PREMATURE RUPTURE OF MEMBRANES

(PROM) AND PRETERM LABOUR

WEDNESDAY GROUP NSH1
Pyrea Yebba Dingha = 3818689

Chinenye Sonia Obianika =3818451

Indiphile Mcunukeli =3856474

Nosibusiso Matshini = 3841991

Amahle Makhonkco = 3860010

Sheila Pinkie Masusu = 3867425

Anna Mbilane = 3725569

Talani Maswanganyi = 3860709

OVERVIEW
 Premature rupture of membranes(PROM)
-Definition and diagnosis
-Symptoms
-Effects on maternal and the foetus
-management of PROM
 Preterm labour
-Definition
-Predisposing factors signs and symptoms
-Management of a client with preterm labour
Scenario 1
At 10h00 Mrs Sulaiman-Rakiep is admitted to labour ward with complaints of lower abdominal pain.
Contractions are monitored and a vaginal examination is done. Findings are as follows: BP 130/70
mmHg, Pulse 60 bpm, Temperature 36,6 degrees Celsius, Contractions - 3 strong, cervix 4cm dilated,
1,5cm long, station-2, LOA, no caput, no moulding. Urine: 100ml –NAD, FHR 144bpm, no decelerations.
At 12h00 Mrs Sulaiman-Rakiep is re-evaluated and the findings are as follows: BP 130/90mmHg, Pulse
74bpm, Temperature 37 degrees Celsius, Contractions – 4 strong, cervix 6cm dilated, 1 cm long, ROP
position, Station-1, + caput, no moulding, Urine 80ml – NAD, FHR 155bpm, no decelerations.
At 14h00 findings were as follows: BP 130/85mmHg, Pulse 100 bpm, Temperature 37,5 degrees Celsius,
Contractions - 3 strong, cervix 6cm dilated, 0,5cm long, ROP position, station -1, ++caput, + moulding.
Urine 50ml - + ketones, FHR 155bpm, no decelerations. At 16h00 Mrs Sulaiman-Rakiep is re-assessed and
findings are as follows: BP 130/85mmHg, Pulse 111bpm, Temperature 37,6 Celsius. Contractions – 2
strong,1 moderate, cervix 7cm dilated, fully effaced, OP position, station1. ++ caput, ++ moulding.
Urine 30ml - ++ ketones, FHR 158bpm, no decelerations. Diagnose Mrs Sulaiman-Rakiep and manage
her condition.
Scenario 2
Lindie Chekerwa is accompanied by her mother to the MOU with lower abdominal pains since 2 o’
clock the morning. She is anxious and sweating profusely. She is a 20year old Gravida 02 Para 01 at 28
weeks gestation. Lindie booked at Bishop Lavis MOU and had missed one booked antenatal visit.
In her previous pregnancy she was treated for syphilis. Vital signs are as follows: Urine: 2+ Leucocytes,
Protein 1+, Blood 1+. Respiration: 24 beats per minute, BP is 134/80, Pulse is 90 beats per minute, and
Temperature is 37.8°C. On vaginal examination you observe a greenish offensive discharge. Fundal
height is 28 cm. Foetus is longitudinal in lie and cephalic presentation. HOB 5/5. Presenting part is not
palpable above the symphysis. Foetal heart rate is162 beats per minute and 2 contractions were felt
in 10min with each one lasting 20 and 25 seconds. Her cervix is soft and not dilated. No rupture of
membranes noted
Scenario 3
Kim K is a 27-year-old G3 P2 who arrived at Mitchell’s Plain MOU labour ward with a history of lower
abdominal pain for 10 hours. It is determined that she is unbooked. Her first baby was born in 2010 at
36 weeks gestation and the second baby was born in 2013 also at 36 weeks gestation. Kim never
initiated antenatal care with both pregnancies because of her drug addiction. She was found to be
addicted to “tik” since the age of 14 years. Both babies spent time in the neonatal unit until they
gained the required weight. They are both alive and living with Kim’s parents. Kim appears
disorientated with dilated pupils. She is obviously under nourished with unkept clothes and hair. Her
friend who escorted her reports that she is still addicted to “tik” and last used 3 hours ago. Kim is
uncooperative during the admission. As a result, a clear history could not be obtained with regards to
her LNMP, medical history, etc. She was forcefully brought in because of the pain she was
experiencing. Her friend has no idea how far pregnant she is.
An examination yielded the following findings: Vital signs: BP: 100/60; Pulse: 110; Temp: 38 deg;
Urinalysis: 2+ Ketones, 2+ blood. Abdominal assessment: SFH of 32 cm; longitudinal lie; breech
presentation. Two contractions were felt in 10 minutes lasting for 35 seconds each. Foetal heart rate:
168 bpm before a contraction and 180 bpm after. Vaginal examination: Vulva and vagina is normal;
cervix is 3cm dilated and well effaced. Membranes are intact. A diagnosis of preterm labour with
foetal distress in the latent phase was made. Arrangements for transfer to high risk facility is made and
the patient is commenced on IV therapy and a urinary catheter is inserted. Her observations as well as
foetal heart rate was to be repeated every 15 minutes until transfer. Kim refuses to lie on her side and is
constantly wanting to leave. She manages to get off the bed and tries to leave the MOU when the staff
becomes busy with another emergency. The staff finds her in the passage standing in a pool of fluid
On examination it is found that her membranes have ruptured. The midwife manages to get her
back on the bed and perform a vaginal examination. Her cervix is now 7cm dilated and the foetal
buttocks can be felt along with the cord. The foetal heart rate is now 148 bpm before a contraction
and 120 bpm after.
 PREMATURE RUPTURE OF MEMBRANES(PROM)

PROM is the rupture or breakage of the amniotic fluid sac before the onset of labor. it is called preterm
premature rupture of membranes (PPROM) if it occurs before 37 week of pregnancy. Pre-labour rupture of
the membranes may occur near the due date(at 37 weeks or later,when pregnancy is considered full
term)or If rupture is preterm, delivery is also likely to be too early(preterm)
DEFINITION Anna Mbilane 3725569

DIAGNOSIS:
The diagnosis of PROM requires a thorough history, physical examination, and selected laboratory
studies. Patients often report a sudden gush of fluid with continued leakage. The patient should be
asked whether they have contractions, bleeding, or had intercourse recently. It is important to verify
the patients estimated due date because this information will direct subsequent treatment. A
speculum examination should be done to evaluate if any cervical dilatation and effacement are
present.
 Anna Mbilane 3725569

When PROM is suspected, it is important to avoid performing a digital cervical examination as

they have shown to increase morbidity and mortality.
 POOLING TEST: Evidence of fluid pooling in the vagina or leaking from the cervical 0s when the
patient coughs or when fundal pressure is applied, will help determine PROM.
 Anna Mbilane 3725569

NITRAZINE TEST: The normal vaginal pH is between 4.5 and 6.0, whereas the amniotic fluid is more
alkaline with a pH of 7.1 to 7.3. Nitraine paper will turn blue when the pH is above 6.0. However the
presence of contaminating substances such as blood, semen can also cause Nitraine paper to turn

blue giving a false positive result.

 Anna Mbilane 3725569

FERN TEST: A separate swab should be used to obtain fluid from the posterior fornix or vaginal side walls. Once

the fluid has dried on the slide, check for ferning under a low power microscope. The presence of ferning indicates

PREMATURE RUPTURE OF MEMBRANES.

 Anna Mbilane 3725569

During the speculum examination, a DNA probe or cervical culture for chlamydia and gonorrhoea
should be performed because women with these infections are more likely to have PROM.
SYMPTOMS OF PROM Talani Maswanyi 3860709
The most significant sign of PROM is fluid leaking from the vagina. When the mother’s water breaks,
it may feel like a slow trickle of fluid from the vagina or a sudden gush of fluid that is pale yellow or
clear
Vaginal bleeding
Pelvic pressure
No contractions
PROM and infection often occur together. It therefore is crucial to recognize the signs of infection in
a pregnant woman. Signs of maternal infection include the following:

 An increase in the foetal heart rate

 Contractions of the uterus (womb)
 Talani Maswanganyi 3860709
Increased heart rate and temperature in the mother
 Tenderness of the uterus
 Bad smelling vaginal discharge
 Increased white blood cell count or a change in the pattern of white blood cell type in the
mother
Like the case of the patient Lindie Chekerwa shows that she is having an infection and not really
PROM as her vital signs were as follows;
Urine: 2+ Leucocytes, Protein 1+, Blood 1+. Respiration: 24 beats per minute, BP is 134/80, Pulse is 90
beats per minute, and Temperature is 37.8°C. On vaginal examination you observe a greenish
offensive discharge. Fundal height is 28 cm. Foetus is longitudinal in lie and cephalic presentation.
HOB 5/5. Presenting part is not palpable above the symphysis. Foetal heart rate is162 beats per
minute and 2 contractions were felt in 10min with each one lasting 20 and 25 seconds
 Sheila Pinkie Masusu 3867425
Effects of PROM (premature rupture of membranes) on maternal and the
foetus.
Maternal
 Prolonged first stage of labour due to no fluid wedge
 Prolapsed cord due to malpresentation, hydramnio
Oligohydramnios – the uterus moulds around the fetus because there is no liquor to separate them
Chorio-amnionitis and generalized sepsis
 Maternal death
 Sheila Pinkie Masusu 3867425
Placental abruption, postpartum endometritis, intra-amniotic infection (infection of the membranes
containing the foetus).
Foetus
 Respiratory distress,
 cord compression,
 antepartum foetal death,
 foetal distress,
 Foetal growth restriction or intrauterine death due to prolapse cord
 deformities and pulmonary hypoplasia.
 Infection of the fetus
 Amahle Makhonkco 3860010

Management of PROM
 Hospitalization
 Expectant management (in very few cases of PROM, the membranes may seal over and the fluid ma
stop leaking without treatment, although this is uncommon unless PROM was from the procedure, such a
amniocentesis, early in gestation)
 Bedrest
 Do abdominal examination for tenderness
 Pad checks: fluid leakage: 6hourly
 Fetal monitoring: CTG daily
 Check the fetal condition, determine the gestation as accurately as possible, look for clinical signs o
chorioamnionitis
 Continuously monitoring FHR and uterine contractions
 Amahle Makhonkco 3860010
 No digital vaginal examinations – may contribute to fetal infection
 Monitoring for signs of infection, such as fever, pain, increased foetal heart rate, and /laboratory tests.
 Give medication called corticosteroids that may help mature the lungs of the foetus (lung immaturity
is major problem of premature babies). However, corticosteroids may mask the infection in the uterus.
 Broad spectrum antibiotics: erythromycin 250mg orally 4times daily and metronidazole 400mg orally
3x/daily for 7 to curb or prevent infection
 Corticosteroids betamethasone 12mg IM repeated after 24 hours for feptal lung maturity
 Ultrasound for amniotic fluid index (AFI) and fetal growth
 Allow the pregnancy to continue (to provide time for fetal lungs to mature)
Labour can be induced at 34w
 If there are signs of abruption, chorioamnionitis, or foetal compromise ,then early delivery would be
necessary.
PRETERM LABOUR
 Pyrea Yebba Dingha 3818689

DEFINITION
This is defined as the onset of labour after the gestation of ≥ 24 weeks and before 37 completed
weeks of pregnancy, regardless of the weight of the foetus/baby. Management of this depends on
the gestational age and/or estimated foetal weight by palpation or ultrasound.

Predisposing factors:

Exhausting work coupled with long working hours can put the pregnant
woman at high risk of preterm labour. Reason why at certain weeks of
pregnancy, the expectant mother is placed on maternity leave.
 Chinenye Sonia Obianika 3818451
.
 Pregnancy complications such as placenta previa , placenta accrete, as well as placental
abnormalities like marginal implantation of the umbilical cord, are all risk factors for preterm labour.
 Maternal age of less than 18years and above 37 years, as these are considered high risk pregnant
women, they are also at high risk of having preterm labour.
 Also a woman with history of preterm labour is also at a greater risk of preterm labour in the current
pregnancy.
 Smoking during pregnancy, alcohol and drug, which may deprive the foetus with oxygen, leading
to intrauterine growth restriction and hence preterm labour.
 Chinenye Sonia Obianika 3818451

 Also infection of the maternal genital tract especially with chlamydia trachomatis, gonorrhea,
streptococcus etc. because substance produced by bacteria in the genital tract weakens the
membrane around the amniotic sac which can lead to rupture and hence preterm labour.
 Excessively large uterus like in the case with polyhydramnios ,multiple pregnancy which makes
the uterus contracts when it stretches beyond a certain point
 Accident that causes abruptio placenta can also lead to preterm labour
 Increase emotional stress during third trimester ,owing to increased catecholamine
 Expectant mother with medical condition like gestational diabetes, pre-eclampsia, severe
anemia etc
 Chinenye Sonia Obianika 3818451

 A woman with a cervix insufficiency. This is a cervix that is shorter than normal, which efface and
dilate without contracting. Sometimes the cervix dilates before delivery. Also the case of
incompetent cervix ,where there was cervical tear in previous delivery, the cervix may be weak in
future pregnancy
 Gum infection is also a risk factor to preterm labour as the bacteria that cause gum infection can
trigger the immune system to produce inflammation at the cervix and uterus, causing preterm
labour.
Looking at our scenario, Ms. Kim K previous history and life style puts her at risk of preterm labour.It is reveal
that her previous two babies were born and 36weeks .Also, she is a drug addict, which is one of the risk
factors for preterm labour.Her special investigation reveals signs of genital infection due to the high
temperature rate, tachycardia, ketones which might be signs for starvation or dehydration and blood in the
urine. Also being under nourished posed as a risk for preterm labour.
 Pyrea Yebba Dingha 3818689

Signs and symptoms

Any of the following signs or symptoms that occur above 24weeks or less than 37weeks gestation
 Abdominal pain, menstrual-like cramping or more than 4 contractions in one hour
 More vaginal discharge as usual
 The presence of show, that is mucus-like or bloody discharge,
 Leaking water representing rupture membrane,
 Any vaginal bleeding or spotting
 More pressure on the pelvic area
• Low back pain especially if it’s dull or rhythmic
 Indiphile Mcunukeli 3856474

Management of Preterm Labour

As earlier stated, management of preterm labour will depend on the gestational age and/or
estimated foetal weight by palpation or ultrasound.
Gestational age ≥ 34 weeks (or estimated foetal weight ≥ 2 kg if gestation unknown)
 Look for underlying causes of preterm labour, e.g. chorioamnionitis or other infections with fever
andntachycardia, or abruptio placentae.
 Manage labour as for term pregnancies. There is no need to transfer from a clinic or community
health centre to a hospital.
Gestational age 26-33 weeks (or estimated foetal weight 800 g – 1999 g if gestation unknown)
 Transfer from a clinic or community health centre to a hospital*. Give tocolysis single dose
Nifedipine or IV salbutamol to suppress contractions during transfer.
 Indiphile Mcunukeli 3856474

At the hospital, Look for a possible cause for the preterm labour- e.g. vaginal discharge or UTI; do urine
MCS before commencement of antibiotics.
 Run a CTG tracing.
 If there is evidence of abruptio placentae or chorioamnionitis, allow labour to proceed under close
foetal monitoring with CTG, or consider caesarean section.
 If cervix is ≥6 cm dilated and there are strong contractions, allow labour to proceed but do not
augment labour. Deliver the baby in a slow and gentle fashion, with an episiotomy if the perineum is
very tight.
 Indiphile Mcunukeli 3856474

If cervix is <6 cm dilated, continue tocolysis. Try and continue suppression of labour until 48 hours have
passed since the first dose of β-methasone.
 Give ampicillin 2 g IV followed by 1 g IV 6 hourly and metronidazole 400 mg orally 3 times daily for 4
days for penicillin allergy, substitute erythromycin 500 mg orally 4 times daily.
 Give steroids (preferably betamethasone 12 mg IM; repeated after 24 hours, or dexamethasone 4
mg (1ampoule) 8 hourly for 48 hours (total dose of 24mg).
The patient can be discharged if she was successfully suppressed [i.e. no contractions for 48 hours].
Repeat cervical assessment before discharge. Make good notes in the Maternity Case record and
change her risk category to “high risk”. If she was a low risk patient.
Follow up should be in 1 week at a high-risk clinic; continue follow up until 34 weeks. Reassess patient
for follow up at a CHC/MOU from 34 weeks onwards.
 Indiphile Mcunukeli 3856474

If the estimated foetal weight is <1500 g, transfer the mother to a hospital with neonatal intensive
care facilities
Gestational age <26 weeks or estimated foetal weight <900 g
Transfer from a clinic or community health centre to hospital.
 Allow labour to proceed.
 If the baby is born alive, resuscitate actively and transfer it from a clinic or community health
centre to hospital.
 Indiphile Mcunukeli 3856474

Contraindications to the suppression of preterm labour

 Foetal distress
 A pregnancy where the duration is 34 weeks of more, or 24 weeks or less
 Chorioamnionitis
 Intra-uterine death
 Congenat abnormalities incompatible with life
 Pre-eclampsia
 Antepartum haemorrhage of unknown cause
 Cervical dilation of more than 6 cm however contractions should be temporarily suppressed
while the patient is being transferred to the hospital where preterm infants can be managed
 Severe intra-uterine growth restriction
 Indiphile Mcunukeli 3856474

Management of patient further after labour has been successfully suppressed

• If there is treatable cause e.g. a urinary tract infection then no further suppression of labour is
necessary after the cause has been treated
• If nothing can be done about the cause of preterm labour e.g. in the case of the multiple
pregnancy or polyhydramnios, Adalat 20 mg may be given orally every 6 hours
REFERENCES
 2006 Fraser DM, Cooper MA & Nolte AGW, Myles Textbook for Midwives , African Edition Church hill
Livingstone
 2015. McCall Sellers, P. MIDWIFERY. Volume 3.
 Guidelines for maternal care: 2015
 Seller’s midwifery 3rd edition 2018
 Betacare.co.za