Controversial Issues in Midwifery Practice: Pre Labor Rupture of Membranes - Essay Example

?Running head: THE ROLE OF THE MIDWIFE AND PRELABOUR RUPTURE OF MEMBRANES The Role of the Midwife and Prelabour Rupture of Membranes (37+weeks Critical Analysis [STUDENT NAME] [COURSE NAME] [DATE] Abstract This paper analyses the literature on prelabour rupture of membranes for term pregnancies (37+ weeks). The paper finds that there is a lot of support for induction for women with PROM with very little research support for expectant management as an option. This author found that a lot of the support for induction stems from one large major study conducted in 1996 and questions whether the evidence in the study is enough to influence women to go with an induction if they would prefer to wait for as long as possible for labour to start naturally. The Role of the Midwife and Prelabour Rupture of Membranes (37+weeks): Critical Analysis The premature rupture of membranes (PROM) at term is the rupture of the membranes before labour has commenced at any time after the 37th of gestation. It is estimated that PROM occurs in 10% of normal pregnancies (Hannah, Ohlsson, Farine et al. 1996). The symptoms include leakage of fluid, a vaginal discharge, bleeding from the vagina, and in some cases pressure on the pelvis. These symptoms are combined with the absence of contractions. Although there are a few tests to determine ROM there are some like any blood contamination of Nitrazine paper that can cause a false-positive result (Hannah, Ohlsson, Farine et al. 1996). The most effective determination of ROM is from an internal examination that finds the pooling of fluid in the vaginal cavity, or a leakage of fluids from the cervix. This internal examination can be confirmed with an ultrasound that will show the level of amniotic fluid in the uterus. Hannah (1998) found that PROM could be influenced through a distension of the uterus in women with multiple pregnancies, cigarette smoking, high levels of amniotic fluid, frequent digital examinations, coitus and infections although she noted that there was no certainty that any of these issues were actually a causal element in PROM. PROM has been implicated in immediate risks such as cord prolapse, cord compression and issues with the placenta as well as maternal infection, neonatal infection, increased caesarean sections and the use of instruments in a vaginal delivery (Alexander 1996, Merenstein 1996). Use of expectant management with PROM has been found to increase the incidences of chorioamnionitis or endometritis which in turn can result in neonatal infection, mortality, chronic lung disease and cerebral palsy (Dare et al. 2006). There is some evidence that suggest that there is an increased risk of infections for mother and baby as the time between PROM and the actual labour increases (Gafni 1997) but this has since been refuted by Hannah (1998) and Seaward (1997). Hannah (1999) determined that women appeared to be happy with the birth process and the standard of care if there was a short time between PROM and birth (c.f expectant management). In most cases women will go into labour by themselves within 24 hours of the ruptured membranes. In cases where contractions have not started within that time there is evidence that infections can occur. There are two schools of thought of what should happen in the case when contractions have not started. The first is that labour should be induced using drugs; the other opinion is that expectant management should be allowed to continue. This paper will look at the evidence supporting both sides of the debate before presenting a critical analysis and a discussion on the role of the midwife in this issue. Literature Review: Inducing Labour Most of the available literature on PROM was actually based on pregnancies that were less than term (37 weeks). That topic has its own set of issues and all of those studies were excluded from this review because the focus is on term pregnancies (37+ weeks). Hannah, Ohlsson, Farine et al. (1996) did one of the largest studies on more than 5000 women who had PROM. The women were randomly selected to either have induced labour with intravenous oxytocin or vaginal prostaglandin E2 gel or expectant management for up to 4 days with induction for complications. Their findings indicated that both groups of women showed similar rates of caesarean delivery and/or neonatal infection. They also noted that the induction with oxytocin did result in lower rates of maternal infection than those found in women who used expectant management. It was also reported that the women who were induced had a better attitude about their labour than the women who continued expectant management (Hannah et al. 1996). A later study by Hannah (1998) showed that labour could actually be delayed for up to 7 days after membrane rupture without significant concerns. Hallak (1999) noted that the longer birth was delayed after PROM the higher the increase use in neonatal care, caesarean rates, as well as uses of analgesia and/or anaesthetic. Johnson (1981) conducted a retrospective study and claimed that in any case where there was a delay in birth of more than 72 hours that there was an increased risk in mortality and intrapartum fever in women. Infection is the biggest complication associated with PROM as is evidenced by the number of studies that have been conducted since 2001 about the use of antibiotics in PROM women who chose an expectant management option despite not going into labour within 24 hours of the rupture. Back in 1997 Seaward et al found that the risk of chorioamnionitis in term women was 10% at the time of the rupture, but that the chance of infection increased to 40% after 24 hours. Other authors have cited the concern about infections (including Hannah et al 1996) but the statistical probability of that occurring has not been specifically stated. Literature Review: Expectantly Managed Labour The first thing that was obvious to this author is that the Hannah et al (1996) study dominates most of the subsequent literature and this has made any support for expectant managed labour difficult to find. Dare et al (2006) noted one study that supported expectant management in term PROM cases. Guise (1992) found that induction can result in “increased frequency of chorioamnionitis, neonatal sepsis, caesarean section and longer hospital stays” (Dare et al, 2006, p.11) Hannah et al (2000) found that women with PROM at term, who opted for expectantly management were more likely to have issues with infections (both maternal and in the infant) if the woman managed her pregnancy at home instead of in a hospital situation. However she also noted that there is not a lot of reliable data about women who chose to stay home and wait for birth after PROM and that this was a limitation of her study. The Role of the Midwife It is common practise for pregnant women to make their own decisions on how they want their pregnancy managed and even in the PROM cases the most a midwife can do is to explain the consequences of induced birth versus expectant management. As already noted the Hannah et al (1996) study is responsible for a lot of medical organisations taking the position that women with PROM should be induced within 24 hours if labour does not start naturally with the most common method used being oxytocin (KEMH, 2008). The NHS Clinical Guidelines (2007) state that in the event of a suspected PROM the woman should be examined via speculum. If PROM is confirmed the woman should be advised that: “risk of serious neonatal infection is 1% rather than 0.5% 60% will go into labour within 24 hours Induction of labour is appropriate after 24 hours” (p.14) In cases of PROM after 24 hours induction of labour is recommended along with the proviso that women stay in hospital a minimum of 12 hours after birth so that the baby can be observed (NHS, 2007, p.14). In KEMH(2008) the information is not as biased toward induction although it is still the preferred option. However the guidelines do note that in the cases of confirmed PROM that “the majority of patients with PROM at term will go into labour within the first 48 hours. Therefore, a brief period of expectant management can be considered in this group” (p.3). Then it goes on further down the page to say “the KEMH preferred option at 37 weeks (or greater) is early induction of labour. However, a woman’s informed choice to be treated expectantly should be respected” and it refers to Dare et al. (2006) as the basis for that decision. Critique of Hannah et al (1996) Goer (2011) did a solid critique on the original Hannah et al (1996) study which was published on the Lamaze International website. In it he considered a number of problems with the research design and the outcomes. For example he noted that Hannah et al (1996) didn’t “consider the effect of epidural analgesia on intrapartum fever confounds chorioamnionitis results” (web) and that if they had then the infection rates might have been lower than recorded in all groups. One limitation to the study that made logical sense to this author is that the “chorioamnionitis rates and possibly neonatal infection rates were confounded by multiple digital vaginal exams” (web). Seaward (1997) found that chorioamnionitis increased steadily with the number of digital vaginal exams independent of other variables and this is probably why KEMH and the NHS both noted that digital exams should not be done in PROM cases. Goer (2011) also noted that neonatal infection rates in the Hannah et al (1996) results were impacted by the vaginal exams and multiple digital vaginal exams during the labour process, which could increase the rates of neonatal infection by up to 250%. This finding was supported by Hannah’s 1997 study which showed similar incidences. Goer (2011) also pointed out that the American College of Obstetricians and Gynecologists (ACOG) recommends induction, with oxytocin for PROM term pregnancies. They have made that decision because of the Hannah et al. (1996) study that said that failure to do so would increase the chances of infections febrile morbidity and the need for neonatal antibiotic treatments (ACOG, 2007). Goer (2011) felt that if the risk of infection was a lot less that originally reported that expectant management could still be a viable option for women who preferred that option. What should a midwife do? Midwives have a duty of care to their pregnant women. The NHS (2007) states specifically that pregnant women have a right to be treated with respect and should be in control of what is happening to them throughout pregnancy and the birth process. Aside from the midwives ethical and legislative determination of care, it should also be remembered that women trust the information from their midwives and it is possible this trust could cause women to rethink their original instincts when making decisions about their labour. This is definitely possible in cases where the woman is going through her first pregnancy, or if she is worried about her health and the health of the baby for whatever reason. The potential for that trust to be misused by midwives who have their own opinions on what should happen in a PROM situation is a logical assumption although this author could find nothing more than anecdotal evidence online that would suggest this is a major problem. It is possible that this criticism is like any other in the medical field – there are always some people who are going to feel that they have been wrongly advised whether that situation is true or not. The key to providing unbiased care would appear to be in the way a woman is given information on which she can make her decisions. For example the language in the KEMH (2008) document suggested that there was a bias towards women accepting the option of induction. Specifically “…a brief period of expectant management can be considered in this group. However, as the time between the rupture of membranes and the onset of labour increases, so do the risks of maternal and fetal infection. Induction of labour reduces those risks” (p.3). This is then followed by a lengthy explanation on the benefits of active management including a specific statement “The KEMH preferred option at 37 weeks (or greater) is an early induction of labour” (p.3). The NHS (2007) uses neutral language and doesn’t specify quite so definitively that induction is their preferred option as well for PROM cases but it is mentioned of course. What concerns this author is that the single biggest contribution to a decision made by health boards in London, America and Australia is all based on one study which when comprehensively critiqued as Goer (2011) has done, has issues in the study design and the conclusions found. Even the main author Hannah (1996) has modified her stance in small ways in subsequent studies. Conclusion The research that is available to midwives does suggest that induced labour is a good idea in cases of PROM when the woman concerned is 37+ weeks. Midwives have a duty of care to ensure that the pregnant women in their care are accurately informed of various options throughout the pregnancy but that the final decision wherever possible should rest with the client, not the midwife. Midwives should take care that they recount risks and consequences in a non-biased way. They should answer the questions their clients ask honestly, but they should keep their own agendas out of the process. Women do trust their midwives and that trust alone is an indicator that clients are more likely to be swayed by the midwife’s opinion or even perceived disapproval than in any other circumstances. If you add to that the insecurity that many women have during their pregnancy, especially if it is their first child, it is logical to assume that their reliance on the advice of their midwife is really strong. There is nothing more wonderful to see than a woman who has been in control of her pregnancy from conception to birth. The joy of the moment of birth and the wonder of the mother is something that is uniquely wonderful to anyone who has the honour of witnessing the act. Midwives are in a unique position to enjoy this situation more often than most people and their contribution to the birth process, through the information they share, is a responsibility that should be taken seriously. The key motive for midwives to do their job should be the knowledge that they are, through their own experience and studies, in a position to positively impact the birth process for all of their clients and part of that job is to empower the client to make decisions about the birth process for themselves. References ACOG. (2007). Premature rupture of membranes. Practice Bulletin No. 80. Centers for Disease Control and Prevention. (2002) Prevention of perinatal group B streptococcal disease. MMWR;51(No.RR-11). Alexander J, Cox S. (1996). Clinical course of premature rupture of the membranes. Seminars in Perinatology 20(5), 369–74. Dare, M. R., Middleton, P., Crowther, C. A., Flenady, V. J., & Varatharaju, B. (2006). Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database Syst Rev(1), CD005302. Gafni A, Goeree R, Myhr T, Hannah M, Blackhouse G, Willan A, et al. (1997). Induction of labour versus expectant management for prelabour rupture of membranes at term: an economic evaluation. Canadian Medical Association Journal, 157(11), 1519–25. Goer, H. (2011). When Research is Flawed: Should Labor Be Induced Immediately with Term Prelabor Rupture of Membranes? Lamaze International Website http://www.lamaze.org/Research/WhenResearchisFlawed/TermPROM/tabid/536/Default.aspx (2011) Guise J, Duff P, Christian J. (1992). Management of term patients with premature rupture of membranes and an unfavorable cervix. American Journal of Perinatology, 9(1), 56–60. Hallak M, Bottoms S. (1999). Induction of labour in patients with term premature rupture of membranes. Fetal Diagnosis and Therapy, 14, 128–42. Hannah, M. E., Ohlsson, A., Farine, D., Hewson, S. A., Hodnett, E. D., Myhr, T. L., et al. (1996). Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TermPROM study group. New England Journal of Medicine, 334(16), 1005-1010. Hannah, M.E., Hodnett, E.D., Willan, A., Foster, G.A., Di Cecco, R., Helewa, M. (2000) Prelabor Rupture of the Membranes at Term: Expectant Management at Home or in Hospital? THE TermPROM STUDY GROUP. Obstetrics & Gynecology, 96(4), 533-538 Hannah M. & Seaward G. (1998) Prelabour rupture of membranes at term: the role of induction of labour. Fetal and Maternal Medicine Review, 10, 61–8. Hannah M. (1999). Commentary: managing labor: what do women really want? Birth, 26(2), 97–8. King Edward Memorial Hospital (KEMH). (2088). Clinical Guidelines: Section B: Obstetrics and Midwifery Guidelines. Department of Health, Western Australia Johnson, J.W.C., Daikoku, N.H., Niebyl J.R., Johnson, T.R.B., Khouzami, V.A., & Witter, F.R. (1981). Premature rupture of the membranes and prolonged latency. Journal of the American College of Obstetricians and Gynaecologists, 57(5), 547–56. Merenstein, G, & Weisman L. (1996). Premature rupture of the membranes: neonatal consequences. Seminars in Perinatology, 20(5), 375–80. National Institute for Health and Excellence (NHS). (2007). Intrapartum Care: Care of health women and their babies during childbirth. NICE clinical guideline 55. London: National Collaborating Centre for Women's and Children's Health Seaward, P. G., Hannah, M. E., Myhr, T. L., Farine, D., Ohlsson, A., Wang, E. E., et al. (1997). International multicentre term prelabor rupture of membranes study: Evaluation of predictors of clinical chorioamnionitis and postpartum fever in patients with prelabor rupture of membranes at term. American Journal of Obstetric Gynaecology, 177(5), 1024-1029. Read More