Management of rupture of membrane

1. TITLE:

Management of rupture of membrane
PURPOSE:

2. 1. To provide and support the decision in the management of patient admitted with rupture of membrane.

   2. Create policy of managing patient with Pre-labor rupture of membranes (PROM) and Preterm PROM (PPROM) to reduce maternal and fetal mortality and morbidity.
      CONDITION/APPLICABILITY:

The policy applied to all women admitted to L&D department with a rupture in membrane.
DEFINITIONS: 

4. 1. Pre-labor rupture of membranes (PROM) refers to membrane rupture before the onset of uterine contractions (previously known as premature rupture of membranes).

   2. Preterm PROM (PPROM) refers to PROM before 37+0 weeks of gestation.
      POLICY:

   5.1.to provide healthcare worker with policy to reduce the risk of fetal morbidity and mortality and to reduce the risk of infection and respiratory destress syndrome

    5.2. to reduce maternal morbidity by covering the patient with the appropriate antibiotics to reduce the risk of endometritis and to avoid early intervention which might lead to increase risk of caesarian section
PROCEDURE:

6. 1. A routine admission care and prerequisite shall be completed and complied.

   2. On admission detail history and examination should include:

      1. Confirm gestational age by early scan or accurate last menstrual period.

      2. A woman presents with a history of leaking fluid.

      3. Abdominal examination to confirm the presenting part, tenderness, and     gestational age.

      4. Confirm leaking by sterile speculum examination, and observing the pooling of amniotic fluid in the posterior vaginal vault.

      5. If pooling is not observed, asking the patient to press on her fundus, cough, and bear down to confirm the diagnosis.

      6. Digital examination should be avoided.

   3. Laboratory test should be done to confirm leaking.

      1. PAMG-1 (Amni Sure) 

         1. Negative result will show one visible line 

         2. Positive result will show two visible lines 

      2. Nitrazine test False negative and false positive test results occur in up to 5% of cases

   4. Ultrasound examination:

      1. To confirm diminished liquor volume

      2. To check presentation and gestational age, fetal weight estimation, and Placenta localization.

   5. Case should be discussed and evaluated by registrar on call.

   6. Women should be council fully about cons and prone of PPROM according to gestational age and the plane of management 

   7. Management according to gestational age:

      1. Gestational age > 37 weeks

         1. If patient have labor pain and contraction, do digital vaginal assessment to confirm the presenting part, cervical dilatation effacement and membrane and admit the patient to the labor room.

         2. If patient have no labor pain and no contraction, admit to the word:

• If the patient GBS negative don’t give antibiotics.

• If the patient GBS positive give the appropriate antibiotics “refer to the protocol of GBS.

• If patient not screen give antibiotics at 18hrs ampicillin 2g IV as loading then follow by 1 g Q 6hrs till the delivery. 

• If vaginal examination done and patient not in labor, patient should be augmented.

2. Gestational age >23week+6days fetal weight >450 g 

   1. Inform the neonatologist and confirm the availability of NICU bed.

   2. Mange the patient conservatively till 34 weeks then induce at 34 weeks gestation. 

   3. Administer antenatal corticosteroids “see the policy of ANC corticosteroid.

   4. Give Magnesium sulfate if gestational age <32 week, and patient eminent delivery “refer to the protocol of Magnesium sulfate”

   5. Administering a seven-day course of prophylactic antibiotics to all women with PPROM who are managed expectantly.

      1. Azithromycin 1 gram orally upon admission, PLUS

      2. Ampicillin 2 grams intravenously every 6 hours for 48 hours. 

Then shift the patient to 

3. Amoxicillin 500 mg orally every 8 hours for an additional five day.

4. Patient allergic to penicillin follow the “antibiotics policy 

6. Tocolysis 

• If it will be given to delay delivery by 48hrs for administration of a course of corticosteroids. 

• Tocolytics should not be administered for:

• More than 48 hours. 

• to patients who are in advanced labor (>4 cm dilation)

• Patient with subclinical or overt chorioamnionitis.

• Non-reassuring fetal testing

• abruptio placentae

• significant risk of cord prolapses

7. Fetal monitoring 

• NST should be started after completed 27 wks gestation 

  • Trans abdominal scan should be done every 7 days 

8. Maternal monitoring:

• Maternal monitoring for sign of infection maternal temperature, presence of uterine tenderness, frequency of contractions, maternal and fetal heart rate and laboratory result should be used all together to decide upon the risk of Chorioamnionitis

• Do the following investigation 

• CBC, white blood cell deferential count and C reactive protein should be done every 3 days, The white cell count will rise 24 hours following administration of corticosteroids and should return to baseline 3 days following administration

• Presence of meconium stain liquor alone is not an indication for delivery. 

• HVS &LVS for GBS on admission

• Urine culture on admission

8. Time of delivery:

   1. The delivery should be between 34-37 weeks if the patient stable without complication after discussing with her the advantages and disadvantages of delivery versus expectant management. 

   2. The delivery should be immediate if intrauterine infection, abruptio placentae, non-reassuring fetal testing, or a high risk of cord prolapse is present or suspected

9. Route of delivery:

   1. Labor should be induced to deliver all patient vaginally in the absence of contraindications to labor.    

   2. Cesarean delivery is performed for standard indications.
      FORMS/ EQUIPMENTS:

7. 1. Management of SROM>37wks

   2. Management Spontaneous rupture of membrane (PPROM)<37wks pathway
      REFERENCE:

8.1. Up to date 2020 

8.2. Green-top Guideline No. 73 June 2019

REVISION:

10. APPROVALS: