Womens & Childrens Services SDMS ID: P2010/0502-001 Clinical Guidelines 2.

32-07WACS Title: Replaces: Description: Target Audience: Key Words:

Prelabour Rupture of Membranes at Term

New Guideline Management of prelabour rupture of membranes at term Midwifery and Medical Staff, Queen Victoria Maternity Unit Rupture of membranes at term

Policy Supported: Purpose: Prelabour rupture of membranes (PROM) occurs in 6 - 19% of all term births. Almost 70% of these women will give birth within 24 hours and almost 90% will deliver within 48 hours. Prelabour rupture of membranes can be treated conservatively for 24 to 48 hours. Above this time the risk of infection outweighs the benefits of waiting. Definition: PROM is the spontaneous rupture of membranes before the onset of contractions after 37 weeks of gestation. Assessment Women who present or telephone with suspected spontaneous rupture of membranes and who are not in labour may be referred to the Pregnancy Assessment Unit for assessment. Diagnosis of PROM Diagnosis is based on a careful history and a physical examination of the women. DO NOT perform a digital vaginal examination as it increases the risk of infection. Document the time and history of the reported vaginal loss. The woman may report a sudden gush, a constant leak or a sensation of wetness within the vagina or on the perineum. Check and record maternal temperature, pulse and blood pressure. Confirm the presence of fetal movement and auscultate fetal heart. Perform an abdominal palpation noting; o symphysis fundal height o lie o presentation o uterine tenderness, irritability, activity If there is no evidence of amniotic fluid on the womans pad or underwear instruct her to lie in a semirecumbent position for 20 minutes to allowing pooling of fluid in the vagina. Perform an Amnisure test (see appendix 1) Consider a sterile speculum to assess cervical dilation and exclude cord prolapse. Perform a high vaginal swab for MC&S and GBS if current status unknown. Perform CTG if expectant management is planned.

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Management Known carriers of group B streptococcus who present with PROM should be treated with IV antibiotics and a plan developed for induction of labour. If pathogens are detected from the genital tract swabs and/or there is clinical evidence of sepsis, antibiotics should be prescribed and active intervention to ensure delivery. Expectant management at home can be offered to women who meet the criteria (see appendix 2). These women should be booked for induction of labour prior to discharge and return for daily assessment. Outpatient Daily Assessment Daily outpatient assessment will be conducted in the Pregnancy Assessment Unit on weekdays and in Ward 4B on weekends. Review womens recordings of loss and temperature Maternal observations pulse and temperature Review pad and confirm loss is clear or pink Abdominal palpation to confirm presentation and noting any tenderness. CTG to assess fetal wellbeing. In Patient Midwifery Management Six hourly observations of temperature and pulse to monitor maternal well being. Regular observations of sanitary pads to assess liquor. Six hour observations of fetal heart rate and regular CTG if prolonged rupture of membranes (> 24 hours). Notify the medical officer if any deviation from normal. Assessment of the risk of infection Mild pyrexia Tachycardia Uterine tenderness Purulent vaginal discharge Cardiotocograph changes fetal tachycardia, reduced baseline variability

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Attachments
Attachment 1 Attachment 2 Attachment 3 Attachment 4 AmniSure Criteria for Expectant Management Information for Women Expectant Management References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _________________________

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APPENDIX 1 AMNISURE Procedure Take the solvent vial by its cap and shake well to make sure all the liquid has dropped to the bottom. Open the solvent vial and put it in a vertical position. Collect a sample from the surface of the vagina using the sterile Polyester swab provided. The Polyester tip should not touch anything prior to its insertion into the vagina. Hold the middle of the stick and while the woman is lying flat on her back carefully insert the Polyester tip of the swab into the vagina unit the fingers contact the skin (no more than 5-7 cm deep). Withdraw the swab from the vagina after 1 minute. Place polyester tip into the vial and rinse the swab in the solvent by rotating for one minute. Remove and dispose of the swab. Tear open the foil pouch at the tear notches and remove the Amnisure test strip. Dip the white end of the Test Strip (marked with arrows) into the vial with solvent for no less than 5 minutes and no longer than 10 minutes. Strong leakage of amniotic fluid will make the result visible early (after 5 minutes) while a very small leak will take the full 10 minutes. Remove the Test Strip if two stripes are clearly visible in the vial (no earlier than 5 minutes) or after 10 minutes. Read the results placing the test on a clean, dry, flat surface. Do not read or interpret the results after 15 minute have passed since dipping the Test Strip into the vial.

AmniSure ROM (Rupture of {fetal} Membranes) Test Product Information

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APPENDIX 2 Criteria for Expectant Management Engaged cephalic presentation Planning vaginal birth No previous LSCS No digital vaginal examination has been performed GBS negative Liquor is clear or pink No fetal or maternal conditions requiring monitoring Maternal observations normal Fetal movements normal and CTG reassuring Willing and able to return the following day for assessment Agrees to refrain from sexual intercourse Capable of and agreeable to monitoring temperature and liquor. Women must agree to: Record temperature 6 hourly and contact 4B if temperature above 37.4C Hospital to supply a thermometer if the woman does not have one. Record pad checks and contact 4B is loss becomes green, offensive or bloody. Note fetal movement Contact 4B if Feeling unwell in any way Experiencing constant abdominal or back pain Contractions commence

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APPENDIX 3 Information for Woman

PRELABOUR RUPTURE OF MEMBRANES (PROM) AT TERM Managing at home after your waters have broken This information is for pregnant women whose waters have broken (the membranes around the baby have ruptured) but labour has not begun. 9 out of 10 women will go into labour within 48 hours of their waters breaking. You have told us that you would prefer to wait as long as possible for an opportunity for labour to begin naturally. If your labour does not begin we have booked you in for an induction of labour on _________________ at ____________. In the meantime you will need to do the following: observe the colour of your vaginal loss each pad change monitor your babys movements If at any time you generally feel unwell (flu like symptoms) or your temperature goes above 37.4C you have bright red vaginal loss there is a change in colour or odour of your vaginal loss you start to contract, or contractions become stronger your baby does not move as much as it has been your abdomen is tender we would like you to telephone 4B on 6348 8960 to discuss your progress. We may ask you to come in to hospital to be looked at again. Please record your temperature on the other side of this page. We will ask you about your general health, temperature, vaginal loss and your babys movements when you telephone us. Other advice: it is not suitable for you to have a bath with ruptured membranes until you are in established labour eat and drink as desired to ensure hydration and energy rest as much as possible if you have no contractions it is important you do not have sexual intercourse when your membranes have ruptured. Remember, if you have any concerns or queries, do not hesitate to ring us at any time. The midwives are available 24 hours a day on 6348 8960.

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Date and Time

Temperature

Colour of fluid on pads

Babys Movements

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APPENDIX 4 REFERENCES Kenyon S, Boulvain M, Neilson J. Antibiotics for preterm rupture of membranes. Cochrane Database of Systemic Reviews 2003, Issue 2. Art. No.:CD001058. DOI: 10.1002/14651858.CD001058. Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database of Systemic Reviews 2006, Issue 3. Art. No.: CD004454. DOI: 10.1002/14651858. CD004454.pub2. Royal College of Obstetricians and Gynaecologist 2004 Clinical Green Top Guidelines: Antenatal Corticosteriods to Prevent Respiratory Distress Syndrome. Online: http://www.rcog.org.uk/index.asp?PageID=511 Royal Womens Hospital Clinical Practice Guidelines 2005 Rupture of membranes, premature at term. Online: http://www.rwh.org.au/rwhcpg/maternity.cfm?doc_id=2367

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