preterm pre-labour ruptured membranes.docx · web viewearly treatment with antibiotics can improve...

CHHS17/248

Canberra Hospital and Health ServicesClinical Guideline Preterm Pre-labour Ruptured MembranesContents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Assessment.............................................................................................................2

Section 2 – Management..........................................................................................................3

Section 3 – Medications............................................................................................................4

Section 4 – Ongoing Observations and Care.............................................................................5

Section 5 – Outpatient Management of a Woman with Preterm Pre-labour Rupture of Membranes...............................................................................................................................6

Implementation........................................................................................................................ 8

Related Policies, Procedures, Guidelines and Legislation.........................................................8

References................................................................................................................................ 8

Definition of Terms...................................................................................................................9

Search Terms............................................................................................................................ 9

Doc Number Version Issued Review Date Area Responsible PageCHHS17/248 1 26/10/2017 01/07/2020 WY&C – Women

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS17/248

Guideline Statement

The purpose of this Guideline is to outline the safe and effective management for the care of the pregnant woman with Preterm, Prelabour Rupture of Membranes (PPROM) (i.e. prior to 37 weeks)

BackgroundPPROM is associated with maternal and neonatal morbidity and mortality. This includes the complications of prematurity for the neonate as well as maternal and neonatal infection (chorioamnionitis and neonatal sepsis). This guideline will aim to reduce the incidence of maternal and neonatal morbidity and mortality.

Key ObjectiveCommunication of clear guidance for the management and care of women with preterm prelabour rupture of membranes in the inpatient and outpatient setting.

Alerts Women with suspected PPROM need careful and timely assessment and management to minimise the risk of maternal or fetal adverse outcomes

Back to Table of Contents

Scope

This document applies to Medical Officers, Registered Midwives and Registered Nurses working within their scope of practice. It also applies to midwifery students working under direct supervision.


Section 1 – Assessment

Confirm gestation by the woman’s maternity record, her Last Menstrual Period (LMP) and ultrasound reports

take a comprehensive history and document all relevant information perform an abdominal palpation to assess fundal height, fetal lie, presentation and

engagement perform baseline observations and document fetal heart rate confirm ruptured membranes. This can be ascertaining a convincing history confirmed by

evidence of liquor seen, sterile speculum examination, ultrasound examination or use of Amnisure®

document findings: colour and volume of vaginal loss collect a high and low vaginal swab for Microscopy, Culture & Sensitivity (MC&S) Perform a urinalysis and collect a mid stream urine sample for urine microscopy and

culture; to rule out Urinary Tract Infection (UTI) assess for evidence of uterine activity/tone/tenderness


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medical staff may consider a vaginal examination to assess vaginal dilation, but only if in labour

perform a cardiotocograph (CTG) if > 28 weeks and consider CTG from viability ( but discuss with obstetrician first).

monitor and document the woman’s vital signs, temperature pulse and blood pressure and urinalysis

monitor and document uterine contractions and vaginal loss.


Section 2 – Management

Management will be dictated by the following factors: gestation presence or absence of infection presence or absence of labour presentation and station of presenting part fetal heart rate (FHR) and/or CTG pattern the woman’s informed choice

Neonatal Consultation notify the Department of Neonatology of the woman’s admission if the woman is <36

weeks or risk factors present Determine whether women can remain at TCH or requires in utero transfer Inform the woman and her partner of possible outcomes as follows:

At the extreme lower end of the gestational age range, (<26 weeks) any prognosis of perinatal outcome will depend on maintaining the pregnancy in the absence of infection. Women with pregnancies of 23-31 completed weeks should have a consultation with a Neonatologist. This consultation is organised through the personal assistant to the neonatologist.

If an urgent consultation is required, clinician to clinician referral must occur at the other end of the preterm gestational age range (>34 weeks gestation), the

outcome may be favourable with expectant management long term PPROM has implications for fetal lung development, there must be a team

discussion prior to any woman with long term PPROM being transferred to a regional hospital.

Initial Investigations FBC, CRP ultrasound: the registrar may perform an initial ultrasound to assess presentation,

amniotic fluid index, and placental location a formal ultrasound from Fetal Medicine Unit (FMU) high and low vaginal swabs for MC &S if not done previously


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urine MC&S.Back to Table of Contents

Section 3 – Medications

Tocolytics Tocolytics are to commence for 48 hours for women ≤32 weeks gestation who are

contracting, but who are not in advanced labour, in an attempt to delay birth (exception is any contraindication such as antepartum haemorrhage). This will allow for appropriate administration of antenatal steroid treatment

administration of oral nifedipine is used for suppression of labour, with careful consideration as to the appropriateness of suppression of labour if there is any clinical suspicion of infection.

Practice Note: Prophylactic tocolytics MUST be ceased after 48 hours.

Steroids all women with a viable fetus (between 24-34 weeks gestation) and preterm ruptured

membranes should commence steroid treatment; betamethasone 11.4mg IM or dexamethasone 12mg IM every 24 hours for 2 doses (steroids can be administered without neonatal input).The optimal treatment to birth interval is ≥24 hours but fewer than 7 days after the start of treatment

if birth is imminent consideration could also be given to repeating steroid dose after 12 hours

a second course of steroids can be administered if the first course is > 1 week previous (one dose only) and delivery is expected soon. Discuss with consultant

Magnesium Sulphate magnesium sulphate infusion for fetal neuro-protection should be considered if there

are signs of labour before 30 -32 weeks gestation and on discussion with Neonatologist (see guideline: Preterm Labour)

Antibiotics:Early treatment with antibiotics can improve the outcome in PPROM

Evidence has shown that with PPROM and NO signs of labour or chorioamnionitis, a 10 day course of an oral erythromycin 250mg every 6 hours, or a single dose of oral azithromycin 1g, is associated with prolonging the pregnancy without significant risk of risk of adverse maternal outcome. Locally, as an alternative, prescribers may prescribe:

Oral Azithromycin 1g every 72 hours for 4 doses. No IV antibiotics will be indicated unless there is evidence of labour or chorioamnionitis.


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Penicillin is to be administered when in established labour or with an induction of labour or other risk factors

MEDICATION DOSE ROUTE FREQUENCY DURATION

Benzylpenicillin 3g for the first dose, then 1.8g

Intravenous 4 hourly Intrapartum

(If allergy but non anaphylaxis to penicillin):

Cephazolin 2 gram stat then 1 gram

Intravenous 8 hourly Intrapartum

(If anaphylaxis to penicillin)

Clindamycin 900mg Intravenous 8 hourly Intrapartum

If evidence of chorioamnionitis ADD:

Gentamicin

Metronidazole

4-6 mg/kg body weight (booking weight)

500mg

Intravenous

Intravenous

Daily

12 hourly

PRACTICE NOTE:If the contractions stop, intravenous antibiotics may be ceased and third daily oral azithromycin given for a total of 4 doses


Section 4 – Ongoing Observations and Care

Commence Preterm Rupture of Membranes pathway Admit for observations for an initial 48 hours and completion of steroid therapy 4 hourly Maternity early warning score (MEWS) fetal heart rate monitor for uterine contractions monitor PV loss daily CTG


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twice weekly FBC and CRP LVS when woman begins to labour T hrombo Embolism-Deterrent (TED) stockings should be worn at all times inform the woman about the importance of personal hygiene and frequent pad changes document findings

Alert: Notify obstetric registrar or consultant obstetrician immediately if: labour begins low vaginal swab indicates the presence of infection any elevation in maternal temperature >37.4°C or pulse > 100, MEWS score ≥ 3 fetal tachycardia is present >160bpm woman complains of signs or symptoms of infection especially ‘flu’ like symptoms or

abdominal pain liquor becomes offensive or discoloured fetal movements are reduced CTG is abnormal women with PPROM should be counselled regarding potential induction at > 37 weeks,

recent research from the PROMPT Trial suggests that there may be benefit in continuation of the pregnancy to beyond 37 weeks gestation. Placental swabs to be taken after birth.


Section 5 – Outpatient Management of a Woman with Preterm Pre-labour Rupture of Membranes

the woman is to be observed in hospital for at least 72 hours if the woman remains well, and she understands her management plan, has a cephalic

presentation and is not in labour, the woman can then be discharged to accommodation that is close to Canberra Hospital if she is from outside Canberra. The woman needs to be able to be assessed twice per week for outpatient management in Maternity Assessment Unit (MAU)

after consultation with the woman and her treating team and the High Risk Meeting recommendations, discharge home can be considered as per individualised care

the antenatal inpatient stay is to be recorded in electronic clinical record data base – Birthing Outcomes System ( BOS) and documented on the woman’s maternity record

a discharge letter is to be sent to the woman’s designated General Practitioner to advise them of the PPROM management plan

MAU folder to be commenced with relevant information and plan. the woman is informed that she is part of the PPROM Outpatient Program MAU, Birthing and or continuity midwife are advised that the woman is being discharged

with the follow up care plan ANC appointment to be made for 2 weeks after discharge


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the woman is to be instructed to take her temperature and pulse three times a day, and she is to observe her PV Loss and monitor fetal movements.

PRACTICE NOTEWomen on the PPROM Outpatient Program will be instructed to call Birthing, MAU or their Continuity Midwife if they experience: reduced fetal movements a rise in temperature feeling generally unwell or with flu like symptoms

She should return promptly for assessment in the MAU or Birthing.

the woman should be assessed twice weekly in MAU for:o CTGo If there is any suggestion of developing infection then a vaginal swab should be taken o FBC and CRP o overall assessment

fortnightly Fetal Medicine Ultrasound assessment the woman is given sufficient oral antibiotics or prescription for antibiotics women who are referred to The Canberra Hospital as in utero transfers can be

considered for transfer back to the referring hospital at 34 – 36 weeks, depending on the individual hospital and services available. However, PPROM from 24-26 weeks has a high risk of neonatal morbidity (lung problems); discussion with neonatology should occur before these women are discharged to regional hospitals

the woman is given the Information Sheet for PPROM management as an outpatient

Care of the Newborn the baby who is born following PPROM at >36 weeks will be managed as per NICU or as

an inpatient for 48 hours according to NEWS or Department of Neonatology- Developmental Care Babies born to women with PPROM and who are GBS positive –follow the Early Onset Group B Streptococcus Guideline and NEWS chart for newborn observations



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Implementation

The Guideline will be available via the ACT Health Intranet “Policy Clinical Guidance” tab and will be accessible to all practitioners. Education on the implementation of the policy will be provided to medical officers and midwifery staff to inform practice.


Related Policies, Procedures, Guidelines and Legislation

Guidelines Induction of Labour Meconium Stained Liquor Management of Early Onset Group B Streptococcal Disease Fetal surveillance Neonatal Early Warning Score (NEWS) Maternal Early Warning Score (MEWS) Preterm labour Department of Neonatology: Developmental Care

Back to Table of ContentsReferences

1. Preterm Labour and Birth. Queensland Clinical Guidelines. Dec 2014, amended June 2016. www.health.qld.gov.au/qcg

2. Duff, P 2007 Preterm premature rupture of membranes, Up-To-Date (16.1)3. Maternity Care in SA Preterm Prelabour Rupture of the Membranes 21 March 20114. NICE Clinical guideline: Intrapartum care of healthy women and their babies during

childbirth. July 2008. 5. Royal College of Obstetricians and Gynaecologists Guideline 2004, guideline no. 7,

antenatal corticosteroids to prevent respiratory distress syndrome.6. Royal Australian and New Zealand College of Obstetrician and Gynaecologists; Preterm

Prelabour Rupture of Membranes https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women's%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/RCOG-Preterm-Prelabour-Rupture-of-Membranes.pdf?ext=.pdf

7. Royal College of Obstetricians and Gynaecologists Guideline October 2010, guideline no. 7, antenatal corticosteroids to prevent respiratory distress syndrome.

8. The Women’s (the Royal Women’s Hospital, Victoria. Rupture of the membranes: preterm premature (PPROM).

9. William E Scorza, MD. Management of premature rupture of the fetal membranes at or near term. Up-to-date 2010.



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Definition of Terms

PPROM Preterm Prelabour Ruptured MembranesLMP Last menstrual periodUTI Urinary tract infectionCTG cardiotochographFHR Fetal heart rateFMU Fetal Medicine unitMAU Maternity Assessment Unit LVS Low vaginal swabGBS Group B streptococcus ROM rupture of membranesIOL Induction of labour


Search Terms

Rupture of membranes, PROM, PPROM, ROM, Premature, Prolonged, Prelabour, Tocolytics

Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

(to be completed by the HCID Policy Team)Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair


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preterm pre-labour ruptured membranes.docx · web viewearly treatment with antibiotics can improve...

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