[CG] Prelabour rupture of membranes at term

On initial telephone contact with the woman a history should be taken, including date and time of the suspected ruptured membranes. 

If the woman reports any of the following she should be advised to attend hospital for assessment as soon as possible: 

• Vaginal bleeding
• Green or offensive liquor
• She feels unwell or has a raised temperature      
• The fetal movements have changed
• The fetal position was not cephalic at last antenatal visit
• She has a history of group B Streptococcus (GBS) this pregnancy or a past history of a neonate affected by GBS   
• Previous Caesarean section           
• Multiple pregnancy
• There are maternal complications

All other women with suspected prelabour rupture of membranes at term should be seen by a midwife within 12 hours.

• Perform an abdominal examination and confirm lie and presentation and auscultate fetal heart.
• Speculum examination IF required to make Diagnosis
• Sterile speculum examination, after the mother has adopted the left lateral position for 20 mins. A low vaginal swab should be sent to bacteriology, together with a sample of amniotic fluid if a pool is demonstrated. Ultrasound scan is not routinely required.
• All non-Green Pathway cases should have a CTG performed.
• A digital examination should not be performed unless active labour is suspected or CTG abnormalities are present.

Neither the Term PROM study (Hannah et al. NEJM 1996 334; 16:1005-10) nor a metaanalysis (Mozurkewich & Wolf. Obstet Gynecol 1997 89; 6:1035-43) showed any significant difference in neonatal infection or caesarean section rates between those women who were induced immediately and those who were managed expectantly. The 2006 Cochrane review by Dare and colleagues confirmed these findings. Active management however was associated with a significant reduction in maternal infection (chorioamnionitis and endometritis).

Therefore the woman should be given 3 options:

1. Expectant management at home and readmittance 24-48 hours later, if she has not laboured, for induction.
2. Expectant management in hospital and induction 24-48 hours later if she has not laboured.
3. “Immediate” induction with Syntocinon (Labour Ward permitting).

ADDITION RE COVID‐19 (Added 25th March 2020)

If a woman is suspected of having Covid‐19 then investigations for Covid‐19 should be sent and the patient given an induction of labour date for 48 hours later (unless there are maternal or fetal concerns requiring earlier delivery). The patient should be discharged home. The swab results should be chased so staff know whether PPE is required for labour/delivery. The patient should be informed of the result.

Expectant management at home should only be offered if the woman meets the following criteria:

• Not in labour
• Singleton pregnancy
• Cephalic presentation with head fixed in pelvis
• Clear liquor
• Apyrexial
• Previously uncomplicated antenatal history
• No evidence of being a carrier for Group B Strep.
• No geographical issues

NICE (2007) advise: ‘Assess fetal movement and heart rate at initial contact and then every 24 hours after rupture of membranes while the woman is not in labour, and advise the woman to report immediately any decrease in fetal movements.’ Therefore, if IOL is being delayed more than 24 hours then the woman should be reassessed by a midwife every 24 hours to assess maternal and fetal wellbeing.

If an inpatient admission is indicated a MEWS chart should be commenced and an individual plan of ongoing care discussed and documented in the maternal records.

If IOL is delayed more than 48 hours then maternal observations and the fetal heart rate  should be recorded every 4 hours.

Prelabour Rupture of Membranes at term is no longer an indication for intrapartum antibiotic prophylaxis for Group B Streptococcus (see Group B Strep Prophylaxis guideline)

If the diagnosis of PROM is not confirmed, clinically the liquor volume is normal and the fetal heart / CTG satisfactory, the woman should be discharged home.

If there is any suspicion that the patient may be in labour then vaginal assessment should be performed and management plan agreed with woman.

Patient information leaflet - What to look for after your waters have broken. (pdf)