SDMS ID: P2010/0507-001 2.

26-07WACS
Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Preterm Prelabour Rupture of Membranes Spontaneous rupture of membranes prior to 37 weeks gestation. Midwifery and Medical Staff, Queen Victoria Maternity Unit Rupture of membranes, lung maturation, tocolysis P2010/0508-001 Tocolysis for Threatened Preterm Labour P2010/0490-001 Group B Streptococcus Purpose: The management of preterm prelabour rupture of the fetal membranes (PPROM) is aimed at offering the neonate the best chances of survival with the least possibility of morbidity. Although the aim should be to prolong gestation to gain sufficient maturity, this can only be done in the absence of fetal infection or hypoxia. Definition: PPROM is the spontaneous rupture of membranes before the onset of contractions prior to 37 weeks of gestation. Diagnosis of PPROM An accurate diagnosis of rupture of the membranes is crucial to management. 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 Commence a CTG is there is any tenderness or uterine activity. If having uterine tightenings >1:10 notify the obstetric registrar or consultant 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 If the diagnosis remains uncertain perform an Amnicator or Amnisure test Perform a sterile speculum examination to assess cervical dilation and exclude cord prolapse. Perform a high vaginal swab for MC&S Blood for FBC and CRP Arrange USS of amniotic fluid volume if there is a history suggestive of PPROM in the absence of clinical signs.

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Management Management decisions are influenced by: Gestational age of the fetus at the time of membrane rupture Presence of overt infection Advanced labour Evidence of fetal compromise If less than 36 weeks gestation, consultation with paediatric registrar/consultant is required to develop a management plan and/or transfer to facility with level III neonatal nursery. Consider suitability for participating in the PROMPT trial. Special Considerations If a cervical suture is present, there is a very high risk of sepsis. The suture should be removed as soon as possible. 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, whatever the gestation. Group B Streptococcus Known carriers of group B streptococcus who present with PPROM should be treated with IV penicillin and consideration given to augmentation of labour: in the setting of extreme prematurity <30 weeks the risk of GBS sepsis must be weighed against the increased risk of prematurity. When GBS status is unknown in women less than 36 weeks gestation with PPROM GBS chemoprophylaxis should be commenced until GBS status is known (as per Group B Streptococcus Clinical Guidelines WACSClinProc2.15). Tocolysis If PPROM occurs before 34 weeks and labour begins tocolysis should be given to allow the administration of corticosteroids providing there is no sign of sepsis (fever, maternal and/or fetal tachycardia, uterine tenderness, and irritability, leucocytosis), antepartum haemorrhage or other contraindication to steroid use. Antenatal corticosteroids Corticosteroids are recommended for lung maturation between 24 weeks and 34 weeks gestation. Two doses of Betamethasone 11.4mg are given intramuscularly 24 hours apart, for prophylaxis against neonatal respiratory distress syndrome. Woman with diabetes mellitus will require additional monitoring if corticosteroids are administered. Antibiotics Antibiotic treatment following PPROM is associated with a statistically significant delay in women giving birth and reductions in major markers of neonatal morbidity. The antibiotic of choice is erythromycin 250 mg four times per day. (Giles et al 2004 & Kenyon et al 2003). In the event of infection individualised intravenous antibiotic management is to be initiated following discussion with the consultant. 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 gestation greater than 30 weeks. Notify the medical officer if any deviation from normal. Rest in bed with toilet privileges for first 48 hours. Consideration of maternal psychosocial issues associated with hospitalization and uncertain fetal outcome. Maternal education to ensure understanding of diagnosis and prognosis.
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Assessment of the risk of infection Mild pyrexia Tachycardia Uterine tenderness Purulent vaginal discharge Cardiotocograph changes fetal tachycardia, reduced baseline variability Risks of PPROM Labour which may intervene at any time resulting in preterm birth. Chorioamnionitis, which may be followed by fetal and maternal systemic infection if not treated promptly Oligohydramnios if prolonged PPROM occurs, with associated fetal problems including pulmonary hypoplasia Psychosocial problems resulting from uncertain fetal and neonatal outcome and long term hospitalisation Cord prolapse Malpresentation associated with prematurity Primary antepartum haemorrhage Attachments Attachment 1 Attachment 2 AmniSure References

Performance Indicators: Review Date:

Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS 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 Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by: Dr A Dennis Co-Director (Medical) Womens & Childrens Services

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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 References Giles M, Garland S & Oats J. Management of preterm prelabor rupture of membranes: an audit. How do the results compare with clinical practice guidelines? Australian and New Zealand Journal of Obstetrics and Gynaecology 2005:45: 201-206 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 Corticosteroids to Prevent Respiratory Distress Syndrome. Online: http://www.rcog.org.uk/index.asp?PageID=511

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