FOI REF: 20/173a

12 May 2020

FREEDOM OF INFORMATION ACT

I am responding to your request for information under the Freedom of Information Act. The answers to your specific questions are as follows:

1. Clinical guidance for use of the Actim PROM test in force as of May 2011?

We confirm we did not start testing for Actim PROM until 2013 therefore we do not hold this information.

2. Clinical Guidelines for the management of women with ruptured membranes before and after 37 weeks gestation as in force in May 2011?

Please see attached document.

Further to our response of 3rd April, we subsequently received the following request from yourself and our reply is detailed below:

The policy you kindly disclosed (attached) relates to the Pre-Labour Rupture of Membranes after 37 weeks gestation only. Please can you confirm whether there was a policy in force during May 2011 which related to PROM before 37 weeks gestation? If so, I would be grateful if you could please forward me a copy of this for my records.

Please see the attached clinical guidelines, section 5.6.2 PPROM (Preterm Prelabour rupture of membranes).

If I can be of any further assistance, please do not hesitate to contact me.

Cont…/

Should you be dissatisfied with the Trust’s response to your request, please write to Lynette Wells, Director of Corporate Affairs, East Sussex Healthcare NHS Trust ([email protected]) quoting the above reference.

Yours sincerely

Linda Thornhill (Mrs) Corporate Governance Manager [email protected]

CLINICAL GUIDANCE NOTES

2.3 PRE-LABOUR RUPTURE OF MEMBRANES AFTER 37 WEEKS GESTATION (PROM).

Written/Produced By: Title/Directorate Date: Nicky Mason Senior Midwife Practice Development April 2004 Anne Heseltine Lecturer Practitioner Senior Midwife Clinical Risk Mr D Pascall Consultant obstetrician 2008

Person Responsible for Chair of the Guideline Implementation Group for Monitoring Compliance & Maternity Services Review Signature & Date

Multi-disciplinary Evaluation/Approval

Name Title/Speciality Date: Professional Midwifery Forum Sept 2004 Obstetric and Gynaecology Oct 2004 Directorate Guidelines Group Maternity August 2008

Ratification Committee

Issue Date of Next Date Name of Committee/Board/Group Number Issue & Review Ratified (Administrative Version Date use only) 2004111 October October 22/10/04 Clinical Governance & Risk Management 2004 v1 2007 Committee 2008274 Nov August 10/11/08 Clinical Governance Committee 2008 V2 2011

2.3 PRE-LABOUR RUPTURE OF MEMBRANES AFTER 37 WEEKS GESTATION (PROM).

1. Relevant to:

1.1 This guidance applies to all maternity staff.

2. Purpose of Guidance:

2.1 This document provides guidance on how to care for women with pre-labour rupture of membranes.

3. Refer to:

3.1.1 2.6 Use and Interpretation of Electronic Fetal Monitoring (CTG) Including Fetal Blood Sampling

3.1.2 2.8 Induction of Labour & Dose Regime for Syntocinon infusion for women undergoing induction of labour

3.1.3 5.3 Meconium stained liquor in labour

3.1.4 Perinatal guidelines for prevention and management of Group B streptococcal disease (GBSD)

3.1.5 Patient Information Leaflet from Intranet. ‘Information for Women’, ‘If your waters break before labour starts (PROM)’.

4. Process to Follow:

4.1 Introduction

4.1.1 Pre labour rupture of membranes is defined as Spontaneous rupture of membranes after 37 weeks gestation in the absence of regular contractions.

4.2 Principles

4.2.1 60% of women will go into spontaneous labour within 24hrs after rupturing their membranes

4.2.2 The risks of infection in mother and baby increases when the duration between the rupture of the membranes and the onset of labour is more than 24 hours. . Planning birth within a specified time frame will increase the probability of a healthier outcome.

4.2.3 It is recommended that expectant management of labour should not exceed 96 hours as there is no evidence on outcome longer than this duration

2.3 Pre-labour Rupture of Membranes after 37 Weeks Gestation (PROM) Page 2 of 7

4.2.4 It is recommended that women who have had pre-labour rupture of membranes for greater than 24 hours are offered antibiotic therapy when they are in labour

4.2.5 Women with known or suspected Group B streptococcal infection may have greater risks associated with expectant management and their care should be planned on an individual basis. Immediate induction of labour should be considered

4.3 Determining spontaneous rupture of membranes:

4.3.1 It may not be possible to establish or confirm the diagnosis with any degree of confidence if the possible rupture of membranes has occurred some hours previously, as most of the fluid may no longer be in the vagina.

4.3.2 In these circumstances confirmation will depend on taking a careful history from the woman.

This should include:

ƒ When and how the gush of fluid occurred ƒ Whether anything has happened before, ƒ Approximately how much fluid was lost, ƒ What the colour was like, ƒ Whether it smelt of anything ƒ Whether there was any vernix seen

4.3.3 Following discussion with the woman, consent should be obtained to perform a sterile speculum examination and a high vaginal swab taken for microscopy (+/- Chlamydia).

4.3.4 Vaginal examination should be avoided in order to reduce the risk of intra- uterine infection.

4.3.5 Spontaneous rupture of membranes may be said to have occurred if:

ƒ There has been a gush of fluid from the vagina and continued leaking ƒ There is a pool of fluid in the posterior fornix on speculum examination ƒ Oligohydramnios is found on ultrasound following a clear history of sudden release of fluid from the vagina.

4.3.6 Identifying when spontaneous rupture of membranes has occurred and documenting the time of occurrence is vital to the outcome of any of the care options.

4.4 Care following confirmation of Rupture of Membranes: 2.3 Pre-labour Rupture of Membranes after 37 Weeks Gestation (PROM) Page 3 of 7

4.4.1 Recent evidence (NICE)

4.4.2 “There is high-level evidence that shows an increase in neonatal infection when membranes rupture compared to intact membranes (1% vs 0.5%). This risk increases with the duration of membrane rupture. Expectant management up to 24 hours shows no evidence of a significant increase in neonatal infection rates.”

4.4.3 Comparison of the effects of planned early birth (immediate induction or induction within 24 hours) versus expectant management (no planned intervention within 24 hours.

4.4.4 There was no significant difference in neonatal infection (2.3% vs 2.9%), perinatal mortality or low apgar scores.

4.4.5 Women in the planned early birth group were less likely to develop endometritis or chorioamnionitis, although there was no significant difference between groups regarding postpartum fever.

4.4.6 There was no difference between groups regarding mode of birth

4.4.7 Care should be individualised according to the risks of infection, the risks of induction and the woman’s wishes.

4.5 The options for care are:

4.5.1 Options for care should be discussed with the woman and information given on:

ƒ The risk of infection ƒ The use of antibiotics in labour ƒ Timing of induction of labour if labour does not start spontaneously within a given time frame

4.6 Expectant management

4.6.1 Women who are healthy and have had a normal pregnancy with no other contraindication at the time of confirmation of PROM may be offered Expectant Management to a maximum of 96 hours (see information leaflet)

4.6.2 As the time between the rupture of membranes and the onset of labour increases so do the risks of infection for the mother and baby. Induction of labour reduces these risks and expectant management should not exceed 4 days (96 hours). There is no evidence for expectant management greater than 96hours after membrane rupture.

4.6.3 N.B Induction of labour should be considered if a digital vaginal examination has been performed as this increases the risk of neonatal infection, 2.3 Pre-labour Rupture of Membranes after 37 Weeks Gestation (PROM) Page 4 of 7

4.6.4 Induction of labour

4.6.5 Women may be offered induction of labour at any time interval after PROM (0- 96 hours)

4.6.6 Induction of labour is appropriate after 24 hours

4.6.7 If spontaneous labour does not follow confirmation within the agreed time frame the mother will be admitted and offered induction of labour (see guideline 2.8 Induction of labour and 2.9 Syntocinon Regimen)

4.6.8 Women who present with any complications (mother or baby) should be referred to the on call Obstetric Registrar.

4.6.9 Once a decision has been made with regard to the care options, exact timing and planning for induction of labour should be organised on an individual basis to coincide with the time the woman ruptured her membranes and the staffing of the delivery suite.

4.6.10 For women who have PROM overnight this will mean adjusting the timing of induction either forwards or backward so that induction of labour with oxytocin can commence in the morning.

4.6.11 This planning of a proposed induction of labour should occur for all women, including those anticipating expectant management and subsequent spontaneous labour.

4.7 Antibiotic therapy

4.7.1 It is recommended that women who have had pre-labour rupture of membranes for greater than 18 hours are offered antibiotic therapy when they are in labour as prophylaxis for Group B strep – either:

4.7.2 Penicillin:G 3g intravenously initially and then 1.5g at 4 hourly intervals until delivery (If Penicillin allergic, use clindamycin 900mg intravenously every 8 hours until delivery)

4.7.3 Women with suspected chorioamnionitis should receive the following regime

4.7.4 When chorioamnionitis is suspected

4.7.5 Women who are febrile (temperature > 38 degrees C) and clinically suspected to have chorioamnionitis, should receive broad spectrum antibiotic therapy including an agent active against GBS and this will replace GBS-specific antibiotic prophylaxis.

4.7.6 Use the following antibiotics at the specified dose, frequency and route:

• Amoxycillin 2g IV 6hly • Plus Gentamicin 4-6mg/kg 2.3 Pre-labour IVRupture daily of Membranes after 37 Weeks Gestation (PROM) • Plus MetronidazolePage 5 of 7500m g

4.7.7 If allergic to penicillin, use Cephazolin 2g IV 8hly or Cephalothin 2g IV 6hly as a substitute for amoxicillin.

4.7.8 Refer to Group b strep guideline if required PERINATAL GUIDELINES FOR PREVENTION AND MANAGEMENT OF GROUP B STREPTOCOCCAL DISEASE (GBSD)

4.8 FETAL SURVEILLANCE

4.8.1 Fetal well being (fetal movement and heart rate) must be confirmed at the time of confirmation of ruptured membranes and then every 24 hours following membrane rupture while the woman is not in labour

4.8.2 Advise the woman to report immediately any decrease in fetal movements

4.8.3 Advise the woman to record her temperature every 4 hours during waking hours and to report immediately any change in the colour or smell of her vaginal loss

4.8.4 If spontaneous labour commences intermittent monitoring can be used for women who are healthy and have had an otherwise uncomplicated pregnancy.

4.8.5 Where oxytocin infusion is commenced continuous electronic fetal monitoring is recommended (see guideline 2.9)

4.8.6 Following birth see guideline 7.3 (Babies at risk of group B strep) and liaise closely with the paediatric team with regard to care of the baby

4.9 MECONIUM STAINED LIQUOR

4.9.1 Where there is pre-labour Meconium staining of the liquor the on-call Obstetric should be informed and an individual management plan made

4.9.2 Close supervision of the fetal heart rate patterns is essential to ensure that prompt action is taken if required

4.9.3 For women who have Meconium staining of the liquor in labour please see guideline 5.3 Meconium stained liquor in labour)

5. Monitoring compliance

5.1 There will be compliance with implementation of this guidance as part of professional accountability to provide quality care based on evidence or current known best practice. Compliance with this will be monitored via the Directorate monitoring and reporting systems inherent in adverse incident reporting, risk assessment and risk management (including trend

2.3 Pre-labour Rupture of Membranes after 37 Weeks Gestation (PROM) Page 6 of 7

assessment); Labour Ward Forum, Clinical audit 6 – 9 months after any practice changes, Perinatal morbidity and mortality meetings.

6. Exceptions for compliance

6.1 None

7. References/furthers sources of advice

Enkin et al (2000) A Guide to effective Care in Pregnancy and Childbirth Oxford: Oxford University Press.

National Institute for Clinical excellence (2001) Induction of Labour – Inherited Clinical Guideline D London: National Institute for Clinical Excellence.

Royal College of Obstetricians and Gynaecologist (2003) Prevention of early onset neonatal Group B Streptococcal Disease in UK obstetric units, January 2007. www.rcog.org.uk/index.asp?pageID=1301

National Institute for Clinical excellence (2007) Intrapartum care guideline – Inherited Clinical Guideline D London: National Institute for Clinical Excellence.

2.3 Pre-labour Rupture of Membranes after 37 Weeks Gestation (PROM) Page 7 of 7 CLINICAL GUIDANCE NOTES

2.4 PRE-TERM LABOUR INCLUDING ANTENATAL STEROID THERAPY AND TOCOLYSIS AND PRE-TERM BIRTH

Written/Produced By: Title/Directorate Date: Mr P Rafferty & Mr J Zaidi Consultant Obstetrician April 2004 Anne Heseltine Senior Midwife Risk Management Specialist Midwife Practice Development Dexter Pascall Consultant Obstetrician August 2008

Person Responsible for Chair of the Guideline Implementation Group for Monitoring Compliance & Maternity Services Review Signature & Date August 2008

Multi-disciplinary Evaluation/Approval

Name Title/Speciality Date: Senior midwives forum Obstetrics and Gynaecology April 2004 Consultant Obstetricians April2004

Clinical Governance facilitator April 2004 Midwifery Professional Forum Sept 2004 Obstetric and Gynaecology Oct 2004 Directorate Clinical Guideline Group August 2008

Ratification Committee

Issue Date of Next Date Name of Number Issue & Review Ratified Committee/Board/Group (Administrative Version Date use only) 2004112 October 2004 Oct 2007 22/10/04 Clinical Governance and Risk v1 Management Committee February Oct 2007 2005 v1.1 2008286 Nov 2008 v2 Nov 2011 17/11/08 Clinical Governance Committee 2.4 PRE-TERM LABOUR INCLUDING ANTENATAL STEROID THERAPY AND TOCOLYSIS AND PRE-TERM BIRTH

1. Relevant to:

1.1 This guideline applies to all maternity staff.

2. Purpose of Guidance:

2.1 This document provides guidance on caring for women with pre-term labour including the use of antenatal steroid therapy and tocolysis. Care during pre- term birth is also included.

3.1 Refer to:

3.1.1 2.1 Care in Labour (First and Second stage)

3.1.2 2.6 Use and Interpretation of Electronic Fetal Monitoring (CTG) including Fetal Blood Sampling

3.1.3 5.1 Immediate care of the Neonate following Birth (including resuscitation and temperature control)

4.1 Process to Follow:

4.1.1 Definition

4.1.2 Pre-term birth is defined as being before 37 completed weeks of pregnancy.

4.1.3 Most mortality and morbidity is experienced by babies born before 34 weeks.

4.2 Principles

4.2.1 Prevention and treatment of preterm labour is important to reduce adverse events for the child.

4.2.2 The prognosis is significantly affected by gestational age, the use of steroids, the presence or absence of underlying chorioamnionitis and the availability of neonatal intensive care.

4.3 Guidelines for care

4.3.1 Any women with suspected preterm labour should be assessed in an acute unit.

4.3.2 Assessment to diagnose preterm labour is extremely important and should involve senior obstetric and midwifery staff.

2.4 Pre-term Labour Including Antenatal Steroid Therapy and Tocolysis and Pre-term birth Page 2 of 13 4.3.3 Diagnosis is based on the presence of:

- Regular uterine activity, with a contraction frequency of at least 1 in 10

Evidence of progressive cervical change e.g. dilatation or effacement

4.4 Women should have assessment of:

ƒ Gestation ƒ Urinalysis for proteinuria ƒ MSU for culture (treat if proteinuria and symptoms) ƒ Speculum to obtain HVS and cervical assessment ƒ FBC (+/- Kleihauer) ƒ CTG (caution should be taken with interpretation prior to 30 weeks ƒ gestation) ƒ 4 hourly temperature, and blood pressure and pulse ƒ Consider Ultrasound (assessment of presentation, weight estimation and liquor volume)

4.4.1 Care should include:

4.4.2 Steroid therapy for lung maturation in the baby

4.4.3 Review options for care:

4.4.4 Conservative management

4.4.5 Tocolysis

4.4.6 Transfer to another unit with neonatal intensive care facilities

4.4.7 Birth (mode of delivery and care)

4.4.8 Immediate care of the neonate

4.4.9 Consider bacterial screening: for infection if temperature greater than 38.5

4.4.10 Consider Cervical cerclage (Consultant decision)

4.4.11 Prophylactic antibiotics if preterm prelabour rupture of membranes

4.5 Care options

4.5.1 Decisions regarding the management should be in conjunction with the senior Paediatrician and should revolve around:

4.5.2 Detecting and treating the cause of the preterm labour (i.e. UTI)

2.4 Pre-term Labour Including Antenatal Steroid Therapy and Tocolysis and Pre-term birth Page 3 of 13 4.5.3 Commencement of steroid therapy

4.5.4 Consideration of tocolysis

4.5.5 Consideration of transfer of the woman to a unit with neonatal intensive care facilities

4.6 ANTENATAL CORTICOSTEROIDS TO PREVENT RESPIRATORY DISTRESS SYNDROME

4.6.1 PHILOSOPHY

4.6.2 Antenatal corticosteroids treatment is associated with a significant reduction in the rates of neonatal Respiratory Distress Syndrome, neonatal death and intraventricular haemorrhage.

4.7 GUIDELINES FOR CARE

4.7.1 Women at risk of preterm labour should be offered antenatal corticosteroid treatment

4.7.2 Woman should be advised that the use of a single course of antenatal corticosteroids does not appear to be associated with any significant maternal or fetal adverse effects

4.7.3 The effect of treatment is optimal if the baby is born after 24 hours but less than 7 days after the start of treatment

4.7.4 Antenatal corticosteroids therapy should be considered for women between 24 and 36 weeks gestation with any of the following:

ƒ Threatened pre-term labour ƒ Ante partum haemorrhage ƒ Pre-term rupture of membranes ƒ Any condition requiring elective preterm delivery

4.7.5 Corticosteroids may be given to women with a multiple pregnancy

4.7.6 Women with diabetes mellitus should have consultation with experienced diabetic/obstetric team to decide whether to have antenatal corticosteroids and if commenced to regulate diabetic control

4.7.8 Corticosteroid therapy should not be used if a woman has systemic infection

4.7.9 Dose and route of administration:

4.7.10 Two doses of Betamethasone 12mgs given intramuscularly 24 hours apart.

Or Four doses of dexamethasone 6mg given IM 12hours apart. 2.4 Pre-term Labour Including Antenatal Steroid Therapy and Tocolysis and Pre-term birth Page 4 of 13 4.7.11 If repeated doses are contemplated senior opinion should be sought.

4.8 Conservative management

4.8.1 Conservative management may be appropriate in the following situations:

ƒ SROM without contractions or cervical dilatation and no evidence of infection

ƒ Uterine activity but no cervical change and intact membranes

ƒ Minimal cervical change in the absence of uterine activity

ƒ Successful arrest of preterm labour without significant cervical dilatation

5.1 Cervical cerclage

5.1.1 This should not be performed in the presence of active preterm labour

5.1.2 Women should be counselled regarding the potential risks associated with the surgery, the risk of possible subclinical infection and the additional risk of stimulating uterine contractions.

5.1.3 The assessment of cervical length can assist in predicting the subsequent risk of preterm delivery and therefore assist in decision making.

5.1.4 The decision to perform a cervical cerclage should be taken only at consultant level and performed by a consultant obstetrician.

5.2 TOCOLYSIS

5.2.1 There is no clear evidence that tocolytic drugs improve outcome for the neonate, however they may reduce the proportion of births occurring up to seven days after beginning treatment. Therefore the available evidence should be discussed with the woman and her preferences taken into account.

5.2.2 A senior obstetrician should make the decision regarding whether or not to use tocolysis following discussion with the woman.

5.2.3 Factors to consider prior to deciding to use tocolysis:

5.2.4 Is the labour advanced > 4cms dilated

5.2.5 Would prolonging the pregnancy be hazardous (e.g. intrauterine infection or placental abruption)

5.2.6 Tocolysis should be considered for women who: 2.4 Pre-term Labour Including Antenatal Steroid Therapy and Tocolysis and Pre-term birth Page 5 of 13 5.2.7 Are very pre-term

5.2.8 Need transfer to a hospital that can provide neonatal intensive care

5.2.9 Have not yet completed a full course of corticosteroids

5.2.10 Tocolysis should not be considered in the following conditions:

ƒ An intrauterine death ƒ Suspected chorioamnionitis ƒ Suspected fetal compromise ƒ Significant bleeding ƒ Hypertension > 160/110 ƒ Pre-existing maternal complications e.g. cardiopulmonary disease, uncontrolled Hypothyroidism or diabetes ƒ Cervical dilation >4cms

5.2.11 Atosiban or nifedipine are the current drugs of choiceThey appear to have comparable effectiveness and fewer adverse effects than ritodrine. Atosiban is licensed for this usage in the UK but nifedipine is not. Consultants only may wish to use scientifically recognised but unlicensed drugs such as Nifedipine.

5.2.12 There is no trial directly comparing atosiban and nifedipine

5.2.13 When indirectly compared with Betamimetics as the common comparator, nifedipine treatment was shown to be associated with a significant reduction in RDS compared with atosiban.

5.3 ATOSIBAN

5.3.1 Dose and administration

5.3.2 Atosiban may be administered in 3 steps:

Step Regimen Injection/Infusion Rate Atosiban dose 1 0.9ml i.v. bolus Give over 1 minute using 6.75mg solution for injection (6.75mg/0.9ml)

2 3 hours i.v. loading infusion 24ml/hour (using diluted 18mg/hour using solution for infusion solution- concentration (0.75mg/ml-5ml amps) 0.75mg/ml) diluted according to

2.4 Pre-term Labour Including Antenatal Steroid Therapy and Tocolysis and Pre-term birth Page 6 of 13 instructions below 3 8ml/hour (using diluted 6mg/hour subsequent i.v. infusion solution with using solution for infusion for concentration 0.75mg/ml) maximum of 45 hours (0.75mg/ml-5ml amps) diluted according to instructions below

5.3.3 Dilution instructions for solution for infusion Withdraw and discard 10ml solution from a 100ml bag of 0.9% NaCl or 5% dextrose. Add 10ml (2x5ml) atosiban concentrate for infusion giving a concentration of 75mg/100ml (0.75mg/1ml).

5.3.4 Prepare new 100ml bags in the same way as described above to allow the infusion to be continued.

5.3.5 Duration of treatment should not exceed 48 hours and the total dose given should not exceed 330mg. Maintenance tocolysis is not recommended for routine practice.

5.3.6 Re-treatment: In case re-treatment with atosiban is needed, treatment should be re-administered in the 3 steps outlined above.

5.4 Care during infusion:

5.4.1 Maternal side effects: most commonly nausea, followed by headache, dizziness, hot flushes, vomiting, hypotension, injection site reactions and hyperglycaemia.

5.4.2 Maternal monitoring:

ƒ Pulse ƒ Respirations ƒ Blood pressure half hourly ƒ Temperature four hourly

5.4.3 Fetal Monitoring:

5.4.4 Continuous electronic monitoring (CTG)

5.4.5 The infusion should be stopped if any of the following are present:

ƒ Maternal heart rate of > 130 bpm ƒ Diastolic BP drops by 30mm Hg ƒ Chest discomfort and shortness of breath ƒ Pathological CTG recordings 2.4 Pre-term Labour Including Antenatal Steroid Therapy and Tocolysis and Pre-term birth Page 7 of 13 5.5 NIFEDIPINE

5.5.1 Dose and administration

5.5.2 Nifedipine 10mg capsules orally every 15 minutes for one hour There is little difference in bioavailability when nifedipine capsules are given orally and swallowed whole, bitten and swallowed, or bitten and held sublingually. However, there have been isolated reports of sublingual nifedipine causing fetal demise.

5.5.3 Followed by:

5.5.4 30mg of slow release nifedipine (Adalat Retard®) tds until contractions stop or course of steroids completed or successful transfer to a unit with neonatal intensive care facilities

5.5.5 Care during administration:

5.5.6 Side effects of hypotension, headache, flushing, tachycardia, palpitations, dizziness and nausea.

5.5.7 Maternal monitoring:

ƒ Pulse ƒ Respirations ƒ Blood pressure quarter hourly during the first hour ƒ Subsequently half hourly until contractions cease ƒ Temperature four hourly

5.5.8 Fetal monitoring:

5.5.9 Continuous electronic monitoring (CTG)

5.5.10 Treatment should be stopped if any of the following are present:

ƒ Maternal heart rate of >130 bpm ƒ Diastolic BP drops by 30mm Hg ƒ Chest discomfort and shortness of breath ƒ Pathological CTG recordings

5.6 Aftercare

5.6.1 Maintenance tocolysis is not recommended

5.6.2 PPROM (Preterm Prelabour rupture of membranes)

5.6.3 These women should be initially assessed in an acute unit

2.4 Pre-term Labour Including Antenatal Steroid Therapy and Tocolysis and Pre-term birth Page 8 of 13 5.6.4 Confirmation by visualisation of liquor at introitus or on speculum examination is necessary.

5.6.5 Following discussion with the woman, consent should be obtained to perform a sterile speculum examination and a high vaginal swab taken for microscopy (+/- Chlamydia).

5.6.6 Vaginal examination should be avoided in order to reduce the risk of intra- uterine infection.

5.6.7 Spontaneous rupture of membranes may be said to have occurred if:

ƒ There has been a gush of fluid from the vagina and continued leaking ƒ There is a pool of fluid in the posterior fornix on speculum examination ƒ Oligohydramnios is found on ultrasound following a clear history of sudden release of fluid from the vagina.

5.6.8 Identifying when spontaneous rupture of membranes has occurred and documenting the time of occurrence is vital to the outcome of any of the care options.

5.6.9 The woman should be monitored as an inpatient for the initial 48 hours following confirmed PPROM. There is also the opportunity to discuss prophylactic steroids

5.6.10 Monitoring of Pulse, Temperature and nature of vaginal loss.

5.6.11 The RCOG suggests PO erythromycin for 10 days following the diagnosis of PPROM 5.6.12 Women with PPROM (and no evidence of chorioamnionitis) being treated with antibiotics such as cephalosporins for UTI do not need additional prophylaxis, as likely causes of infection should be adequately covered

5.6.13 Upon discharge after 48hrs the woman should be monitored via the DAU with

• weekly HVS • twice weekly FBC

5.6.14 The Mother should be taught how to keep a temperature chart and advised of the triggers to seek medical attention

5.6.14 These include:

2.4 Pre-term Labour Including Antenatal Steroid Therapy and Tocolysis and Pre-term birth Page 9 of 13 • sudden increase in loss of liquor • Change of liquor colour, odour • Temperature > 37.8 • Persistent abdominal pain or tenderness

5.6.15 A discussion on the timing of elective delivery with the consultant is necessary

5.7 MANAGEMENT OF PRETERM LABOUR AND BIRTH

5.7.1 PHILOSOPHY

5.7.2 The woman at imminent risk of preterm birth requires an immediate assessment as to whether transfer to an obstetric with neonatal intensive care facilities. The decision will depend upon:

5.7.3 Gestational age

5.7.4 The imminence of the expected birth

5.8 GUIDELINES FOR CARE

5.8.1 There should be early communication between the obstetric and neonatal staff to establish the ability of the unit to access the admission of the baby.

5.8.2 The neonatal team should make every effort to speak to the mother to prepare her for the birth and the care immediately afterwards.

5.9 Mode of Birth

5.9.1 There is insufficient unbiased information to determine the benefits to the baby of caesarean section in preterm birth

5.9.2 A decision to undertake a caesarean section should be discussed with the Consultant Obstetrician who should consider the impact of an upper segment caesarean section in subsequent pregnancies

5.9.3 Delivery by caesarean section of a baby at 28weeks gestation or less should be performed by an experienced obstetrician

5.9.4 If caesarean section is being performed with a breech presentation, an assessment should be made of the lower segment of the uterus to determine if it is sufficiently wide to permit easy delivery of the head

5.9.5 Avoid ventouse delivery in gestations less than 34 weeks

5.9.6 There is no unbiased evidence to suggest that routine use of forceps to deliver the pre-term baby confers more benefit than harm

2.4 Pre-term Labour Including Antenatal Steroid Therapy and Tocolysis and Pre-term birth Page 10 of 13 6.1 Care in labour

6.1.1 Mother Assessment of maternal pulse half hourly, hourly BP, 2 hourly temp, urinalysis, abdominal palpation

6.1.2 Pain relief

6.1.3 Adequate analgesia is as important for women giving birth preterm as for women giving birth at term. An epidural block is probably safer than narcotics however there are no controlled studies to substantiate this. The routine use of epidural for pre-term breech presentation as a means of reducing the urge to push before full dilatation is also not substantiated.

6.1.4 Fetal monitoring

6.1.5 Continuous electronic monitoring (CTG) is recommended

6.1.6 Fetal blood sampling (FBS) is not recommended in gestations under 34 weeks

6.1.7 Assessment of ongoing progress

6.1.8 A schedule of vaginal examinations should be decided for each individual woman

6.1.9 Palpation of contractions

6.1.10 The WHO partogram should be used to record observations and monitor the progress of labour.

6.2 Carers and Birth attendants

6.2.1 Experienced Obstetricians and Midwives and should care for women with pre- term labour.

6.2.2 A paediatrician should attend all preterm births.

6.2.1 Additionally, consider having an experienced neonatal nurse present in situations of extreme prematurity or fetal compromise.

6.2.3 The Consultant Paediatrician should attend birth in the following circumstances:

ƒ Any birth under 30 weeks ƒ Any pre-term birth with anticipated medical problems and/or congenital anomalies ƒ Severe fetal compromise 2.4 Pre-term Labour Including Antenatal Steroid Therapy and Tocolysis and Pre-term birth Page 11 of 13 6.3 Amniotomy

6.3.1 Leave intact to protect fetal head where possible

6.4 Episiotomy

6.4.1 Routine episiotomy for preterm birth is not recommended.

6.4.2 IMMEDIATE CARE OF THE PRETERM NEONATE

6.4.3 Follow guideline ‘5.1 Immediate care of the neonate’ anticipating that early may be required.

6.4.4 It is important for the mother of a preterm baby to see and if possible touch her baby prior to transfer to the neonatal unit.

6.4.5 Transfer to the neonatal unit should be prompt

5. Monitoring compliance

5.1 There will be compliance with implementation of this guidance as part of professional accountability to provide quality care based on evidence or current known best practice. Compliance with this will be monitored via the Directorate monitoring and reporting systems inherent in adverse incident reporting, risk assessment and risk management (including trend assessment); Labour Ward Forum, Clinical audit 6-9 months after any practice changes, Perinatal morbidity and mortality meetings, Clinical debriefing, staff appraisal, performance management and Midwifery Supervision.

6. Exceptions for compliance

6.1 Consider Guideline 7.4 Diabetes in Pregnancy. When giving Corticosteroids to diabetic Mothers

7. References/furthers sources of advice

Confidential Enquiry into Stillbirths and Neonatal Deaths in Infancy (2003) Project 27/28 An enquiry into the quality of care and its effects on the survival of babies born at 27/27 weeks, Norwich: The Stationary Office.

Enkin,M, Keirse, M, Neilson, J Crowther C, Duley, L, Hodnett, E and Hoffmeyer, J (2000) A Guide to Effective Care in Pregnancy and Childbirth (3rd Ed) Oxford: Oxford University Press.

Royal College of Obstetricians and Gynaecologists (2003) Tocolytic Drugs for Women in Preterm Labour (1B) Clinical Green Top Guidelines RCOG

2.4 Pre-term Labour Including Antenatal Steroid Therapy and Tocolysis and Pre-term birth Page 12 of 13 Royal College of Obstetricians and Gynaecologists (2003) Antenatal Cortocosteroids to Prevent Respiratory Distress Syndrome (7) Clinical Green Top Guideline. RCOG

Ferring Pharmaceuticals Ltd. June 2002 Atosiban. Summary of Product Characteristics

Nifedipine (Clinical pharmacology) –Pfizer 2000

CoomarasamyA, Knox E, Gee H,Song F and Khan K. Effeectiveness of nifedipine versus atosiban for tocolysis in preterm labour: a meta;analysis with an indirect comparison of randomised trials BJOG2003. Vol110, 1045-1049.

Papatsonis D, Flenady V, Cole S, Liley H. oxytocin receptor antagonists for inhibiting preterm labour. Cochrane Review Art no.: CD004452. DOI: 10. 1002/14651858. CD 004452. pub2.

2.4 Pre-term Labour Including Antenatal Steroid Therapy and Tocolysis and Pre-term birth Page 13 of 13