Pre labour rupture of membranes

Audience

For all midwifery staff within NHS Borders

SRM after 37 weeks of gestation

Advise women with suspected spontaneous rupture of membranes (SRM) after 37 weeks to phone labour ward for an initial triage assessment over the phone.  This should include assessment of risk factors, such as:

• meconium-stained liquor
• vaginal bleeding
• blood-stained liquor
• reduced fetal movements
• continuous abdominal pain
• unpleasant smelling liquor, or any change in the colour or smell of her vaginal loss
• the woman feeling unwell
• group B streptococcus carriage or infection in this or a previous pregnancy where a plan has been made for intrapartum antibiotic prophylaxis in this pregnancy
• the baby has abnormal lie or presentation (for example, transverse lie or breech)
• fetal growth restriction
• low-lying placenta.

If any of these risk factors are present or if there is uncertainty, the woman should be advised to immediately attend the BGH for an urgent in-person review. 

• All women with suspected SRM but no risk factors on initial phone triage assessment -
  • Should be offered to be seen as soon as possible if she has any concerns
  • Should be offered a choice of immediate induction if she wishes or expectant management
  • Are to be seen in person within 12 hours and if anything changes advised to call back sooner than planned review.

Initial face to face assessment –

• Perform an abdominal examination and confirm lie and presentation and auscultate fetal heart.
• Presentation should be confirmed with ultrasound
• Avoid digital examination in the absence of contractions
• Speculum is not required if it is clear that membranes have ruptured
• If it is uncertain whether SRM has occurred, offer the woman a speculum examination.
• Amniosure can be used if uncertainty remains but is not required routinely
• Advise women with confirmed SRM that the risk of serious neonatal infection is 1% (compared to 0.5%) with intact membranes, and may increase over time
• Advise women that 60% will go into labour within 24 hours of SRM.
• Document the women’s choice as to immediate induction or expectant management.
• If the women has had a positive group B streptococcus test at any time in their current pregnancy, or a previous pregnancy where the baby developed group B strep infection, offer immediate induction of labour, or caesarean section if it has been planned.

Expectant Management after confirmed SRM at Term

For women who choose expectant management, offer induction of labour if labour has not started naturally after approximately 24hours

• Do not offer lower vaginal swabs or CRP unless clinical concerns
• Advise the women to record her temperature every 4 hours during waking hours and report immediately any change in colour or smell of vaginal fluid.
• Bathing or showering is not associated with increase in infection
• Having sexual intercourse may increase the risk of infection
• Cephalic presentation should be confirmed on scan before going home.

Induction of Labour

 Should be offered as soon as possible for those women who wish immediate induction

• Should be offered after 24 hours to women who choose expectant management
• Palpate abdomen for lie, presentation and engagement
• Confirm cephalic presentation with ultrasound scan
• For women with a Bishops score of 6 or less, 1mg Prostin can be offered first, followed by syntocinon infusion after 6 hours if regular uterine activity as not commenced.
• For women with Bishops score of more than 6, syntocinon infusion can be started immediately.
• After 24hrs from SRM, offer continuous fetal monitoring once in established labour.