JIMMA UNIVERSITY

INSTITUTE OF HEALTH
COLLEGE OF HEALTH SCIENCES
SCHOOL OF MIDWIFERY
3rd year midwifery/2023
PREMATURE RUPTURE OF MEMBRANE
(PROM) AND
PRETERM LABOUR(PTL)
Premature/pre-labor rupture of Membrane
Outlines of the presentation

 Objectives
 Introduction
 Premature rapture of membrane(diagnosis ,management,)
 Summary
Objectives
At the end of the session students will be able to:

 Diagnoses premature rapture of membrane

 Manage premature rupture of membrane

 Prevent complications following premature rupture of

membrane

 Provide care for women with rupture of membrane

Introduction
 Definitions: Premature / pre-labor rupture of fetal membranes
is rupture of membranes (ROM) before the onset of labor.
 Prolonged PROM is rupture of membranes for > 12 hours
CLASSIFICATION
 Term PROM: is rupture of membranes at or after 37
completed weeks of gestation.
 Preterm PROM: is rupture of membranes before 37
completed weeks of gestation.
Incidence
 PROM occurs in approximately 8-10% of pregnancies.
 Preterm PROM complicates 3% of pregnancies.
 PROM is the clinically recognized precipitating cause of
about one third of all preterm births.
Predisposing factors
 Polyhydramnios
 Intra amnionic infection
(chorioamnionitis)
 Low tensile strength of the
fetal membranes
 Lower socioeconomic status
 Cigarette smoking
 Other Infections: STI , UTI,
cervicitis, bacterial vaginosis.
 Fetal malformations
 Cervical insufficiency
 Previous history of PROM
 Second and third trimester
bleeding(e.g.abruptio
placenta)
 Amniocentesis
 Previous conization/cerclage
 Multiple pregnancies
 Malpresentations
 Unknown factors
APPROACH TO MANAGEMENT OF PROM

 Confirm the diagnosis of ROM.

 Evaluate for the presence of chorioamnionitis and labor.
 Determine the gestational age and evaluate the fetal condition.
 Subsequent management based on the above findings.
CONFIRM THE DIAGNOSIS OF ROM

History(HX):
 The classic clinical presentation of PROM is a sudden "gush"
of clear or pale-yellow fluid from the vagina.
 Many women describe intermittent or constant leaking of
small amounts of fluid or just a sensation of wetness within
the vagina or on the perineum.
 NB: Vulval pads can be moistened with urine or other vaginal
discharge.
Examination /Diagnostic evaluation:
Sterile speculum examination
 The best method of confirming the diagnosis of PPROM is
direct observation of amniotic fluid coming out of the cervical
canal or pooling in the vaginal fornix.
 If amniotic fluid is not immediately visible, the woman can be
asked to push on her fundus, Valsalva, or cough to provoke
leakage of amniotic fluid from the cervical os.
 Pooling in the vaginal fornix needs further evaluation as the
collection may be due to excessive vaginal discharge or urine.
Examination /Diagnostic evaluation cont..
 Presence of meconium, vernix caseosa or lanugo hair in the fluid
pooling indicates PROM while presence of uriniferous smell
suggests urinary incontinence.
 Note that: sterile speculum examination can also help to check for
the presence of cord prolapse and to assess cervical status.
 Digital examination should be avoided because it may decrease the
latency period (i.e. time from rupture of membranes to delivery)
and increase the risk of chorioamnionitis.
 Unless immediate delivery has planned.
Diagnostic cont..
 If PROM is not obvious after visual inspection, examine the
fluid for ferning or PH.
 Ferning test: Obtain fluid by swabbing the posterior fornix
(avoid cervical mucus to decrease chance of false positive
result).
 Spread some fluid on a slide & let it dry for at least 10 minutes.
Examine it with a microscope and look for a fern-leaf pattern
(arborization).
 The test is not affected by meconium, vaginal PH & blood.
Ferning test
Diagnostic cont..
Nitrazine paper test:
 Hold a piece of nitrazine paper in a hemostat (artery forceps)
& touch it against the fluid pooled on the speculum blade.
 A change from yellow to blue indicates presence of amniotic
fluid (PH >6 - 6.5).
 False negative tests results can occur when leaking is
intermittent or the amniotic fluid is diluted by other vaginal
fluids.
 False positive results can be due to the presence of alkaline
fluids in the vagina, such as blood, seminal fluid, or soap.
Diagnostic cont..
Pad test:
 Can be helpful when there is no pooling & no leakage from
cervix.
 Place a vaginal pad over the vulva & examine it one hour
later visually & by odor.
 Wetting with no urine and no vaginal discharge (vaginitis)
may suggest PROM.
 If the diagnosis remains in question, repeat the test.
Diagnostic cont..
Ultrasound examination: Performed to look for reduction of
amniotic fluid volume.
 It is an ideal non-invasive technique for the detection of the
residual amount of amniotic fluid.
 Oligohydramnios is diagnosed if the measurements of the
largest pocket of the amniotic fluid are less than 2cm.
Diagnostic cont..
Dye injection:
 Through abdominal needle under ultrasonic guidance into the
amniotic sac and observation of its passage through the
external os or even in the vulval pad.
 Ultrasonographically guided transabdominal instillation of
indigo carmine dye, followed by observation for passage of
blue fluid from the vagina within 30 minutes of
amniocentesis.
Evaluate for the presence of chorioamnionitis and
labor
Signs of infection (chorioamnionitis):Chorioamnionitis is
diagnosed if >or 2 criteria:
 Maternal fever/Maternal Temperature ≥ 38°c
 Uterine tenderness
 Foul smelling amniotic fluid through the vagina/Offensive
vaginal discharge
 Maternal or fetal tachycardia
 Increased WBC count
 DETERMINE THE GA AND EVALUATE THE FETAL
CONDITION
 Confirm the gestational age of the fetus (using LMP, early
U/S).
 Perform ultrasound to determine fetal presentation and lie.
 Electronic fetal monitoring to identify occult umbilical cord
compression.
 Do biophysical profile or NST.
SUBSEQUENT MANAGEMENT

Indications for expedite delivery: Immediate delivery of

the fetus may be indicated in the following circumstances
 Onset of labor/active labor with advanced cervical dilation
 Gestation age ≥ 37wks
 Evidence for non-reassuring fetal status/Intrauterine fetal death
 Evidence for chorioamnionitis
 Lethal congenital anomalies/Malformed fetus
 If there is high risk of cord prolapse (e.g., transverse lie) and
 Evidence of placental abruption with significant vaginal
bleeding
Management Cont…
 Note that if the gestational is below 34 weeks and both the fetal

and maternal conditions are stable, expectant management can

be considered for abruption placenta in a setting where close

follow up is possible.
 The woman’s activity is limited to modified bed rest and

complete pelvic rest.

 Blood pressure, heart rate, and temperature must be

measured ≥ 3 times a day.

Expectant management
Admit to the ward:
 Transfer patients with early preterm PROM to a higher health
facility with newborn intensive care, if possible.
 Avoid digital cervical (pelvic) examination.
 Advise bed-rest, to potentially enhance amniotic fluid re-

accumulation & possibly delay onset of labor.

 Expectant management
Administer antenatal corticosteroids :
 Betamethasone 12 mg intramuscularly 24 hours apart for two

doses or
 Dexamethasone 6 mg IM 12 hours apart for four doses) for

lung maturity.
 Note that if preterm birth is considered imminent, treatment for
short duration still improves fetal lung maturity and chances of
neonatal survival.
 Therefore, the first dose of corticosteroids should be
administered even if the ability to give the second dose is
thought to be unlikely.
Expectant management
Antibiotics
 Ampicillin 2gm IV QID and Erythromycin 250 mg P.O QID
for 48 hours followed by Amoxicillin 500 mg P.O TID &
Erythromycin 250 mg. P.O QID for 5 days.
 Azithromycin may be substituted for Erythromycin with
regimen of 500mg PO on day 1 followed by 250mg PO daily
for 6 days.
 If there is onset of labor and in the absence of signs of uterine
infection, discontinue antibiotics after delivery.
Expectant management
Neuroprotection:
If gestational age is less than 32 weeks and preterm birth is likely
within the next 24 hours, consider magnesium sulfate for
neuroprotection.
Monitoring and Follow up
 Maternal pulse & temperature - every 4-6 hours
 FHR - every 4-6hrs (& if possible CTG 2x daily)
 Uterine tenderness or irritability (or pain) - daily
 WBC count & differential - changes, every 2-3 days
 Amniotic fluid appearance & odor - daily
Labor and delivery for term PROM without infection:

 If cervix is favorable, labor is induced, unless there are

contraindications to labor or vaginal delivery, in which case
cesarean delivery is performed.
 If cervix is unfavorable, ripen the cervix (preferably with PO
misoprostol)
Management of near-term PROM (34-37 weeks)
 Induction or expectant management is acceptable management
options depending on local resources
Reading assignment
 Treatment of chorioamnionitis?
 Complications PROM

 PROM is a complicating factor in as many as one third of

premature births.
 A significant risk of PPROM is that the baby is very likely to be
born within a few days of the membrane rupture.
 Another major risk of PROM is development of a serious
infection of the placental tissues called chorioamnionitis,.
 Other complications that may occur with PROM include
placental abruption, compression of the umbilical cord, cesarean
birth, and postpartum (after delivery) infection.
Complications cont…
Maternal complication
 Preterm labor
 Maternal infection
 Postpartum endometritis
 PPH and APH
 Wound infection
 Cesarean delivery
Fetal complication
 Fetal skeletal deformities and
distress
 Chorioamnionitis
 Neonatal sepsis
 Cord prolapse
 Fetal death
 preterm birth and
associated complications
 long-term sequelae such as
cerebral palsy, pulmonary
hypoplasia
Discussion
 Can you prevent PROM?
Summary

 Definition of PROM?
 Diagnosis of PROM?
 Management of PROM?
 Complication of PROM?
Thank you for your attention!
Questions ?
Comments?
Preterm labour
 Objectives
• After completing the session students will be able to:

• Define preterm labour

• Diagnoses preterm labour

• Manage preterm labour

• Prevent neonatal complications preterm labour

• Provide care for women and newborn after preterm labour

 Introduction
• Definition :Preterm labor refers to the onset of labor before

the 37 completed weeks of gestational age.

• Preterm labour (PTL) is defined as regular uterine contractions

accompanied by progressive cervical dilation and/or

effacement at less than 37 weeks.

 Introduction cont..

• It is a global problem (with prevalence ranging between 5%

and 18%) and a major contributor to neonatal morbidity and
mortality
• A difference of 10 days can change the chance of survival
from near zero to 30% or from 30% to 55%.
• The importance of accurate dating cannot be overstated in the
management of PTL.
 Classification of preterm labour
 Early preterm: 28–32 completed weeks.
 Moderate preterm: 32 plus 1 day to 33 weeks plus 6 days.
 Late preterm: 34 completed weeks –36 weeks plus 6 days.
 Risk factors of preterm birth(PTL)

Preterm delivery may be secondary to:

• Spontaneous PTL with intact membranes

• Preterm premature rupture of membranes

• Indications of PTBs
 RISK FACTORS
Socio-demographic conditions
• Low socioeconomic status
• Extremes of maternal age( <18 years and >35 years)
• Unsupported/ unwanted pregnancy
• Smoking, alcohol consumption
• Excess physical work/ activity
Gynecologic conditions
• Congenital uterine anomalies
• cervical insufficiency
• intramural/ sub-mucus myoma
• uterine synechiae/adhesions.
 RISK FACTORS CONT..
Medical conditions: • Anemia
• UTI • Asthma
• Malaria • Thyroid diseases
• HIV • Obesity
• Syphilis • under nutrition.
• Bacterial vaginosis • Chorioamnionitis
• DM
• Hypertension
 RISK FACTORS CONT..
• Obstetric conditions: restriction
• Previous history • Fetal malformations
• Family history • Placental abruption
• Multifetal gestation • Amniocentesis, ECV, cervical
• Short inter pregnancy procedures during pregnancy.
interval (< 6 months)
• Polyhydramnios
• Fetal macrosomia
• Intrauterine demise
• Abnormal fetal monitoring
findings Intrauterine growth
 Complications of preterm labour
• Seventy-five percent (75%) of neonatal mortality occurs in
infants born preterm.

• Preterm babies are ten times more likely to die than the
babies born at term
• The long-term sequelae of PTB include: Central nervous system
complications, such as cerebral palsy Neurodevelopmental delay
Respiratory complications, such as bronchopulmonary dysplasia
• Blindness and deafness

• Others such as sepsis ,RDS, hyopglcemia,hypothrmia

 Complication cont..
• Physical, psychological, and financial burdens associated with

the diagnosis, management, and outcome of preterm labour

and delivery are significant.

• Preterm babies are more prone to serious illness and death in

the hours, days, and weeks following delivery. Those who

survive are at greater risk of lifelong complications.

 Complications cont..

• Risk comes from the increased difficulties that they encounter

with breathing, feeding, and body temperature regulation, along

with susceptibility to infection and neurological injury.

• Neonatal morbidity and mortality following preterm birth can

be reduced through interventions provided to the mother before

or during pregnancy, and to the preterm infant after birth.

 DIAGNOSIS OF PRETERM LABOUR

• Women should be instructed early in their antepartum care to

be vigilant for signs and symptoms of impending PTL.
History:
• Abdominal cramps and back pain(Frequency, intensity,
duration, changes with time)
• Pelvic or lower abdominal pressure
• Changes in type and amount of vaginal discharge (mucus,
bloody or leakage of watery fluid).
• Review history of pregnancy with the woman (estimated date
of delivery , menstrual history, ultrasounds)
 DIAGNOSIS OF PRETERM LABOUR CONT..

• History:
• Review, Medical, surgical, obstetric, Gynecologic, social
history
• Examine the prenatal record for menstrual history, estimated
date of delivery, information from dating ultrasound.
 Physical examination
• Timely physical assessment to confirm(signs of labor and
length of the pregnancy).
• Four uterine contractions per 20 minutes or eight contractions per
60 minutes which are accompanied by one of the following.
 Rupture of membranes

 Cervical dilation greater than 2 cm

 Effacement exceeding 80%

 Confirm Fetal size and presentation

 Determine uterine tone and tenderness, amniotic fluid volume

 Cervical assessment
• Sterile speculum exam initially to rule out preterm pre-labour
rupture of membranes (PPROM) and to obtain cultures, if
indicated.
• Digital examination after prerupture of membranes ruled out
to determine position, dilation and effacement.
 INVESTIGATIONS
• WBC with differential count
• Urine analysis/culture and sensitivity
• Ultrasound (biophysical profile, fetal weight estimation)
 Management of preterm labour
 To ensure appropriate management of PTL, every health
care provider should have the skills to:
1. Identify the cause of PTL and treat the underlying cause,
when possible
2. Attempt to arrest or stop labour when appropriate
3. Intervene to minimize neonatal morbidity and mortality
 Management of preterm labour cont..
Prolongation of pregnancy
• No intervention has been shown to reduce the incidence of
PTB.
• However,tocolysis has been shown to prolong pregnancy for
48 hours or more
• This provides an opportunity for the administration and
absorption of glucocorticoids.
• It also allows for the transportation/ in-utero transfer of the
woman to a setup where there is best possible neonatal care of
the preterm newborn.
 Management of preterm labour cont..

Tocolytics: drugs work to inhibit contractions of uterine

smooth muscle.
• Provide window for administration of antenatal
corticosteroids and/or in-utero fetal transfer to an appropriate
neonatal health care setting.
• Tocolytic therapy is considered when cervical dilatation is less
than 4cm; uterine contraction is fewer than 4-5 within an hour
with no cervical change.
 Management of preterm labour cont..

• Nifedipine is the preferred drug for tocolysis.

• Do not give a combination of tocolytic agents as there is no
additional benefit.
• Tocolytic therapy is considered when:
• Contractions are resulting in a demonstrated cervical change
and cervical dilatation is less than 4 cm.
• Uterine contraction is more than 4-5 within an hour with no
cervical change.
 Management of preterm labour cont..

Contraindications for tocolytics

• Any contraindications to continuing the pregnancy, this
include:
• Preterm prelabor rupture of membranes (PPROM)
• Cervical dilatation >4 cm and effacement >80%.
• Chorioamnionitis
• Ante partum hemorrhage
• Cardiac disease
• Fetal death
• Fetal congenital abnormality not compatible with life
 NIFEDIPINE DOSE

• Loading oral dose of 20 mg followed by 10– 20 mg every 4–8

hours for up to 48 hours.
• Inform the woman to be aware of side effects of Nifedipine
such as headache, flushing, dizziness, tiredness, palpitations
and itching.
• Monitor maternal and fetal condition: pulse, blood pressure,
signs of respiratory distress, uterine contractions, loss of
amniotic fluid or blood, fetal heart rate, fluid balance.
 Neuroprotection
• Administer MgSO4 up to 32 weeks of gestation to prevent
preterm birth-related neurologic complications

• MgSO4 IV 20% 4 gm over 10–15 minutes, followed by IM 5

gm every 4 hours for 24 hours.

• Assess urine output, respiratory rate and deep tendon reflexes

when administering MgSO4.

• Contraindications to MgSO4: Myasthenia gravis, myocardial

damage, impaired renal function.

• Magnesium-sulphate infusions should not be used during

antenatal in-utero transfer.
 Management of preterm labour cont..

Corticosteroids:
• Dexamethasone 6 mg IM BID for 48 hours(four dose) or
• Betamethasone 12 mg every 24 hours for 48 hours(two dose).
• It takes 48 hours after the first dose for the full benefit to be
achieved.
• An incomplete course of steroid therapy may still offer
worthwhile benefits.
 Management of preterm labour cont..
• A single repeat course of antenatal corticosteroid is
recommended if preterm birth does not occur within 7 days
after the initial dose,
• A subsequent clinical assessment demonstrates a high risk of
preterm birth in the next 7 days.
• This recommendation should only be applied if the
gestational age is less than 34 weeks of gestation.
 Mode of delivery

• Discuss the general benefits and risks of caesarean section and

vaginal birth with women in suspected, diagnosed or
established preterm labour,
• Avoid vacuum-assisted birth for pregnancies less than 34
weeks of gestation.
• Prepare for management of preterm or low birth weight baby
and anticipate the need for resuscitation.
 Reading assignment
• Secondary prevention of preterm birth(Cerclage and
Progesterone compounds)
 Summary
 Preterm labour?

 Risk factors of preterm labour?

 Complication preterm labour?

 Diagnosis and treatment of preterm labour?

Thank you for your attention
Questions ?
Comments?