O&G SAQs · Intrapartum care — labour and birth
Term prelabour rupture of membranes — structured SAQ (15 marks)
FRANZCOG-format structured SAQ on term PROM in a group B streptococcus positive nulliparous woman: sterile speculum assessment and the quantified harm of digital examination, the TERMPROM and Cochrane numbers for the counselling conversation, intrapartum antibiotic prophylaxis with doses and the 4-hour target, and applying the NICHD Triple I criteria. Per-sub-part marking rubric included.
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FRANZCOGMRCOGABOG
Prompt
A 27-year-old G1 at 39+3 weeks presents at 07:00 having had a gush of clear fluid at 04:00 with continued leaking. She is not contracting. Observations: temperature 36.8 degrees Celsius, HR 82 bpm, BP 116/72 mmHg. The uterus is soft and non-tender, the presenting part is cephalic and 3/5 palpable, and the CTG is normal. Her group B streptococcus swab at 36 weeks was positive. (a) Describe your initial assessment, naming one examination you would avoid and quantifying the harm it causes. (4 marks) (b) She asks whether she should be induced or wait. Summarise the evidence you would give her, with numbers. (4 marks) (c) State how her group B streptococcus result changes your plan, and write the intrapartum antibiotic prescription. (4 marks) (d) At 16:00 her temperature is 38.4 degrees Celsius on two readings 30 minutes apart with no obvious source and the fetal heart baseline is 168 bpm. Classify and manage. (3 marks)
How this SAQ is marked
Twelve SAQs, 180 marks, two 2-hour papers — roughly 15 marks and 20 minutes each. This question is graded on three things: the discipline of your examination, the numbers you can hand a woman, and a correct antibiotic prescription. Bullet points with figures beat paragraphs without them.[1][4]
Reveal model answer and mark schemeShowHide
(a) Initial assessment and the examination to avoid (4 marks)
One mark for history, one for maternal and fetal assessment, one for the sterile speculum with what you look for, one for naming and quantifying the avoided examination. [4][9]
- History: exact time of rupture (04:00 — write it in the notes), colour and volume of fluid, fetal movements, group B streptococcus status, gestation confirmed from the dating scan, and any fever or recent illness.[9]
- Maternal assessment: temperature, pulse, blood pressure, respiratory rate; abdominal palpation for tenderness, lie, presentation and engagement.[5]
- Sterile speculum: pooling in the posterior fornix, liquor colour and smell, cervical appearance, and exclusion of a visible cord. This is the diagnostic examination. If pooling is equivocal, use IGFBP-1 or PAMG-1, remembering false positives with blood, semen and infection.[9]
- Fetal assessment: CTG on admission and a plan for ongoing fetal movement awareness.[4]
- Avoid the digital vaginal examination until labour is established or induction begins. In the TERMPROM predictor analysis, compared with 0 to 2 examinations the odds ratio for clinical chorioamnionitis was 2.06 for 3 to 4, 2.62 for 5 to 6, 3.80 for 7 to 8 and 5.07 for more than 8.[4]
(b) The evidence for the conversation (4 marks)
One mark per correctly quoted comparison, maximum four. Marks are lost for "induction is better" without figures. [1][2]
| Outcome | What the evidence shows |
|---|---|
| Clinical chorioamnionitis | 4.0% with oxytocin induction versus 8.6% with expectant management in TERMPROM (P less than 0.001) |
| Postpartum fever | 1.9% versus 3.6% (P = 0.008) |
| Neonatal infection | Not significantly different across the four TERMPROM groups (2.0% to 3.0%) |
| Caesarean section | Not significantly different, 9.6% to 10.9%; Cochrane average risk ratio 0.84 (95% CI 0.69 to 1.04) |
| Maternal infectious morbidity (Cochrane) | Average risk ratio 0.49 (95% CI 0.33 to 0.72) favouring planned early birth |
| Early-onset neonatal sepsis, definite or probable (Cochrane) | Risk ratio 0.73 (95% CI 0.58 to 0.92) |
| Rupture-to-birth interval | 10.1 hours shorter with planned early birth |
Close with the acceptability point: women in TERMPROM viewed induction more positively than expectant management, and the companion analysis of women's evaluations supports that.[5][8]
(c) Group B streptococcus — what changes and the prescription (4 marks)
Two marks for correctly stating the change in plan with a justification, two for a correct prescription including the 4-hour target. [3][6]
- The plan changes to prompt induction with intravenous oxytocin. In the TERMPROM substudy of 4834 swabbed women, colonisation predicted neonatal infection in the prostaglandin and expectant groups but not in the oxytocin induction group: among colonised women, neonatal infection was 2.5% with oxytocin induction and over 8% in all other groups.[3]
- Home expectant management is off the table, because intrapartum antibiotic prophylaxis must be running well before the birth.[6]
| Element | Prescription |
|---|---|
| First line | Penicillin G 5 million units intravenously as a loading dose, then 2.5 to 3.0 million units every 4 hours until birth (ANZ gram equivalent: benzylpenicillin 3 g then 1.8 g every 4 hours) |
| Alternative | Ampicillin 2 g intravenously loading, then 1 g every 4 hours until birth |
| Penicillin allergy, low anaphylaxis risk | Cefazolin 2 g intravenously loading, then 1 g every 8 hours |
| Penicillin allergy, high anaphylaxis risk, susceptible isolate | Clindamycin 900 mg intravenously every 8 hours |
| Target | At least 4 hours of penicillin, ampicillin or cefazolin before birth counts as adequate prophylaxis |
(d) The 16:00 deterioration (3 marks)
One mark for the classification, one for naming the criteria met, one for the management. [5]
- Classification: suspected Triple I (intrauterine inflammation or infection or both). She has a documented fever — 38.4 degrees Celsius repeated after 30 minutes and still at or above 38.0 degrees Celsius — without a clear source, plus a baseline fetal tachycardia over 160 bpm.[5]
- Say what would make it "confirmed": amniocentesis-proven infection (positive Gram stain, low amniotic fluid glucose or positive culture) or placental histopathology diagnostic of infection. Neither is required to act.[5]
- Management: start broad-spectrum intravenous antibiotics per local protocol in addition to the group B streptococcus prophylaxis already running, continue continuous fetal monitoring, and expedite the birth by the safest route. Chorioamnionitis is not itself an indication for caesarean. Inform the neonatal team, minimise further vaginal examinations, send the placenta for histopathology, and debrief her afterwards.[5][9]
References9ShowHide
- [1]Hannah ME, Ohlsson A, Farine D, Hewson SA, Hodnett ED, et al. Induction of labor compared with expectant management for prelabor rupture of the membranes at term N Engl J Med, 1996.PMID 8598837
- [2]Middleton P, Shepherd E, Flenady V, McBain RD, Crowther CA Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more) Cochrane Database Syst Rev, 2017.PMID 28050900
- [3]Hannah ME, Ohlsson A, Wang EE, Matlow A, Foster GA, et al. Maternal colonization with group B Streptococcus and prelabor rupture of membranes at term: the role of induction of labor Am J Obstet Gynecol, 1997.PMID 9369819
- [4]Seaward PG, Hannah ME, Myhr TL, Farine D, Ohlsson A, et al. 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 Am J Obstet Gynecol, 1997.PMID 9396886
- [5]Higgins RD, Saade G, Polin RA, Grobman WA, Buhimschi IA, et al. Evaluation and Management of Women and Newborns With a Maternal Diagnosis of Chorioamnionitis: Summary of a Workshop Obstet Gynecol, 2016.PMID 26855098
- [6]Verani JR, McGee L, Schrag SJ Prevention of perinatal group B streptococcal disease--revised guidelines from CDC, 2010 MMWR Recomm Rep, 2010.PMID 21088663
- [7]American College of Obstetricians and Gynecologists Prevention of Group B Streptococcal Early-Onset Disease in Newborns: ACOG Committee Opinion, Number 797 Obstet Gynecol, 2020.PMID 31977795
- [8]Hodnett ED, Hannah ME, Weston JA, Ohlsson A, Myhr TL, et al. Women's evaluations of induction of labor versus expectant management for prelabor rupture of the membranes at term Birth, 1997.PMID 9460311
- [9]American College of Obstetricians and Gynecologists Prelabor Rupture of Membranes: ACOG Practice Bulletin, Number 217 Obstet Gynecol, 2020.PMID 32080050