Key Clinical Information
Premature rupture of membranes (PROM) is defined as ROM that occurs before the onset of labor.
Ninety percent of women with PROM will enter labor by 24 hours post-ROM. When there is greater than 24 hours between ROM and delivery of the infant, prolonged rupture of membranes is said to occur. Preterm premature rupture of the membranes is ROM that occurs before term. Complications of premature rupture of the membranes include com- plications related to preterm birth following PROM, fetal distress related to cord compression, and fetal infection. Maternal complications include maternal intra-amniotic infection, increased risk of Cesarean delivery, and postpartum endometritis (Varney et al., 2004; ACOG, 1998).
Care of the Woman with Premature Rupture of the Membranes 165
Client History:
Components of the History to Consider
• LMP, EDC, gestational age
• Relevant prenatal and maternity history
•• GBS status
•• Complications of current or previous pregnancy
•• Previous PROM
•• Last pap results
•• STI testing and results
•• New sexual partner(s)
• Current signs and symptoms
•• Onset of symptoms
•• Duration of symptoms
•• Amount, color, consistency of vaginal leakage
•• Last sexual activity
•• Presence of warning signs
■ Fever or chills
■ Palpitations
■ Uterine tenderness
■ Flank tenderness
• Presence of risk factors for PROM (Varney et al., 2004)
•• Nonvertex presentation
•• Previous pregnancy with PROM
•• Chorioamnionitis
•• Polyhydramnios
•• Multiple gestation
•• Vaginal group B strep or other pathogenic vaginal flora
•• Smoking > 1⁄2pack per day
•• Nutritional deficiencies
•• Family history of PROM
•• Cervical conization
Physical Examination:
Components of the Physical Exam to Consider
• VS with temps q 1–2 hours
•• Maternal fever (temp > 32.2°C or 99°F)
•• Maternal or fetal tachycardia (maternal HR
> 100, FHR > 160)
• Abdominal exam
•• Amniotic fluid volume/ballottement
•• Presence of contractions
•• Estimated fetal weight
•• Determine fetal presentation, lie
•• Frequent evaluation of fetal FHR
•• Palpation for uterine tenderness
• Sterile speculum exam
•• Visualization of leakage of amniotic fluid
•• Visualization of cervix is possible
•• Collection of specimen(s) for examination
■ Ferning
■ Nitrazine
■ GBS culture or screen
• SVE (defer or limit exams)
•• Cervical dilation
•• Effacement
•• Station
•• Confirm presentation
•• Rule out cord prolapse
Clinical Impression:
Differential Diagnoses to Consider
• Premature rupture of membranes
• Urinary incontinence
•• Physiologic
•• Secondary to urinary tract infection
• Increased vaginal secretions due to
•• Pregnancy
•• Vaginitis
•• Sexually transmitted infection
•• Intercourse
• Cervical cancer
Diagnostic Testing:
Diagnostic Tests and Procedures to Consider
• Vaginal fluid evaluation
•• Nitrazine or pH testing (pH 7.0–7.7)
•• Ferning
•• Wet prep and KOH
• Cultures as indicated
•• If expectant management planned
■ GBS culture of vagina and rectum
■ Chlamydia/gonorrhea status
• Ultrasound evaluation
•• Oligohydramnios/AFI
•• Biophysical profile
•• Guidance for amniocentesis
• Amniocentesis for fetal pulmonary maturity testing
• CBC with differential
•• Maternal leukocytosis (WBC > 16,000 with no labor)
• Urine for UA and C & S
•• Clean catch
•• Straight cath specimen
• Fetal surveillance
•• NST if > 32 weeks gestation
•• Daily fetal movement counts
•• Biophysical profile/AFI
Providing Treatment:
Therapeutic Measures to Consider
• Bed rest recommended for
•• Nonvertex presentation
•• Preterm PROM
• Antibiotic prophylaxis (see GBS)
• Expectant management based on gestational age (ACOG, 1998)
•• Term
■ Labor and birth occur within 28 hours in 95% of cases
■ Observation of 24–72 hours acceptable per ACOG
■ Avoid digital exams until labor well established
■ Induction of labor (see Induction)
•• Preterm with no additional complications
■ Conservative management preferred
■ Birth generally occurs within 7 days
■ Glucocorticoids to enhance fetal lung maturity
■ Tocolysis (rarely)
■ Transport to center with newborn special care
Providing Treatment:
Alternative Measures to Consider
• Watchful waiting
•• No internal exams
•• Temps q 2 hours
•• Daily CBC
•• Adequate hydration and nutrition
•• Await onset of labor
• Stimulation of labor with natural remedies (see Induction)
Providing Support:
Education and Support Measures to Consider
• Discuss significance of PROM
•• Anticipated fetal outcome for gestational age
•• Anticipated newborn care
Care of the Woman with Premature Rupture of the Membranes 167
•• Risks and benefits of options for care
•• Maternal risk with PROM
■ Ascending intrauterine infection
■ Increased incidence of intervention
•• Fetal risks with PROM
■ Umbilical cord compression
■ Ascending or preexisting infection
•• Potential need for medical care
•• Potential for change in
■ Birth plan
■ Location of birth
■ Birth attendant
• Signs and symptoms of
•• Chorioamnionitis
•• Neonatal sepsis
•• Postpartum endometritis
Follow-up Care:
Follow-up Measures to Consider
• Document
• Review results of
•• Maternal testing
•• Fetal surveillance
■ Fetal kick counts
■ NST
■ Biophysical profile
■ Serial AFI
■ FHR
• Intermittent auscultation of FHT
• Continuous fetal monitoring
• Cervical ripening or induction of labor (see Induction of Labor)
•• Essential if amnionitis suspected
•• ROM > 24–72 hrs
• Reassess for signs or symptoms of complications
•• Maternal fever
•• Abdominal tenderness
•• Abnormal FHT patterns
■ Tachycardia
■ Bradycardia
■ Nonreassuring FHR patterns
• Update plan as changes occur
• Expedite birth if
•• Symptoms of infection develop
•• Fetal compromise occurs
•• Maternal preference
• Evaluate postpartum for
•• Endometritis
•• Other infection
•• Newborn sepsis
• Offer time for discussion and processing
•• Labor and birth events
•• Outcomes
•• Potential effect on future pregnancies
Collaborative Practice:
Consider Consultation or Referral
• OB/GYN service
•• Documented PROM with
■ Delay in onset of labor
■ Signs or symptoms of
• Infection
• Cord prolapse
• Fetal compromise
• Pediatric service
•• Onset of labor with fetal or maternal infection
•• For birth as indicated by fetal status
•• Newborn evaluation following prolonged ROM
• For diagnosis or treatment outside the midwife’s scope of practice