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					                       Prelabour Rupture of Membranes


PROM

PROM is defined as the spontaneous leaking of amniotic fluid before the onset of
labour. Term gestation is defined as pregnancy ≥37 weeks. The incidence of
PROM at term is approximately 8%. There are many potential causes of PROM
including; idiopathic, polyhydramnios, infection, cervical or uttering abnormalities,
and lifestyle. Ninety percent of women enter labour within the first 24 hours after
rupture.

The options for management should be reviewed thoroughly with clients and
include the benefits and risks of either immediate induction post rupture or
expectant management. This discussion must include risks of infection to mother
and baby, risk of failed induction and CS. Appropriate management is based on
the following steps:

       - Diagnosis of PROM
              Obtain a full history from the client regarding fluid loss from the
              vagina: timing, amount, color, present state, fetal movements.
              Complete diagnosis may require a sterile speculum exam.
              Evidence of PROM include; pooling of fluid in the posterior formix of
              the vagina, free flow of fluid from the cervix. The fluid may be
              examined for ferning using a slide and microscope, or by using a
              nitrazine swab to test the pH of the fluid. The latter of the two
              methods has a potential for false positives due to the presence of
              blood, semen, urine, and infection, thus ferning may be a more
              appropriate method of confirm diagnosis.

       - Assessment of maternal and fetal wellbeing
             Advise NST for fetal wellbeing and uterine activity
             Monitor maternal vitals including pulse and temperature at regular
             intervals

       - Assessment of labour status
             *Note: Digital exam should be avoided if at all possible. Cervical
             dilation and effacement may be assessed by sterile speculum
             exam, as well as ruling out cord prolapsed. Digital cervical
             assessment is indicated if the woman is in labour, if there is non-
             reassuring fetal status, or if the os is not visible by speculum. Any
             vaginal exam may increase risk of ascending infection and should
             be much avoided with expectant management.

       - Review associated conditions
              If signs or symptoms of umbilical cord prolapsed, follow emergency
              skills procedure.
              If presentation unknown, confirm fetal presentation by U/S,
              abdominal palpation or vaginal exam*.



                                                                          June 2008
                      Prelabour Rupture of Membranes


             If woman is GBS positive or unknown, advise intravenous antibiotic
             prophylaxis and induction of labour with oxytocin.
             Assess for infection by swabs or cultures, if indicated.

      - Discuss options for management
             For GBS negative clients with no associated conditions, offer the
             options of immediate induction (planned management) with
             oxytocin or expectant management. Important facts to mention:
             -There is no significant increase in risk of CS with either option
             -There is a significant increase risk of chorioamnionitis with
             expectant management with the number needed to treat (NNT) at
             50, ie for every 50 women undergoing planned management, one
             case of chorioamnionitis will be avoided. Some research shows an
             increase in cases of infection with vaginal exams, though a review
             of many studies shows no significant differences.
             -There is a lower incidence of endometritis with planned
             management
             -There is no significant different in neonatal outcomes with either
             option although research shows that planned management may
             decrease admissions to neonatal intensive care unit with a NNT of
             20.
             -Overall, the difference between the two options is slight; therefore
             women need to have the appropriate information to be able to
             make informed choices.
             -Note: there is no clear guideline for management with PROM and
             thick meconium though it is mentioned in some research that
             planned management is best.

See following page form MORE OB PROM decision tree

CMO discussions, consultations and transfers
Category 2
-PPROM between 34 & 37wks
-Prolonged rupture of Membrane




                                                                       June 2008

				
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Description: PROM effacement