Examination:

• Taking vital signs
  • BP – gestational hypertension or pre-eclampsia (PET) can develop in any stage of pregnancy after 20 weeks’ gestation
  • Pulse rate, respiratory rate, O2 saturations
• Palpate the abdomen
  • Determine fetal presentation
  • Measures fundal height – is it appropriate for gestational age?
• CTG – an indicator of fetal wellbeing
  • From 26 weeks’ gestation onwards, this should be standard
  • At less than 26 weeks it wouldn’t be a standard practice to put a CTG on, unless the patient was in labour. A fetal heart rate auscultation is usually sufficient
  • Every department will have a different policy on when to use a CTG
• Urine dipstick test, assessing for protein, leucocytes, nitrates or suggestion of infection
• Speculum examination
  • Place patient into a comfortable position with ankles together and knees out to the side
  • Ensure you have adequate visualization of the cervix
  • Note whether there is any fluid leaking out through the vagina, particularly coming through the cervix
  • Is the cervix open or closed? Multiparous women may have a cervix that appears to be open but this may just be due to a parous cervix
  • Ask the patient to bear down (Valsalva maneuver) to see whether there is any fluid coming out of the cervix

• Preterm labour
  • Delivery before 37 weeks’ gestation
  • Risks to the baby – lower birth weight, issues with breathing on delivery, low blood sugars, increased risks of jaundice
  • Most of these babies will spend a few weeks in the nursery for support
  • The risks of preterm labour correlate to the gestational age in terms of outcomes
• Chorioamnionitis
  • Infection of the placenta and the amniotic fluid
  • Places the fetus and mother at increased risk of sepsis
• Because of these two risk factors we admit patients to the wards and they will usually stay in hospital until they deliver
• Some women who have PPROM early in their pregnancy may end up on an outpatient management basis if the hospital offers that

• Antibiotics
  • This is shown to reduce the risk of chorioamnionitis
  • In the ORACLE I study (see References below), erythromycin was shown to prolong pregnancy, although long term follow-up showed no significant difference to children’s health and development in the long term
  • In patients that are known to be Group B Streptococcus (GBS) negative, or there is access to immediate testing, erythromycin alone can be given at a dose of 250mg QID
  • Where GBS status is unknown, eTG recommends 48 hours of IV ampicillin until the GBS is excluded
  • If GBS positive the patient should receive at least 7 days thereafter of oral amoxicillin and erythromycin
  • Augmentin should be avoided as in the ORACLE study, this was associated with an increased risk of necrotising enterocolitis
• High vaginal swab (during speculum exam) and low vaginal swab – sent for MC&S
  • It may be helpful in the extreme preterm cohort, to run additional tests for ureaplasma and mycoplasma
• Pad chart to monitor the volume of losses, any change in the colour of the fluid suggestive of infection
• Monitor for signs of chorioamnionitis
  • Pulse rate, respiratory rate – q4hrly observations (temperature) and maternal tachycardia
  • Change in the colour of the PV loss
  • Abdominal tenderness
  • Fetal tachycardia on CTG
• Daily CTG
• Ultrasounds every 1-2 weeks
• Routine bloods – FBC and CRP twice weekly – although a diagnosis of chorioamnionitis is clinical, a sudden rise in the white cell count or CRP can be suggestive of early infection
• Timing of delivery is controversial
  • Determine if there is any immediate concerns for the fetal or maternal wellbeing
  • In the absence of any signs of chorioamnionitis, a normal CTG and a well grown baby, then most centres would advocate to get to 36-37 weeks’ gestation in this particular setting
  • The average length of baby staying in utero in the setting of PPROM is around 9 days
  • If aiming for delivery at 37 weeks’, there is no strong evidence for steroids for fetal lung maturation
  • If less than 34 weeks’ gestation, steroids should be administered in the setting of PPROM
• If an inpatient for a long time, don’t forget routine care such as 75g OGTT, vaccinations and anti-D if Rhesus negative

• Amnisure – bedside immunoassay which detects fetal glycoprotein, placental alpha macroglobulin-1 (PAMG-1) which is highly concentrated in amniotic fluid. A sterile swab is taken during a speculum exam which takes 5 minutes to run
• Amnicator – A nitrazine-based test, which is a sensitive pH indicator. It looks like a cotton bud and is placed in the posterior fornix during the speculum exam. An immediate colour change from orange to black will be seen if the pH is > 6.4 (usually the vagina has a pH of < 6.0), suggesting the presence of amniotic fluid. It will also change colour if it’s placed on a wet sanitary pad where amniotic fluid is present
• ActimPROM – A test which detects the presence of insulin-like growth factor binding protein-1 (IGFBP-1) in the vagina through specific monoclonal antibodies. Like PAMG-1 in the Amnisure, IGFBP-1 is present in the amniotic fluid in high amounts
• Some of these tests cannot be used if there is a history of bleeding (blood undermines test result) or recent intercourse
• Beware of the false positive test result – this commits the patient to an inpatient stay until delivery
• Oligohydramnios or low amniotic fluid index (AFI) compared to recent scans may also be suggestive of ruptured membranes

• In the absence of infection or fetal or maternal distress, aim for delivery at 37 weeks’ gestation
• The average duration of pregnancy post PPROM is around 9 days
• Timing of delivery is based on the balance between maternal and fetal wellbeing and will depend on the degree of prematurity – you may have a higher threshold for delivery if the baby is 25 weeks’ as opposed to 35 weeks’ gestation

• In the setting of PPROM, this usually means bringing on the labour through artificial means where it hasn’t started spontaneously by itself
• Syntocinon is a synthetic version of oxytocin which the body produces naturally to cause uterine contractions. It is titrated with an aim of about 4 contractions every ten minutes (4:10)
• When an induction is required for other issues e.g post-dates, hypertension, fetal growth restriction etc. there are other methods
• Cervical ripening is when we prime the cervix aiming to soften and dilate it up to a point of around 2-3cm dilated before performing an artificial rupture of membranes (ARM)
• Cervical ripening can be performed with prostaglandins such as with Cervidil which a pessary on a string and is placed into the vagina and can be left in for 12 hours, or prostaglandin gel
• There are also mechanical means of ripening the cervix – Cooks catheter, Foleys catheter, where water is injected into a balloon that dilates the cervix
• Consider what the indication is for IOL – if IUGR, cautious use of prostaglandin (not reversible) as hyperstimulation from the prostaglandin may cause fetal distress. Mechanical means alone may be considered.
• Once an ARM is performed, an Oxytocin infusion can be commenced to bring on contractions

• Go back to basics – take vital signs
• Commence a CTG to assess for regular uterine contraction and evidence of fetal distress
• Digital vaginal examinations have increased risk of infections
• Preference initially is to do a speculum examination (may see fetal head) although this cannot determine exact dilatation
• If the cervix appears open, perform a vaginal examination – if the patient is 3-4 cm dilated or more and /or contracting regularly transfer to Birth Unit ASAP provided vaginal delivery is appropriate. If a LSCS is required then transfer to theatre.
• IVC insertion and bloods (FBC, CRP and Group & Hold)
• Commence continuous electronic fetal monitoring (CTG) because they are preterm with PPROM
• Analgesia will depend on the maternal request – nitrous gas, epidural block (however women in preterm labour may deliver quickly, limiting time for an epidural block). Avoid morphine (increased risk of respiratory depression in the preterm baby and risk of precipitous delivery)
• Notify paediatrics – to be in attendance at the time of delivery

• This is an obstetric emergency
• Get help – notify your registrar and call an obstetric emergency
• Review the CTG to establish the duration of the drop in the heart rate – deceleration or bradycardia?
  • As an SRMO, interpreting CTGs is something you need to start learning
  • A deceleration is defined as a drop in the fetal heart rate of at least 15bpm for at least 15 seconds. These are common in labour and associated with contractions
  • If there is a deceleration, observe its correlation to the contractions – whether it is early, variable or late
  • A bradycardia is a drop in the fetal heart rate is below 100bpm for more than 5 minutes
  • A bradycardia isn’t an uncommon occurrence following an epidural block citing
  • Often there may be a drop in the blood pressure of a patient after receiving an epidural
  • Immediate management: left lateral position to reduce aorto-caval compression, measure the patients BP, give an IV fluid bolus
  • If hypotensive this can be due to sympathetic blockade and can be treated with an IV fluid bolus or may require ephedrine
• If requiring ephedrine, have the anesthetic doctor in the room
• Repeat vaginal examination – the baby could be sitting on the perineum, about to be born which explains the bradycardia
• If the patient has an oxytocin infusion running, stop the oxytocin drip until the CTG has improved and then you can restart

• A postpartum haemorrhage (PPH) is an obstetric emergency
• Call an emergency. Make sure your registrar or consultant is aware
• Examine the patient with a DRSABCD approach
• Ascertain a brief history from the midwife
• Confirm the volume of blood loss
• Estimate volume already lost (ask midwife to weigh blueys and sponges) and establish whether the blood loss is ongoing
• Assess background risk factors for causes of PPH such as fibroid uterus, a coagulopathy, multiparity or a previous PPH
• Determine if active third stage management of labour has been performed. If not, give 10 units of oxytocin IM
• Examination
• Determine if the placenta is in situ – if it has been delivered, was it intact or did it have ragged membranes?
• IVC in situ – ensure the patient has got an active Group & Hold. If they haven’t, and don’t have a cannula ready, put in two 16-gauge cannulas and send off an urgent FBC, group and hold, and a coagulation profile if the blood loss is over a litre
• Examine uterine tone. Massage the uterus and expel any clots. If you’re waiting for help to come and the bleeding is severe, start bimanual uterine compression
• Insert an indwelling catheter to aid contraction of the uterus. This will also help with fluid balance monitoring
• Examine for genital tract trauma. Apply pressure and suture to stop the bleeding
• If the uterus is atonic:
• Commence an oxytocin infusion – 40 units of oxytocin in 1 litre of Hartman’s or normal saline solution, delivering 10 units of oxytocin per hour (250mL/hr)
• Tranexamic acid 1g stat – an antifibrinolytic which has been shown to reduce mortality and morbidity from postpartum haemorrhage as per the WOMAN trial (see References below)
• Consider ergometrine – 250micrograms IM for the initial dose and theoretically, can give up to 1 milligram total in sequential doses, but in clinical practice never give more than 500 micrograms total. If administering intravenously, give as a slow push and monitor for cardiac effects
• Hypertension is a contraindication for ergometrine. Avoid in certain cardiac conditions.
• Rectal misoprostol – 800 to 1000 micrograms
• If still not controlled:
• Go to operating theatre (OT)
• Call the anaesthetic team
• Consent the patient for examination and exploration under anaesthesia
• In OT
  • Check inside the uterus to make sure there is no placental tissue or membranes, exclude cervical tears, and repair any genital tract trauma
  • May need a Bakri balloon which helps to tamponade the bleeding
  • If those measures aren’t successful, we may need to perform a laparotomy for B-lynch sutures, ligation of the uterine arteries or internal iliac arteries or, as the last resort, hysterectomy
  • May need to get interventional radiology involved
• Once resolved, monitor the patient’s haemodynamic status, ensure adequately fluid replaced with crystalloid plus or minus blood and other clotting factors if needed
• Repeat bloods 4-6 hours later depending on the volume of loss and the patient’s haemodynamic status

• Things can change in obstetrics in the blink of an eye
• Keep on your toes, stay alert and make sure you always go back and assess your patients methodically

Kenyon SL, Taylor DJ, Tarnow-Mordi W. Broad-spectrum antibiotics for preterm, prelabour rupture of fetal membranes: the ORACLE I randomised trial. The Lancet. 2001 Mar 31;357(9261):979-88.

Shakur H, Roberts I, Fawole B, Chaudhri R, El-Sheikh M, Akintan A, Qureshi Z, Kidanto H, Vwalika B, Abdulkadir A, Etuk S. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. The Lancet. 2017 May 27;389(10084):2105-16.