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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 

 


Section 2 - Symptoms


Prelabour rupture of membranes

PROBLEM

  • Watery vaginal discharge after 22 weeks gestation.

GENERAL MANAGEMENT

  • Confirm accuracy of calculated gestational age, if possible.

  • Use a high-level disinfected speculum to assess vaginal discharge (amount, colour, odour) and exclude urinary incontinence. 

If the woman complains of bleeding in later pregnancy (after 22 weeks), do not do a digital vaginal examination. 

DIAGNOSIS

Table S-20 

Diagnosis of vaginal discharge

Presenting Symptom and Other Symptoms and Signs Typically Present

Symptoms and Signs Sometimes Present

Probable Diagnosis

• Watery vaginal discharge

• Sudden gush or intermittent leaking of fluid

• Fluid seen at introitus

• No contractions within 1 hour

Prelabour rupture of membranes

• Foul-smelling watery vaginal discharge after 22 weeks

• Fever/chills

• Abdominal pain

• History of loss of fluid

• Tender uterus

• Rapid fetal heart rate

• Lighta vaginal bleeding

Amnionitis

• Foul-smelling vaginal discharge

• No history of loss of fluid

• Itching 

• Frothy/curdish discharge

• Abdominal pain

• Dysuria

Vaginitis/cervicitisb

• Bloody vaginal discharge

• Abdominal pain

• Loss of fetal movements
• Heavy, prolonged vaginal bleeding

Antepartum haemorrhage

• Blood-stained mucus or watery vaginal discharge (show)

• Cervical dilatation and effacement

• Contractions

Possible term labour or

Possible preterm labour

a Light bleeding: takes longer than 5 minutes for a clean pad or cloth to be soaked.

b Determine cause and treat accordingly.

 

MANAGEMENT

PRELABOUR RUPTURE OF MEMBRANES

Prelabour rupture of membranes (PROM) is rupture of the membranes before labour has begun. PROM can occur either when the fetus is immature (preterm or before 37 weeks) or when it is mature (term).

 

CONFIRMING THE DIAGNOSIS

The typical odour of amniotic fluid confirms the diagnosis. 

If membrane rupture is not recent or when leakage is gradual, confirming the diagnosis may be difficult:

  • Place a vaginal pad over the vulva and examine it an hour later visually and by odour.

  • Use a high-level disinfected speculum for vaginal examination:

- Fluid may be seen coming from the cervix or forming a pool in the posterior fornix;

- Ask the woman to cough; this may cause a gush of fluid.

Do not perform a digital vaginal examination as it does not help establish the diagnosis and can introduce infection. 

• If available, do tests:

- The nitrazine test depends upon the fact that vaginal secretions and urine are acidic while amniotic fluid is alkaline. Hold a piece of nitrazine paper in a haemostat and touch it against the fluid pooled on the speculum blade. A change from yellow to blue indicates alkalinity (presence of amniotic fluid). Blood and some vaginal infections give false positive results;

- For the ferning test, spread some fluid on a slide and let it dry. Examine it with a microscope. Amniotic fluid crystallizes and may leave a fern-leaf pattern. False negatives are frequent.

MANAGEMENT

  • If there is vaginal bleeding with intermittent or constant abdominal pain, suspect abruptio placentae.

  • If there are signs of infection (fever, foul-smelling vaginal discharge), give antibiotics as for amnionitis.

  • If there are no signs of infection and the pregnancy is less than 37 weeks (when fetal lungs are more likely to be immature):

- Give antibiotics to reduce maternal and neonatal infective morbidity and to delay delivery:

- erythromycin base 250 mg by mouth three times per day for 7 days;

- PLUS amoxicillin 500 mg by mouth three times per day for 7 days;

- Consider transfer to the most appropriate service for care of the newborn, if possible;

- Give corticosteroids to the mother to improve fetal lung maturity:

- betamethasone 12 mg IM, two doses 12 hours apart; 

- OR dexamethasone 6 mg IM, four doses 6 hours apart.

Note: Corticosteroids should not be used in the presence of frank infection. 

- Deliver at 37 weeks;

- If there are palpable contractions and blood-stained mucus discharge, suspect preterm labour

  • If there are no signs of infection and the pregnancy is 37 weeks or more:

- If the membranes have been ruptured for more than 18 hours, give prophylactic antibiotics in order to help reduce Group B streptococcus infection in the neonate:

- ampicillin 2 g IV every 6 hours;

- OR penicillin G 2 million units IV every 6 hours until delivery;

- If there are no signs of infection after delivery, discontinue antibiotics.

- Assess the cervix:

- If the cervix is favourable (soft, thin, partly dilated), induce labour using oxytocin;

- If the cervix is unfavourable (firm, thick, closed), ripen the cervix using prostaglandins and infuse oxytocin or deliver by caesarean section.

 

AMNIONITIS

- ampicillin 2 g IV every 6 hours;

- PLUS gentamicin 5 mg/kg body weight IV every 24 hours;

- If the woman delivers vaginally, discontinue antibiotics postpartum;

- If the woman has a caesarean section, continue antibiotics and give metronidazole 500 mg IV every 8 hours until the woman is fever-free for 48 hours.

- If the cervix is favourable (soft, thin, partly dilated), induce labour using oxytocin.

- If the cervix is unfavourable (firm, thick, closed), ripen the cervix using prostaglandins and infuse oxytocin or deliver by caesarean section.

Top of page

 

Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support

Emergencies

General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages

Symptoms

Shock

Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems

Procedures

Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia

Ketamine

External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section

Symphysontomy

Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy

Episiotomy

Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy

Appendix

 

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