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Pre Term Pre-Labour Spontaneous Rupture of Membranes (Less Than 37 Weeks) Policy

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Pre Term Pre-Labour Spontaneous Rupture of Membranes (Less Than 37 Weeks) Policy Document ID: MATY083 Version: 1.0 Facilitated by: Eleanor Martin, Educator Last reviewed: October 2015 Approved by: Maternity Quality Committee Review date: October 2018 Pre Term Pre-Labour Spontaneous Rupture of Membranes (Less Than 37 Weeks) Policy Hutt Maternity Policies provide guidance for the midwives and medical staff working in Hutt Maternity Services. Please discuss policies relevant to your care with your Lead Maternity Carer. Purpose This guideline outlines the practice that relates to the management of pre-term pre- labour spontaneous rupture of membranes (PPROM). Guideline The clinical significance of SRM varies with the gestational age and the time interval between the SRM and birth. Pre-term pre-labour SRM are more likely to be triggered by underlying infection (RCOG, 2010). Prolonged SRM delivery intervals increase the risk of chorioamnionitis and perinatal morbidity and mortality. Optimal clinical management needs to factor into account the full clinical presentation, results of investigations and ongoing clinical developments. Gains in fetal maturity and / or hopes to avoid an intervention cascade following induction of labour, must be balanced with the need to avert significant perinatal sepsis. Scope All medical, midwifery and nursing staff employed by Hutt Valley DHB. All Hutt Valley DHB Maternity access holders. Definitions Pre-term pre-labour rupture of membranes, also referred to as PPROM Pre-labour spontaneous rupture of membranes (SRM) prior to 37 weeks gestation. Principles of care for PPROM include: • Establishing a diagnosis, • Exclude underlying infection or haemorrhage • If SRM associated with PV bleeding: vasa praevia must be considered. • Exclude malposition • If cord prolapse suspected a digital examination is required. • management in accordance with gestational age Acute assessment of PPROM LMCs are advised to inform all women antenatally about the symptoms and signs of pre-labour SRM and who to contact if this occur. (Refer algorithm Appendix 1). < 37 weeks gestation pre-labour SRM Prior to 37 weeks, it is recommended that there be a prompt assessment at HVDHB delivery suite and that a specialist consultation occurs (referral guideline 4023). Assessment • Obtain maternal history • Confirm gestational age- reviewing clinical data regarding last menstrual period and early scan reports. • Consider underlying pathology or complications: e.g. Chorioamnionitis, antepartum haemorrhage, vasa praevia, • Perform a clinical examination including: ° Assessment of any liquor on sanitary pads- including the amount and blood or meconium staining ° Maternal temperature and pulse and blood pressure ° Observation of uterine contractions ° Fetal size, lie and presentation ° Liquor volume and membrane status ° Mid Stream Urine ° CTG Sterile speculum (Ideally after a woman has rested for 20 – 30 minutes to allow any leakage of liquor to pool in posterior vaginal fornix). ° Look for liquor ° Low vaginal and rectal swab – Group B Streptococcus. ° Sample examination under microscope: take a swab of vaginal fluid onto a glass slide and allow drying for 10 minutes. Ferning confirms presence of liquor. ° Amnicator ° Avoid digital vaginal examination • CTG • Complete Blood Count • Ultrasound ° A further formal scan in the scanning department is recommended when clinical situation permits. Clinical management according to gestational age if ruptured membranes is confirmed . Prior to 32 weeks gestation: transfer to CCDHB (consultant to consultant). Prior to transfer consider the need for antenatal steroids, tocolysis and oral erythromycin (RCOG, 2010) Consider magnesium sulphate for neuro-protection after consultation with Obstetric and Paediatric SMO (refer appendix on magnesium sulphate protocol). Assessment for 32-34 weeks gestation • Complete assessment as above and transfer to secondary care unit. • Liaise with SCBU and paediatric RMO. If SCBU full will need to transfer to an available hospital. Pre Term Pre-Labour Spontaneous Rupture of Membranes (Less than 37 Weeks) (MATY083) Page 2 of 7 ° Daily CTG or if the clinical picture changes ° Monitoring should include an assessment of: 4 hourly maternal temperature, pulse ° (An elevated maternal or fetal heart rate will often be the first indicator of chorioamnionitis). ° liquor loss-volume/ colour/ odour ° Obstetric SMO /RMO review is urgently indicated if: (a). clinical signs of sepsis develop –immediate augmentation or induction recommended or (b). Onset of labour is suspected. ° For daily review by obstetric SMO / RMO • Steroid administration from 23- 34 weeks (see appendix 2)(RCOG, 2010) Prophylactic oral erythromycin for 10 days (RCOG, 2010) • If GBS has been detected at any stage during the pregnancy regardless of the gestation prophylactic antibiotics is recommended as per GBS prophylaxis policy. Induction of labour should be considered if there is a suspicion of chorioamnionitis (RCOG, 2012). • For gestations under 34 weeks first dose of steroids can be given followed by a second dose 24 hours. • Delivery should be considered at 34 weeks of gestation. Where expectant management is considered beyond this gestation, women should be informed of the increased risk of chorioamnionitis and the decreased risk of respiratory problems in the neonate (RCOG, 2010) Indications for augmenting labour: from 32-34 weeks • gestation progressed to 34 weeks and course of steroids completed • clinical concern regarding chorioamnionitis or fetal compromise • C/S indicated for / obstetric indications Management of premature labour following premature SRM Antibiotics: All women will receive Intrapartum antibiotics Tocolysis is not recommended in the presence of PPROM. This could have adverse effects, such as delaying delivery from an infected environment, due to an association between intrauterine infection, prostaglandin and cytokine release and delivery (RCOG, 2010). Plan of care for birth 34 weeks - < 37 weeks gestation • Immediate induction of labour is recommended after discussion with woman and on call obstetric team. • For IOL, refer IOL guideline • Prostaglandins are not contraindicated A conservative approach can be supported once the woman has been fully informed of potential risks to baby and herself. ° There are no signs of sepsis ° There is no history of GBS ° There is no fetal distress Pre Term Pre-Labour Spontaneous Rupture of Membranes (Less than 37 Weeks) (MATY083) Page 3 of 7 ° 4 hourly maternal temperature and pulse are normal ° Daily CTG, ° There has been no digital VE ° There are no other indications for IOL The care plan is to be clearly documented in the woman’s clinical notes References Bramberger, P. & Lawrence, J., Braun, D. & Saunders, B., Contreras, R. & Petitti, D. (2000). The influence of Intrapartum antibiotics on the clinical spectrum of early onset Group B Streptococcal infection in term infants. Pediatrics, (106) 244-250. Carlan, S. J., O’Brien, W. F., Parsons, M. T., Lense, J. J. (1993). Preterm premature rupture of membranes; a randomised study of home versus hospital management. Obstetric Gynaecology , 81 (1) 61-64. Consensus Guideline. (2013). The prevention of early-onset neonatal Group B Streptococcus infection. Nz Working Group. Dare, M.R., Middleton, P., Crowther, C. A., Flenady, V., Varatharaju, B. (2006). Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD005302. DOI: 10.1002/14651858.CD005302.pub2. Duff, P. (2010). Preterm premature rupture of membranes. http://www.uptodate.com/online/content/topic . Flenady, V. & Jenkins-Manning, S. (2007). For the Queensland Clinical Practice Guidelines Working Party on the prevention of early onset Group B Streptococcal Disease, Centre for Clinical Studies, Mater Health Services: Brisbane Guinn, D. A., Atkinson, M. W. (2001). Single vs weekly courses of antenatal corticosteroids for women at risk of preterm delivery: A randomised controlled trial. JAMA, 286 (13) 1581-1587. Howarth, G., Botha, D. J. (2001). Amniotomy plus intravenous oxytocin for induction of labour. Cochrane Database of Systematic Reviews 2001, Issue 3. Art No.: CD003250.DOI:10.1002/14651858.CD003250 . Kenyon, S. L., Taylor, D. J., Tarnow-Mordi, W. for the ORACLE II Collaborative Group. (2001). Broad spectrum antibiotics for spontaneous preterm labour: The Oracle II randomised trial. Lancet , 357; 989-994 Kenyon S, Boulvain M, Neilson JP. Antibiotics for preterm rupture of membranes. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD001058. DOI: 10.1002/14651858.CD001058. Maternity Services Notice Pursuant to Section 88 of the NZ Public Health and Disability Act. 2000 Pre Term Pre-Labour Spontaneous Rupture of Membranes (Less than 37 Weeks) (MATY083) Page 4 of 7 Royal College of Obstetricians and Gynaecologists (2010). Preterm Prelabour Rupture of Membranes. Green-top Guideline No. 44. Royal College of Obstetricians and Gynaecologists. (2012). The prevention of early- onset neonatal Group B Streptococcal disease. Green-top Guideline No. 36. Stutchfield, P., Whitaker, R., Russell, I. (2005). Antenatal betamethasone and incidence of neonatal respiratory distress after elective caesarean section; Pragmatic randomised trial. http://www.bmj.com/cgi/content/full/331/7518/662 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (2012). Maternal Group B Streptococcus in pregnancy: screening and management. College Statement, C-Obs 19. Appendices Appendix 1:
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