Prelabour / Prolonged Rupture of Membranes

UK Midwifery Archives


These archives contain extracts from discussions held on the UK Midwives and Consumers email list, a discussion group for people interested in midwifery in the UK. Open to midwives, students, mothers, and anyone interested in improving maternity services in UK. Posts in these archives express the views of the individual authors, and not those of the Association of Radical Midwives.


Prelabour / Prolonged Rupture of Membranes


Abbreviations:

PROM: prelabour rupture of membranes, sometimes referred to as premature rupture of membranes. Can also be used to mean prolonged rupture of membranes
PPROM: preterm prelabour rupture of membranes, ie before 37 weeks
SROM: spontaneous rupture of membranes
ROM: rupture of membranes
IOL: Induction of labour
IV: intravenous
NICE : National Institute of Clinical Excellence
RCOG : Royal College of Obstetricians and Gynaecologists


Rupture of Membranes at Term

Extract from the NICE/RCOG booklet, About Induction of Labour – Information for Pregnant Women, Their Partners and Their Families :
(www.nice.org.uk/article.asp?a=17330)

If your waters break before labour starts

Sometimes a woman’s waters break before labour starts. This happens in about one in twenty pregnancies and is known as prelabour rupture of the membranes (or PROM). When this happens, about nine out of ten women will go into labour naturally within twenty-four hours. The longer the time between PROM and the birth of the baby the higher the risk of infection to you or your baby.

If you are more than 37 weeks pregnant and your waters have broken but you have not gone into labour you should be offered the choice of either:

· Induction of labour

OR

· A “wait and see approach” to see if labour will start naturally

As a wait and see approach carries a slight risk of infection, you will need to:

  • check your temperature twice a day
  • check for changes in the colour or odour of your amniotic fluid (“waters”)
  • check for any other signs of fever (e.g. shivers, flushing)

If you have not gone into labour after, at most, four days induction is strongly recommended.

If your waters break before you go into labour, your chances of having a caesarean section will not be increased by choosing either induction or “wait and see”.

Extract from the short form of the NICE/RCOG guidelines on induction of labour:

(www.nice.org.uk/article.asp?a=17321)

National Institute for Clinical Excellence

Inherited Clinical Guideline D
Induction of Labour
Issue Date: June 2001

Induction of labour in the presence of prelabour rupture of the membranes (PROM)

Prelabour rupture of the membranes (PROM) occurs in 6-19% of term pregnancies.
The risks of PROM at term relate to maternal/neonatal infection and prolapsed cord. Epidemiological data on time interval from PROM to spontaneous labour suggests that most (86%) women go into spontaneous labour within 24hrs of rupturing their membranes. The rate of spontaneous labour after this is about 5% per day.

As the time between the rupture of the membranes and the onset of labour increases, so do the risks of maternal and fetal infection. Induction of labour reduces these risks.
Women with prelabour rupture of the membranes (PROM) at term (>37 weeks) should be offered a choice of immediate induction of labour or expectant management.

Expectant management of women with prelabour rupture of the membranes at term should not exceed 96 hours following membrane rupture.


Here are some extracts from the more detailed NICE/ RCOG evidence- based full clinical guideline on induction of labour:

(www.nice.org.uk/pdf/inductionoflabourrcogrep.pdf)

2.2.3 Induction of Labour in the presence of Prelabour Rupture of the Membranes (page 9)

Women with prelabour rupture of the membranes at term (over 37 weeks) should be offered the choice of immediate induction of labour OR expectant management.

Expectant management of women with prelabour rupture of the membranes at term should not exceed 96 hours following membrane rupture.

5.5 Induction of Labour in the presence of Prelabour Rupture of the Membranes (page 28)

5.5.1 ….Epidemiological data on time interval from term PROM to spontaneous labour demonstrates that most women go into spontaneous labour within 24 hours of rupturing their membranes.

86% of women will labour within 12-23 hours
91% will labour within 24-47 hours
94% will labour within 48-95 hours
6% of women will not be in spontaneous labour witthin 96 hours of PROM.

As the time between the rupture of the membranes and the onset of labour increases , so may the risks of maternal and fetal infection. Induction of labour may reduce these risks.


literature search by Carrie on prolonged/prelabour rupture of membranes is available on this site. As a result of Carrie’s research, her unit’s policy was changed so that women with spontaneous rupture of membranes at term wait three days before induction – by which time most of them will have gone into spontaneous labour anyway….


Could anyone tell me what their protocol is for women with 24 hour ROM at term? We give prophylactic antibiotics to all women once they are in labour and have had ROM for 24 hours.


We have the same practice at our hospital. We have had this routine for the last two years. The paediatricians wanted it. As far as I know we have never seen a case of infection in the newborn child. We had a study where women with PROM (that is, half of them included in the study) would wait for three days before any action was taken. The outcome of that study did not show any adverse effects for the newborn in the “wait-group”. With that in mind, I always feel reluctant to give antibiotics. I don´t believe that it is without risk to increase the amount of antibiotics given.

Karin


In the Hospital where I work every woman who has had SROM receives IV antibiotics – Benzilpenicillin – after 18hrs, whether they are in labour or not. I shouldn’t say every woman, just the ones who are at term. They are augmented, but the prems are deemed okay to leave alone and hopefully “spontaneously” labour.

So the women are brought in and given a low vaginal swab on SROM, then a loading dose of Benzilpen, and when in labour, IV Benzilpen till delivered. Luckily if there are no markers then the baby is left on four hourly obs. If there are any markers, ie temp in labour or previous Group B Strep postive, then the baby is kept on IV antibiotics for five days, or till the CRP shows no infection.

We are a little bit paranoid…..no? I wish we could start routinely swabbing all women at near term like Canada does, then we wouldn’t feel the need to waste antibiotics and augment everyone who has 18 magic hours of SROM.

Kelly


There is an article by Julie Beckwith and Michael Read in British Journal of Midwifery, Feb 1996, Vol 4, No 2, pp74-76, about prelabour rupture of membranes at term, and one unit’s response to the issue. It is a small study about home versus hospital management, rather than whether or not to prescribe routine antibiotics. It is clear that none of the experimental group had antibiotics, but less clear whether or not the control group were given antibiotics. It gives a good summary of other studies, is well referenced, reasonably up to date (there may be more recent stuff as well, but I can’t instantly lay my hands on it) and clearly written. The conclusion is:

“The evidence to support the need for hospitalization of women with PROM is unclear. Further study is needed before creating restrictive policies for the care of women especially when research findings are conflicting. If informed choice for women is to proceed, professionals will have to accept the limitations of their knowledge base in some areas and allow more liberalized policies to be formed. We believe that home management for mothers with PROM at term is a safe policy and an acceptable alternative to the majority of mothers who do not wish to spend time unnecessarily in hospital away from their families.”

I appreciate that this is not answering the question you asked, but I hope it will give you some research evidence to get your teeth into, rather than just going on other hospitals’ protocols, which often are out of date and not research-based at all.

Melanie


I found a thesis by Lars Ladfors, a Swedish doctor who reliably informed me that they don’t give their women prophylactic antibiotics! I do worry about bugs becoming sensitive; I wonder how many cases of MRSA there are and are they on the increase.

Gail


Hello from Norway, where it is not universally routine practice to give antibiotics for ROM alone. At my unit we don’t even admit mothers to hospital if they only have ROM at term. They are checked to confirm the ROM diagnosis and fetal wellbeing, and cultures are taken. Then they monitor temperature at home and wait up to three days with daily contact with the ward, to see if labour will start on its own. They are instructed not to take tub baths or put anything in their vaginas, and to observe the draining fluid and contact us if any color should appear. The ones who develop any symptoms of concern are treated according to the clinical picture. The ones still not in labour after 3 days are induced with pitocin IV. The babies are observed for signs of infection the first two to three days (temp-pulse-resp. rate- C-reactive protein tests) and again, treated as needed. They are on the ward with their mothers, fed on demand and treated otherwise no differently from any other babies.

If the ROM has occurred before 37 weeks, we are more concerned that infection may be the cause and the treatment protocol is quite different, but still does not include routine antibiotics to either mother or baby in the absence of strong suspicion of infection.

Hospitals differ in their protocols, but we are neither radical nor stodgy by Norwegian standards.

Rachel


There seems to be a huge problem where I work with women being induced after 24 hours with what turns out later(when bulging forewaters are seen or felt) to have been a hindwater leak. Our protocols seem to make no distinction, though I become suspicious when leaking seems to stop and women aren’t needing a pad, but it makes no difference and they are induced with syntocinon etc willy nilly regularly, I believe leading to unecessary CS even in multiparous women who have previously birthed vaginally, usually for ‘distress’ of the baby.

SROM is diagnosed on speculum poll of liquor seen or positive amnistick. On the contrary women who present with premature rupture of membranes are treated conservatively and sent home after a spell in hospital if it ‘heals over’ .I have questioned this illogicality but hey I must be missing something! They tell me they induce all term or nearly SRMs because there is a risk of infection whether fore or hindwater rupture. Frustrated I Am – help!

Katherine.


We are currently in dialogue (!!) with our paediatricians and obstetricians, trying to change our prelabour spontaneous rupture of membrane policy from induction at 24hrs to 48hrs. Currently all infants born after 48hrs of SROM receive antibiotics, so inducing after 48hrs means more infants getting antibiotics (but fewer inductions) unless we can alter the policy. I would be interested to hear from anyone who works with a 48 hr or more SROM policy to see how you deal with this.


Our Unit recommends IOL at 48 hours post-SROM at term. In the event of prelabour SRM, one of 3 options are recommended:-

a) return home, monitoring colour of liquor, fetal movements and 4 hourly temps.

b) transfer to antenatal ward to await events!

c) workload allowing of course – commence IOL process if SRM is confirmed – no one really chooses this option funnily enough :0))

Our protocol does not advocate antibiotics to SRM after 48 hours.

Our approach to any SRM after 24 hours ….is to recommend the mother and baby remain in hospital for 48 hours, (so if the baby hasn’t already acquired an infection, he/she will no doubt get one!), obtain an ear swab from the baby, followed by 6 hourly temp and resps. Babies would ONLY receive IV antibiotics if signs of infection were apparent OR if the ear swab results showed any “wee beasties!” :0)

Sadly, our policy has changed slightly since ALL woman who attend with prelabour SRM MUST be given an info. leaflet on Group B Strep risk factors and hey presto…..what’s the advice??? IOL!!!

Choccs


On Thursday I looked after a woman who had PROM for 29 hours. She’d had antibiotics in labour and after delivery swabs were taken from the baby’s nose and umbilicus. Also, I was told to take a gastric aspirate sample too. Not having done one before I wasn’t happy to do one. Mum had already given permission for it to be taken. When I observed the midwife taking it I felt sick. They use this thick tube which just about fits into the baby’s nose, ugh, it was horrible. I asked why they did it and why the swabs weren’t enough and they said it was that they could get a result quicker from the gastric aspirate and therefore treat the baby quicker if it had an infection.

This is the first time I have ever come across this method of screening for infection in the newborn. So, do any of you work where this screening method is done? I felt it was very invasive and the baby didn’t like it one bit. I thought the antibiotics the mother had in labour would give some protection to the baby. Still as I’ve never even heard of it before I am sure I have missed something.

Gail

The unit that I work at used to require a gastric aspirate sample to be taken in these circumstances but this policy was reformed about 2 years ago if I remember correctly. Now there is no longer the requirement, just swabs are taken. I believe this would have been research based (the unit may have faults but most policies are researched based). Sorry can’t be more helpful since I cannot quote which research this might have been – perhaps others have some idea?

Sue

My question though is why was the woman having antibiotics? There must have been some clinical indications rather than just PROM for 29 hours – it seems a bit OTT if that was just the case! I wonder whether she was Strep B positive, in which case there could be a strong argument for this method of screening in the neonatologist’s view.

Belinda

Yes Gail, they do it at our place!

You notice I say “they”………actually “I” don’t. I just do the swabs, and no-one has ever complained. The swabs are supposed to be :- baby’s ear, eye, umbilicus, and the maternal side of the placenta…but I think it is more sensible to substitute nose for eye, as it is more of an orifice for nasties to lurk in.

I’m wondering about the IV antibiotics. Was this a prem labour? Or was the woman Strep B positive, or have a heart complaint? We wouldn’t automatically give IVs just for prolonged rupture of membranes.

Chris

It seems to be the unit’s policy of giving iv antibiotics routinely in labour once 24 hours have elapsed since ROM. This is why I couldn’t understand why they took a sample of gastric aspirate from baby to check for infection when the antibiotics mum had in labour must surely have covered her and baby.

They give antibiotics prophylactically to prevent Group B strep in the newborn so if they are checking gastric aspirate why bother giving antibiotics in the first place and if they give antibiotics why bother checking gastric aspirate?

I do hope I am not missing something very basic here!

Gail


What is the reason/evidence behind monitoring women who have SRM but are not in labour?

None that I have heard. We keep them at home unless they have meconium in the waters or unengaged head.

Sara


Preterm Rupture of Membranes

I’d love to get opinions and info/people’s experience with PPROM.

This mother is 35 weeks yesterday with good dates. 2nd baby. her water released yesterday morning and she has been “gushing” since. no surges yet and she is following the prom precautions. she was planning a homebirth.

I don’t have a gbs test result on her – she was negative with her last baby. she is weighing the options between going to the hospital for antibiotics (she knows the hospital increases her risk of infection) and waiting it out. The OB who has agreed to see her says once she is in the hospital, they would do expectant management in the absence of contractions but that he wouldn’t let her go home until the baby is born. we are discussing doing a gbs (just at the introitus, of course) and urinalysis today if she decides to wait it out.

the baby appears to be a decent size and i feel comfortable doing this at home if she makes it to 36 weeks.

what are people’s experiences with babies less than 36 weeks? what are people’s experiences with infection in PPROM? it is difficult to assess in the literature what is real risk and what is set up to cover butts. thanks for any info.

jessica


I have attended a few women with preterm rupture of membranes and it depends very much on them, Yes exclude infection, Self monitor temperature twice a day. Do a urine and ? vaginal swab and assess abdominally and possibly with ultrasound if concerned re lack of liquor – it is made each day – and wait and hospitalise and induce if the risks seem less than continuing with the pregnancy.

One client, a non-practising Midwife, went 2 weeks plus and birthed in her pool at home at 37 weeks and another recent one had a Caesarean Operation for slow progress 8 days after her waters went. Staff couldn’t believe it and she was still leeking clear liquor after 18hrs in labour.

Chris


The OB who has agreed to see her says once she is in the hospital, they would do expectant management in the absence of contractions but that he wouldn’t let her go home until the baby is born

Won’t let her go home? What does he mean – won’t? If I was a friend of hers (as I’m not a midwife and therefore can’t pretend to be), I’d tell her to go in for the antibiotics and then come home again. ‘Won’t let her go home’? What’s her going to do, tie her to the bed?

Sorry, I’m really not getting mad at you, just the OB and I have this terrible tendancy to stick up for Mums-to-be who are in danger of getting pushed into awkward spots and being fed garbage. If she needs antibiotics to help prevent infection then she should get them, without sacrificing her right to a homebirth.

Sally


My eldest was 34wks+3, was whisked off to SCBU, breastfeeding was made a mullock of and I got depressed enough to get pg very quickly in order to do the job right the next time… I don’t recommend the experience!

I read ‘The Birth of a Mother’ a couple of years ago; it really helped me come to terms with some of the stuff that happened when dd1 was born. Among other things, the book describes the mental process that pregnant women go through (and to a certain extent, all those around her) while they build an image of their baby. This peaks at around 7m, then fades so that by 9m it’s not at the forefront of the mother’s mind. The thing here is that the closer to 7m the baby’s born, the more they have to ‘measure up to’ in the mother’s mind. Now the mum of a premmie might already feel like something of a failure bcause her body hasn’t done it’s job of carrying the baby to term, add in this conflict of imaginary baby and real baby and you can see where this is going. So all the things that are important to ‘bonding’ for mum-newborn couples are really really important for premmies.

Keeping the birth as ‘normal’ as possible, facilitating the attachment process, minimising separations are key. Yes, premmies need careful watching, they are at higher risk for a lot of things, but this watching can happen without messing up that relationship.

Tracy


Links to other sources of information:

USA Midwife Archives page on Prelabour Rupture Of Membranes:
www.gentlebirth.org/archives/prom.html

NICE/RCOG booklet, About Induction of Labour – Information for Pregnant Women, Their Partners and Their Families :
(www.nice.org.uk/article.asp?a=17330)

NICE/RCOG guidelines on induction of labour (short form)
(www.nice.org.uk/article.asp?a=17321)

NICE/ RCOG evidence- based full clinical guideline on induction of labour
(www.nice.org.uk/pdf/inductionoflabourrcogrep.pdf)

Premature Rupture of Membranes (PROM) By Elizabeth Bruce, on the Compleat Mother site. Discusses both prelabour and preterm rupture of membranes.
www.compleatmother.com/prom.htm

Preterm Prelabour Rupture of Membranes, from the Dartmouth Hitchcock Medical Center – Straightforward factsheet.
www.dartmouth.edu/~obgyn/mfm/PatientEd/preterm_PROM.html

PROM guidelines from MoonDragon Midwifery Practice
www.geocities.com/HotSprings/Spa/9786/varia2.html

Midwifery Today e-news on premature (ie prelabour) rupture of membranes
www.midwiferytoday.com/enews/enews2n46.asp


AH updated 4 July 2002


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