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PROM

PROM AT TERM… Some Evidence

index-14PROM AT TERM… Some Evidence  

written by Jackie Levine

 

Many define PROM as any release of waters before labor has actually begun…. whether at 32 or 42 weeks. There are recommendations about the management of PROM, but there’ is no definitive proclamation from the CDC or anywhere else  about what one “must” do to a woman after a certain number of hours have gone by without some contrax, especially at “term”.  The statistics about PROM pretty much don’t change….around the world the same % of women will go into labor and will birth  after 12-24 hours,  the same % after 48 hours, then 72 hours, etc, with the same low per centage of mothers and babies sustaining infection. 

It seems that the whole establishment is not convinced about exactly how to handle PROM, and the studies continue. You can find  ACOG practice bulletins on this at least since 2000.  The studies don’t all study things the same way….yes to pelvic exams?  No exams?  Expectant management with testing for fever or other signs of infection?  When and how?  Many mothers are really in early early labor, water breaks but there are no discernible contrax, yet the cervix is slowly slowly beginning to change.  Do these women as qualify as PROM and should they be put in the 24-hour queue? Or should they br  “classified” as being in labor, however early, which takes the “P” out of PROM…

The latest info on this is from the Cochrane, 2014. Here’s the “Background” and the “Conclusion”, followed by the citation.  This information may help mothers-to-be to make the  decision about whether to be treated according to routine, cookie-cutter care  that her OB applies to all clients with PROM at term, or to make sure that  a truly genuine  assessment of her  and her baby’s individual, actual health status is made.

BACKGROUND:

Prelabor rupture of the membranes (PROM) at or near term (defined in this review as 36 weeks’ gestation or beyond) increases the risk of infection for the woman and her baby. The routine use of antibiotics for women at the time of term PROM may reduce this risk. However, due to increasing problems with bacterial resistance and the risk of maternal anaphylaxis with antibiotic use, it is important to assess the evidence addressing risks and benefits in order to ensure judicious use of antibiotics. This review was undertaken to assess the balance of risks and benefits to the mother and infant of antibiotic prophylaxis for PROM at or near term.

AUTHORS’ CONCLUSIONS:

This updated review demonstrates no convincing evidence of benefit for mothers or neonates from the routine use of antibiotics for PROM at or near term. We are unable to adequately assess the risk of short- and long-term harms from the use of antibiotics due to the unavailability of data. Given the unmeasured potential adverse effects of antibiotic use, the potential for the development of resistant organisms, and the low risk of maternal infection in the control group, the routine use of antibiotics for PROM at or near term in the absence of confirmed maternal infection should be avoided.

Cochrane Database Syst Rev. 2014 Oct 29;10:CD001807. doi: 10.1002/14651858.CD001807.pub2.Antibiotics for prelabour rupture of membranes at or near term.Wojcieszek AM1Stock OMFlenady V.

Here’s another concise recent piece of information: JUNE 18, 2015/BCAYLEY Summary: For women with pre-labor rupture of membranes occurring after 36 weeks’ gestation (who do not have a confirmed infection), use of antibiotics does not appear to reduce the risks of endometritis, early-onset neonatal sepsis, maternal infectious morbidity, stillbirth, or neonatal mortality; but use of antibiotics in this situation may be associated with increased rates of cesarean delivery and maternal length of stay in hospital, and potentially could be associated with adverse medication side effects from antibiotic use and the potential for the development of resistant organisms. (In other words, avoiding antibiotic use for prelabor rupture of membranes after 36 weeks’ gestation unless there is a confirmed maternal infection, may be associated with lower risks adverse antibiotic effects, lower rates of cesarean delivery, and shorter maternal stay in hospital; without increasing the risks of any neonatal or maternal morbidity or mortality.)

http://www.ncbi.nlm.nih.gov/m/pubmed/25352443/

 

 

Thank you, Jackie! You know I, Triad Birth Doula, always enjoy sharing your articles.
Interesting thing…in my experience here in NC, I have only had antibiotics offered once for PROM, which mother refused much to the doctor’s distress.
I have had a couple of mothers become sick after 24+ hours and were then given antibiotics as soon as fever appeared. But no wonder with all of the vaginal exams, catheter and internal monitor due to pitocin & epidural.
I have a theory about avoiding PROM….
Around here, and with my clients, I feel that a sudden drop of barometric pressure is all too often the culprit of PROM. So I suggest that when we know this type of weather is going to occur, drink extra water and if safe get in bath tub. If not safe (lightening) lie down so at least gravity is taken out of the picture.
Some may laugh at me but I believe in this.

 

 

 

Premature Rupture of Membranes (PROM)

severe-ne-5jun16

We, of the NC Triad, may just get some severe weather this evening, along with the rest of the east coast.

Why do I mention this?
Because rapidly falling barometric pressure could potentially break your bag of fluids if you are close to 40 weeks.

If your baby and your body are not ready for labor, this is called Premature Rupture of Membranes (PROM).

And this sets you up for a difficult and long labor.
So??? What to do???
I suggest drink, drink, drink that water.
If it is not dangerous, get into water where the pressure can be equalized.
At very least, lie down so that you are taking gravity out of the picture.

And if your water breaks…then you take it one step at the time.

This is a great article about PROM from Rebecca Dekker of Evidence Based Birth

http://evidencebasedbirth.com/evidence-inducing-labor-water-breaks-term/

 

 

 

Premature Rupture of Membranes & Repeated Pelvic Examines

Jacqueline Levine, a sister doula and occasional writer for  Lamaze research blog Science and Sensibility, gracefully gave me permission to post her comments about premature rupture of membranes… or PROM.

Very eye opening!!!

Hello all…There are some studies that point to the fact that repeated pelvic exams in the last month can irritate the membranes and lead to PROM at term (premature rupture of membranes), meaning labor is immanent, and mothers are close to their “due date”, but pelvic exams insert an artificial factor into the circumstances that lead to the healthy beginning of effective labor. Onset of labor may be just a few weeks or days away, but if waters break and labor doesn’t ensue, although mom is almost-but-not-quite ready, they must induce. Pelvic exams are not predictive or probative and unless there is compelling medical reason, should not be done week after week at the end of the last month. Being able to say to a mom that her cervix is softening but still not opening is nice, or to tell her that she is 50% and 1 cm is interesting indeed, but what really does it do for the process? Does it tell her when she’ll go into labor? Not bloody likely! If enough acid in the vagina is pushed to migrate upwards, or mother’s flora (or yikes! foreign germs from the glove covering the inserted hand) are forced up towards, and finally permeate the mucous plug to irritate and eventually disturb the integrity of membranes, they will respond by breaking. Now we have put another whole category of mothers onto the c-section express.

Here are some studies:
* Obstet Gynecol. 1984 Jan;63(1):33-7. Relationship of antepartum pelvic examinations to premature rupture of the membranes.

Lenihan JP Jr*
* Obstet Gynecol. 1987 Dec;70(6):856-60. Histologic chorioamnionitis in pregnancies of various gestational ages: implications in rupture of membranes.Perkins RP, Zhou SM, Butler C, Skipper BJ. SourceDepartment of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque.

* vaginosis and its implication in preterm labor and premature rupture of membranes. A review of the literature. Reynolds HD. Source Yale University School of Nursing, New Haven, CT

There are more studies. This knowledge has been around for a while. When, d’ya suppose, will caregivers heed some evidence-based stuff? Here’s the answer, I guess:

* Do the Medical Policymakers of Maternity Care Resist Changing Their Protocols to Reflect Best-Evidence Scientific Practices for Childbearing Women?

Olatunbosun OA, Eduoard L, Pierson RA. Physicians’ attitudes toward evidence based obstetric practice: a questionnaire survey. Br. Med. J. 316, 365–366 (1998).*
Abstract: In 1998, a questionnaire mailed to family physicians and obstetricians found that only 40% felt that evidence-based medicine was “very applicable to obstetric practice”. Concerning comments from this survey included “obstetrics requires manual dexterity more than science”, “evidence-based medicine ignores clinical experience”, and that following guidelines could result in “erosion of physician autonomy”. These views were described as obstacles to the adoption of evidence-based practices, and the authors recommended emphasis of critical analysis of the literature as part of medical education.”

Let’s let our mothers know about this and Bishop scores and give them the facts so that they can refuse pelvic exams and other procedures except for compelling medical necessity, and wait to get exams until they are well into labor and need to know whether they should be admitted!! There…I’ve said it!!!

Thank you, Jacqueline!!!

If you wish to weigh in….send your comments to

KennyShulman@aol.com