An analysis of the decisions in the management of premature rupture of the membranes.

Abstract

The management of preterm PROM is a complex problem best approached as a number of simple problems to be solved simultaneously. As new information surfaces, the decisions presented in this article can be reevaluated and a new protocol similar to that in Figure 1 developed. On admission of the patient a fetal monitor is placed and intravenous hydration begun. A complete history and physical examination allow accurate estimation of gestational age and diagnosis of ruptured membranes. Any contraindications to tocolysis can be uncovered at this time. If the patient is a candidate for tocolysis, if there are no signs of chorioamnionitis, if there is no fetal distress, and if no contraindications are occurring, then tocolysis may begin. Betamethasone may then be given, (though its use in PROM is not advised), and surveillance for signs of chorioamnionitis may begin. The patient is seen twice daily for abdominal examination. The white blood count is measured at least daily, and maternal vital signs and fetal heart rate are determined every 4 hours. Once signs of chorioamnionitis occur or labor begins (perhaps again) more than 48 hours after admission, then delivery is allowed. If the presentation is vertex, then vaginal delivery is allowed in the absence of fetal distress. Under any other circumstances, abdominal delivery is accomplished. If PROM occurs outside a hospital equipped with a regional intensive care nursery, and if maternal transport can be safely performed, then the mother is transported to a regional center. No digital cervical examination is to be performed until delivery is inevitable.(ABSTRACT TRUNCATED AT 250 WORDS)