Remote Primary Health Care Manuals

Premature rupture of membranes

Rupture of membranes (sudden or continuous fluid loss from the vagina) before the start of regular contractions. Can happen

  • At term (37 or more weeks pregnant) — PROM
  • Preterm (20–36 weeks pregnant) — PPROM
Red Flags — Urgent Medical Consult
  • Signs of sepsis
  • Tender uterus ​
  • Smelly vaginal discharge or pus
  • Cord prolapse — cord comes out before the baby
  • Placental abruption — pain and bleeding when the placenta separates from the uterus before the baby is born
  • PPROM at less than 37 weeks
  • PROM (37 weeks or more) AND
    • More than 18 hours or unknown time since membranes ruptured
    • OR history of or known Group B Streptococcus (GBS) positive

Do not

  • Do not perform a digital vaginal exam ​at any stage — increases risk of infection

Do first

  • Examine genital area
    • If cord at vulva or in vagina — see Cord prolapse straight away
    • If feet or bottom at vulva or in vagina — see Breech birth straight away
    • Medical consult

Ask

  • Vaginal loss
    • When and how it started
    • How much — colour, smell, any blood
    • If happened before in this pregnancy
  • Any abdominal or low back pain or contractions
  • Baby movements

Check

  • Obstetric ultrasound ​report for location of placenta — clear of cervical os (opening of neck of womb)
  • Swab ​results — GBS​, STIs​​, UTI, other infection​
  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • U/A
  • Head-to-toe exam — attention to
    • Vulva — look for sores especially herpes
    • Vaginal loss — colour, amount, smell, blood
    • If bleeding from vagina — see Bleeding in pregnancy
    • Abdominal assessment — tenderness, rebound, guarding
    • Uterus — tender, soft or hard
    • Contractions — see Labour and birth
    • Position of baby, if skilled — head first, breech (bottom or feet first)

Do

  • Sterile speculum exam ​of vagina and cervix to look for amniotic fluid, if skilled
    • Use sterile gloves and sterile speculum
    • Look for pooling of fluid in vagina
    • Ask woman to cough — look for fluid coming out of cervix
    • Do test (eg AmniSure) for amniotic fluid to confirm PROM, if available 
  • Also look for
    • Ulcers inside vagina — may be herpes
    • Cervical dilatation ​(open cervix)
    • Membranes, cord, hair or other part of baby in cervix. If cord seen — see Cord prolapse straight away
    • Discharge
  • High vaginal swabs for MC&S and endocervical swabs for MC&S and gonorrhoea, chlamydia, trichomonas NAAT
  • If not able to do speculum exam — take low vaginal swabs for MC&S and gonorrhoea, chlamydia, trichomonas NAAT, urine for MC&S
  • Put pad between woman’s legs. Change pad at each check
    • If bleeding — save and weigh all pads (1g increase = 1mL loss)
  • Lie woman on left side
  • Explain what is happening and why
  • Put in IV cannula — largest possible, insert 2 if time
  • Medical consult — doctor should talk with obstetrician about antibiotics, steroids and sending to hospital 

Antibiotics

  • If PPROM (less than 37 weeks)
    • Give amoxicillin OR ampicillin IV — 2g, every 6 hours for 48 hours

THEN amoxicillin oral — 250mg, 3 times a day (tds) for further 5 days or until delivery (whichever is sooner) 

AND erythromycin oral — 250mg, 4 times a day (qid) for further 5 days or until delivery (whichever is sooner) 

  • If allergy to penicillin — medical consult for clindamycin IV — 900mg, every 8 hours until birth
  • PROM (37 weeks or more) and more than 18 hours or unknown time since membranes ruptured — will need treatment for GBS

Steroids to mature baby’s lungs — if less than 35 weeks pregnant 

  • Betamethasone ​IM — 11.4mg — 2 doses 24 hours apart
  • OR dexamethasone IM — 6mg — 4 doses 12 hours apart

Sending to hospital

  • All women with PROM or PPROM should be sent to hospital
  • If woman goes home before going to hospital — advise do not use tampons, have sex, have bath or go swimming

Chorioamnionitis (intrauterine infection)

Red Flags — Urgent Medical Consult
  • Temp ​more than 38°C AND any 2 other signs
    • Rapid (fast) breathing (RR more than 18 breath/min)
    • Rapid (fast) pulse (​more than 100 beats/min)
    • Tender uterus ​
    • Smelly vaginal discharge or pus

Do

  • Medical consult
  • Take blood cultures before giving antibiotics
  • Give amoxicillin OR ampicillin IV — adult 2g, every 6 hours (qid)

AND gentamicin IV — 5mg/kg — doses — once a day

AND metronidazole IV — adult 500mg, every 12 hours (bd)

  • If allergy to penicillin — medical consult