| Description |
Aims: This quality improvement project sought to identify trends in management of pregnant patients with prelabor rupture of membranes (PROM) within a midwifery practice in the intermountain west. Background: PROM occurs in 8-11% of term pregnant women and nearly 95% of women will start to spontaneously labor and deliver by 28 hours. Management methods for PROM include watchful waiting to see if labor starts on its own (expectant management) or using medication to induce labor. Infection risk to both mother and neonate are increased with rupture of membranes especially with factors such as rupture over 24 hours, multiple vaginal exams, and preexisting vaginal infections. The rate of intrauterine infection and inflammation (triple I) amongst PROM patients is 7% increasing to 40% when rupture is over 24 hours. Methods: A retrospective chart review was completed of women who were diagnosed with PROM within this midwifery practice between the dates July 1, 2017 and June 30, 2018. The data collected included length of time ruptured, number of vaginal exams, suspected triple I diagnosis, neonatal intensive care unit (NICU) admission, 5-minute Apgar score less than 7, postpartum endometritis diagnosis, and labor augmentation, if any. Additionally, the patients' parity, method of delivery, GBS status, and antibiotic use during labor was collected for a further in-depth review of the characteristics of patients with PROM. Results of this chart review were then disseminated to the midwifery group in a staff meeting and to allow for feedback on the data presented as well as implication for practice. Results: There were 39 deliveries (25 primiparous and 14 multiparous women) that met criteria for inclusion in this study making the incidence of PROM 7.13 % within this midwifery practice. Delivery methods included 26 vaginal deliveries (66%) and 13 cesarean sections (33%). Expectant management without any augmentation was used with 10 patients (26%) and augmentation was used with 28 patients (72%). Expectant management at home was used in 8 cases, of which two developed triple I and ended with cesarean sections. The number of sterile vaginal exams (SVE) averaged 5.28 per patient with 69% of patients having over 3 SVEs and 41% of patients having a baseline vaginal exam in the triage area. Overall, triple I was suspected in 4 patients (10%), all of which were primiparous women. Conclusions: Triple I rates were slightly elevated overall, but much lower for women who were ruptured over 24 hours compared to national average. Reducing the number of vaginal exams and avoiding a baseline vaginal exam in triage setting are potential goals for this practice. Expectant management at home with primiparous women should be monitored closely; however, more data needs to be collected about expectant management at home overall. |
