Canberra Hospital and Health Services Clinical Guideline Pre-labour Rupture of Membranes (prom) Management at Term

CHHS17/165

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.

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  Routine antibiotic administration is not recommended for women with PROM at or near term prior to the onset of labour
  
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  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
  
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  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:
  

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  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)
  

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  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
  
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  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
  

Procedure

• 
  vaginal bleeding
  
• 
  green or offensive liquor
  
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  feeling unwell or has a raised temperature
  
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  decreased fetal movements
  
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  fetal presentation was not cephalic at the last antenatal visit
  
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  history of GBS carriage in this pregnancy or has a past history of a neonate affected by GBS
  
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  history of previous Caesarean Section
  
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  multiple pregnancy.
  

Initial Assessment

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  At this assessment inform obstetric registrar
  
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  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.
  
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  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.
  
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  Document findings including detailed history
  
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  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.
  
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  Avoid vaginal examination unless in established labour
  

Expectant management versus expediting birth

Women who have confirmed ruptured membranes at term should be advised of the following:

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  70% of women with PROM will spontaneously labour and birth in the first 24 hours
  
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  85% within 48 hours and
  
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  95% within 72 hours.
  
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  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
  
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  the increased risk of chorioamnionitis and endometritis with expectant management.(Clinical chorioamnionitis with Induction of Labour 4% versus 8.6%with expectant management – (RANZCOG))
  
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  that should initial expectant management occur, IOL is offered after 18 hours of ruptured membranes
  
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  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:

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  Meconium Stained Liquor
  
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  Induction of Labour
  
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  Fetal Surveillance
  
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  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:

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  Term PROM
  
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  Fixed cephalic presentation
  
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  GBS negative
  
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  No signs of infection (maternal tachycardia, fever, uterine tenderness).
  
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  No digital examination
  
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  No history of cervical suture
  
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  Normal CTG
  

If the woman chooses expectant management the following are advised:

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  daily CTG check maternal observations as per MEWS or more often if clinically indicated
  
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  monitor PV loss and liquor for volume, colour and odour
  
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  monitor for signs and symptoms of labour including presence, frequency, strength and duration of contractions.
  
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  do NOT perform a vaginal examination unless indicated (e.g. woman is in labour).
  
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  midwife to document all assessments attended at home or in hospital
  
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  provide and discuss fact sheet on “Advice for going home now your membranes have ruptured”
  
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  confirm the woman is comfortable with staying or going home and that she is aware of the signs and symptoms of chorioamnionitis
  
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  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:

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  temperature elevated above 37.5C
  
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  maternal tachycardia e.g. ≥ 100
  
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  maternal hypotension (systolic<90mmHg or a ≥ 40mmHg drop from usual)
  
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  abdominal pain/tenderness
  
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  offensive liquor
  
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  abnormal CTG trace
  
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  meconium stained liquor
  

Expediting birth:

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  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))
  
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  consider whether intravenous prophylactic antibiotics are recommended
  
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  document all care, observations, medications and interventions required.
  

Spontaneous onset of labour:

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  consider whether intravenous prophylactic antibiotics are recommended
  
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  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:

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  Ampicillin (or amoxycillin) 2g IV 6 hourly, plus
  
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  Gentamicin 4-6 mg/kg (booking weight) IV daily
  
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  Metronidazole 500 mg IV 12 hourly
  
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  Women allergic to penicillin to be given clindamycin 900 mg IV 8 hourly
  

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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):

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  should remain in hospital for the first 24 hours of life and be observed as per the Neonatal Early Warning score (NEWS) chart.
  
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  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
  
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  If the woman has been febrile in labour continue IV antibiotics for at least 24 hours, followed by a full course of oral antibiotics.
  

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Implementation

This guideline will be:

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  discussed at maternity multidisciplinary education;
  
• 
  distributed to maternity staff
  
• 
  available via the ACT health intranet: Policies and Clinical Guideline
  

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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)
  

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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. 18^th June 2012. Clinical Guideline for the Management Of The Prelabour Rupture of Membranes at Term (Term PROM).
    

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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
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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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