Pre-labour rupture of membranes at term

• Infection (2-3 per cent, in the absence of risk factors, for mothers and babies)
• Placental abruption
• Umbilical cord prolapse or cord compression
• Respiratory distress syndrome in the newborn.

Link to: Term PROM QRA

On the telephone

Careful history taking is essential to determine the possibility of PROM and assess the presence of any complicating risk factors. This assessment is often done over the phone.

Ask these questions:

• What time did the membranes rupture?
• What is the volume, colour and odour of the fluid on the woman's pad (if applicable)?
• Does the woman feel unwell?
• Is the baby is moving normally?
• Does the woman know how her baby was presenting at the last antenatal visit?
• Has she had any medical problems in her pregnancy?
• Does she know her GBS status?
• Is this a singleton pregnancy?
• Has the woman had a previous caesarean section?

In the absence of risk factors, advise the woman to present for assessment within 12 hours of ROM.

If there are any risk factors, advise her to present for assessment as soon as she can attend hospital, without unnecessary delay.

She should tell her midwife or doctor if contractions begin.

On presentation

• Perform a general and obstetric examination.
• Confirm the presence of liquor on the woman's pad, if relevant.
• If no evidence of liquor is present, a sterile speculum examination may be indicated.
• If no liquor is visualised during the speculum examination, a diagnostic tool such as the Amnisure can be used.
• If no liquor is visualised and no diagnostic tools are available, admit the woman for ongoing observation and continue pad checks to confirm or rule out ROM.
• Electronic fetal monitoring to assess fetal wellbeing.

Risk factors that may complicate management of PROM

• GBS positive in this pregnancy - GBS prevention for neonates - Neonatal eHandbook
• Previous birth of a baby affected by GBS disease
• Evidence of infection
• Meconium stained liquor
• Abnormal CTG
• Malpresentation
• Previous caesarean section
• History of cervical suture

Link to: Term PROM QRA

Deciding between active and expectant management of PROM depends on identified risk factors, health service capacity and the woman's preference.

Active management is associated with lower risks of maternal and neonatal sepsis and lower rates of newborn admissions to special care nurseries.

Table 1. Risk of sepsis associated with active and expectant management of PROM*

* Data from the 2017 Cochrane Review - Quality of evidence (GRADE) identified as lowTable 1. Risk of sepsis associated with active and expectant management of PROM*

Active management

Active management is recommended for women with any risk factors and for those women who prefer this option.

If the woman is GBS positive, IV antibiotics should be commenced immediately and IOL commenced as soon as possible.

Commencement of active management may be affected by the health service's capacity to safely provide 1:1 midwifery care.

Oxytocin induction is advised for IOL - See Induction of labour.

Expectant management

In the absence of any complicating risk factors, women may be offered the option of expectant management. This may be as an inpatient or, if appropriate (based on individual circumstances such as travel requirements and support), at home.

The benefit of oral antibiotic prophylaxis prior to spontaneous labour or induction is unclear. For services who choose to offer oral antibiotic prophylaxis, the following regimen is appropriate:

• Amoxycillin 500mg TDS, from 18 hours post-ROM until commencement of intrapartum antibiotics.

Download a patient information sheet

Practice points

• Discuss the management plan with the woman and her support person or family.
• Advise four-hourly observations of temperature, PV loss, fetal movement and uterine activity (during waking hours).
• Ensure the woman understands normal and abnormal parameters and knows to report any abnormal observations.
• Advise the woman to avoid vaginal intercourse.
• Admit for active management if labour is not established by 24 hours after ROM - See IOL eHandbook page.
• Intrapartum antibiotic prophylaxis is indicated for ROM >/= 18 hours:
  • women admitted in labour <18hrs post-ROM - commence antibiotic prophylaxis 18 hours after ROM
  • women admitted >/= 18hrs post-ROM - commence intrapartum antibiotics on admission

Antibiotics

Antibiotics for GBS+ or ROM>18 hours

• IV Benzylpenicillin 3g loading dose
  then
• IV Benzylpenicillin 1.8g every four hours

If the woman has a penicillin hypersensitivity with no history of anaphylaxis

• IV Cephazolin 2g loading dose
  then
• IV Cephazolin 1g every eight hours

If the woman has a penicillin allergy with history of anaphylaxis

• IV Clindamycin 900mg every eight hours

Antibiotics for suspected sepsis/chorioamnionitis

• IV Amoxycillin 2 g loading dose, continuing 1 g every six hours

AND

• IV Gentamycin 5 mg/kg daily

AND

• IV Metronidazole 500 mg every 12 hours

If the woman has a penicillin allergy

• IV Clindamycin 900 mg every 8 hours

Postpartum management

• If chorioamnionitis is suspected, ensure the placenta is sent for histopathological examination.

See the Neonatal eHandbook Neonatal sepsis strategies flowchart.

Babies born to well women and who are not symptomatic of infection

• Routine observations for 12-24 hours post birth as per the VICTOR Newborn chart or your maternity service's schedule of observations
   

Practice note: 95 per cent of neonates who become symptomatic of infection will do so within 24 hours.

Babies born to women who have not received adequate antibiotic cover

Signs of neonatal sepsis:

• Paediatric assessment
• FBE, blood cultures, CRP
• Antibiotics
• Early CRP may need to be repeated at 6-12 hours
• Observe in hospital for 24-48 hours

No signs of neonatal sepsis:

• Observe in hospital for 24-48 hours

Observations:

• As per local guidance
• Document on health service observation and response charts or VICTOR Newborn charts (where applicable)

Babies who are symptomatic of infection

• Perform septic work up and commence antibiotics - Sepsis in neonates - Neonatal eHandbook.
• These babies require continuous monitoring and should be managed in a facility with the capacity to provide this service.

Audit and performance improvement

All maternity services should have processes in place for:

• auditing clinical practice and outcomes
• providing feedback to clinicians on audit results
• addressing risks, if identified
• implementing change, if indicated.

Potential auditable standards for PROM include:

• rates of expectant management
• rates of maternal and neonatal sepsis
• SCN/NICU admission after PROM
• maternal and neonatal readmission for sepsis
• adherence to standards of care.

For further information or assistance with auditing, please contact us.

References

• Immediate delivery compared with expectant management after preterm pre-labour rupture of the membranes close to term (PPROMT trial): a randomised controlled trial (2016). Morris, J. et.al. The Lancet, 387(10017), 444-452.
• Peripartum Group B Streptococcus CPG (2014). Bennett, S. et.al. Working Group Clinical Practice Guidelines Committee, Insurance and Risk Management Program AOM staff.
• Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more) (2017). Middleton, P. et.al. Cochrane Database of Systematic Reviews.
• Practice Bulletin ACOG No 172 October 2016.
• Pre-labour rupture of membranes (PROM)> 37 weeks (2015). SA Department of Health.
• Using vaginal Group B Streptococcus colonisation in women with preterm premature rupture of membranes to guide the decision for immediate delivery: a secondary analysis of the PPROMEXIL trials (2014). Tajik, P. et.al. BJOG: An International Journal of Obstetrics & Gynaecology, 121(10), 1263-1272.
• Term PROM guideline (2014). RANZCOG.
• Pre Labour Rupture of Membranes at Term (Term PROM) Clinical Guideline for Management (2014). NHS Trust Royal Cornwall Hospitals.
• Management of Perinatal Infections (2014). Palasanthiran, Starr, Jones & Giles. NSW: Australian Society for Infectious Diseases.