ELEVATED DIASTOLIC BLOOD PRESSURE View in own window
Next: If pallor on screening, check for anaemia View in own window
Next: Give preventive measures Ensure that all are given before discharge. View in own window
Advise on postpartum care and hygiene
Counsel on nutrition
Counsel on Substance Abuse
View in own window
View in own window
Use this chart for advising on postnatal care after delivery in health facility on D21 or E2. For newborn babies see the schedule on K14. Encourage woman to bring her partner or family member to at least one visit. Advise to go to a hospital or health centre immediately, day or night, WITHOUT WAITING, if any of the following signs:
Go to health centre as soon as possible if any of the following signs:
Discuss how to prepare for an emergency in postpartum
Use these instructions if you are attending delivery at home. Preparation for home delivery
Delivery care
Immediate postpartum care of mother
Postnatal care of newborn
For both
|