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1. Premature Rupture of
Membranes

2. Definitions
Premature Rupture of Membranes:
spontaneous rupture of membranes and
leakage of amniotic fluid prior to the onset
of labour
One hour or more prior to onset of labour
Labour will usually begin spontaneously
within 24 hours of ROM.

3. PROM
Importance to fetus:
Infection and prematurity
Importance to the mother
Infection, obstetric interventions

4. Premature Rupture of
Membranes
Aetiology Often UNKNOWN
Risk Factors: What are they?

5. Premature Rupture of
Membranes: Risk Factors
History:
Prior history of PROM, Prior cervical
surgery, cigarette smoking
Current pregnancy:
Placental pathology, uterine procedures,
uterine trauma

6. Premature Rupture of
Membranes: Risk Factors
Infectious:
Trichimonas, Group B strep, Staphylococcal
Suspected: coitus, digital exams, other
cervicovaginal infections
Gonorrhoea, chlamydia

7. Other definitions
a. Preterm premature rupture of
membranes (PPROM) refers to membrane
rupture prior to term gestation or before 37
completed weeks of gestation;
b. Risk factors for preterm membrane rupture
include:
i. infection
ii. incompetent cervix
iii. trauma

8. Prolonged Rupture of
Membranes
a. Prolonged rupture of membranes
refers to membranes ruptured more
than 18 hours before birth
b. Many caregivers will induce labour
rather than risk prolonged rupture
with possible ascending infection

9. Maternal Risks
MATERNAL RISKS:
Risk of infection
In TERM pregnancies: risk maternal sepsis.
If less than 37 weeks gestation (risk of
maternal infection is not significant).
risk of Caesarean birth.

10. Fetal Risks
Prematurity
Respiratory Distress Syndrome (RDS)
Approx. 20% of babies born after PROM
weigh less than 2500.
The major cause of perinatal death IF
period of gestation is less than 34 wks
is RDS and NOT sepsis.

11. Fetal Risks
By35+ weeks when most fetuses have
pulmonary maturity, SEPSIS is main cause of
perinatal mortality and morbidity.
B beta haemolytic streptococcus is
especially lethal.
Can identify this vaginal culture.
Prolapse of umbilical cord. More common in
premature infants with premature ROM.
Also may have malpresentation—esp preterm

12. PROM
Incidence as high as:
10% of term
30% of preterm pregnancies.
Onset of labour after PROM:
50-70% of mothers will go into labour
within 48 hours

13. Initial Evaluation: 3 Q
Are the membranes ruptured?
Should fetus be delivered?
Is treatment needed?
(antibiotics, steroids)

14. DIAGNOSIS
HISTORY: Important items to obtain
Fluid leakage
Dating of pregnancy
Prenatal risks
Review of systems
Social history

15. Diagnosis
Physical Exam
Brief by complete general exam to look for
signs of other illnesses
Assess Temp, heart rate and blood
pressure (assess for infection)
Fetal heart rate: may indicate infection
(asses by auscultation or EFM)
Assess fetal size and presentation with
Leopold’s maneuvers (cont.)

16. Diagnosis
PELVIC EXAM:
NO VE should be done unless patient is
term or near term till in spontaneous labour.
Risk of infection to fetus and mother is
proportional to the length of time following
the first VE and the number of VEs done.
Evidence shows that duration of latent
phase is decreased in preterm PROM who
have had VEs

17. Diagnosis
INVESTIGATIONS:
Sterile speculum examcervical
dilatation/effacement (visual assessment)
Document if fluid is spontaneous or with
pressure on abdomen.
Pooling of fluid?
pH and fern test
High vaginal swab for culture.
Gonorrhoea; Chlamydia, group B strept

18. Diagnosis (cont.)
Nitrazine test
What colour?
Dark BLUE
Ultrasound test: if little or no amniotic
fluid—suggests ROM

19. Fetal PROGNOSIS
Fetal prognosis: depends on—
fetal maturity: L/S ratio
intrauterine infection.
Although neonatal infection follows PROM
in less that 5% the most dangerous is
group B streptococcus.

20. Further evaluation
CBC: to R/O amnionitis
UA: to r/o UTI
External fetal monitor (EFM): to
diagnose fetal distress/tachycardia
Ultrasound: Dx malformations,
presentation, oligohydramnios
Amniocentesis: to dx fetal lung maturity

21. Management PROM
CONSERVATIVE mgt at HOME:
Vital signs and fetal assessment
There is no excessive loss of amniotic
fluid
No coitus
T q 4 hours at home
Induction of labour: when reaches 37
weeks.

22. Management PROM
MGT if >36 weeks:
Low chance of RDS but risk of infection
is greater.
Ripe cervix: induce labour
Unripe cervix:
Some wait for 24 hours and induce if it
hasn’t started. Ripening of cervix
cytotec.

23. Management PROM
If preterm and delivery inevitable but
not imminent—transfer to hospital with
neonatal care unit.
IF delivery NOT imminent: expectant
management: No VE. Check maternal
temp and pulse, fetal heart tonts
(?tachycardia)
WBC on mother

24. Medications: +/-
Use of tocolytics in PPROM is controversial
Dexamethasone: controversial
between 24-34 weeksdecr. RDS, Intraventricular
haemorage and fetal death
Dose: Dexamethasone 6 mg. q 12 hrs x 4 doses
Use of antibiotics with between PPROM and
delivery is contraversial
Cytotec  if labour doesn’t start might use
oxytoxics.

25. Management (cont.)
Assess FHR when membranes rupture
to determine risk of infection and rule
out
R/O prolapsed cord; note time, colour
and amount of fluid
obtain a baseline maternal temperature
Then take temp q 2 hours, other
vital signs may be routine

26. Management (cont.)
c. Avoid vaginal exams to prevent
introducing microorganisms—
ascending infection
d. Monitor for development of uterine
contractions and evaluate fetal well-
being;
e. decreased amniotic fluid may cause
variable decelerations of FHT.

27. Management
e. Monitor client for signs of chorioamnionitis
(inflammation and infection of fetal
membranes and amniotic fluid); elevated
temp., abdominal tenderness, increased
WBCs and erythrocyte sedimentation rate.
f. Obtain vaginal culture for group B
streptococcus as ordered

28. Management (cont.)
G. Provide client teaching and
reassurance that amniotic fluid is
continuously produced and that there
is no such thin as a dry birth.
RE: Antibiotics: Some caregivers prefer
to wait and treat the newborn.

29. Evaluation
Goal:
Client and fetus remain infection free;
umbilical cord does not prolapse;
client delivers a healthy infant without
complications associated with
prematurity.