Term prelabour rupture of membranes — structured oral station (12 minutes)

Opening prompt — "How do you assess her?"

Model response: [4][5]

• "History first: the exact time of rupture — 5 hours ago, and I would write the clock time in the notes — the colour and volume, fetal movements, whether she feels unwell, and her group B streptococcus status, which she tells me is unknown."
• "Examination: temperature, pulse, blood pressure; abdominal palpation for tenderness, lie, presentation and engagement; then a sterile speculum for pooling in the posterior fornix, liquor colour and smell, cervical appearance and any visible cord. I would take a group B streptococcus swab at the same speculum."
• "I would not do a digital vaginal examination. She is not in labour, and in the TERMPROM predictor analysis the number of digital examinations was the strongest predictor of chorioamnionitis — more than 8 carried an odds ratio of 5.07 compared with 0 to 2."[4]
• "CTG on admission, and I would confirm the gestation from the dating scan."[5]

Examiner is listening for: the time written down, the speculum named first, the digital examination declined with a reason and a number, and the swab taken. [4]

Probe 1 — "She wants to go home and wait. What do you tell her?"

Give her the numbers, not the verdict: [1][2]

• "Most women in your situation go into labour on their own, and waiting is a reasonable choice. In a large study of women who waited, the average time from waters breaking to birth was around 10 to 13 hours, shorter if you have had a baby before."[8]
• "What starting labour now changes is infection. In the biggest trial, an infection in the womb during labour happened in about 4 in 100 women who were induced with the hormone drip, compared with about 9 in 100 who waited. Pooling all the trials, planned early birth roughly halves the chance of infection in the mother and reduces the chance of an infection in the baby."[1][2]
• "It does not make a caesarean more likely — the rates were the same, around 10%."[1][2]
• "And most women in that trial preferred being induced to waiting."[9]
• "So this is genuinely your choice. What I need to sort out first is your group B strep status, because that changes the picture."[3]

Examiner is listening for: numbers in plain language, both options presented, and no coercion. [9]

Probe 2 — "Her group B streptococcus status is unknown. Does that change anything?"

• "Yes. I would take a swab now, but the result will not be back in time to guide the next few hours, so I have to manage on risk factors. Ruptured membranes at term with unknown status is exactly the situation where units differ, and I would follow our local protocol and say which one it is."[6][7]
• "The evidence matters here: a systematic review and meta-analysis found universal culture-based screening associated with lower early-onset group B streptococcal disease than risk-based protocols. So under a risk-based protocol I would have a low threshold for prophylaxis once rupture becomes prolonged or she develops any fever."[7]
• "If she were known positive, my advice would be firmer: induce now with intravenous oxytocin. In the TERMPROM substudy, colonised women had a neonatal infection rate of 2.5% with oxytocin induction and over 8% in every other group."[3]
• "Whatever the status, prophylaxis needs about 4 hours before birth to count as adequate, so I would not want it started at the last minute."[6][5]

Probe 3 — "She still wants to go home. Would you let her, and on what terms?"

Do not simply refuse. Build the safety criteria out loud. [4][6]

• "I would say yes only if all of the following are true: she has a thermometer and knows how to use it; she can check her temperature and pulse at least 4-hourly; she lives close enough to get back quickly and has transport and someone with her; she can tell me back what to watch for; and we have agreed a specific time to review her and a time by which we would induce anyway."
• "The instructions are: no baths, no swimming, no intercourse, and nobody examines her internally. Come straight back for fever, feeling unwell, offensive or discoloured fluid, bleeding, reduced fetal movements or contractions."[4]
• "If she were group B streptococcus positive, or if any of those criteria failed, I would keep her in and explain exactly why."[3][6]

Probe 4 — "She returns at 22 hours. Temperature 38.5 degrees Celsius twice, 30 minutes apart, no obvious source. Fetal heart baseline 170 bpm for 15 minutes. What is this and what do you do?"

• "This is suspected Triple I: a documented fever without a clear source, plus a baseline fetal tachycardia over 160 bpm for 10 minutes or longer. Confirmation would need amniocentesis-proven infection or diagnostic placental pathology, and I do not need either to act."[5]
• "Management: broad-spectrum intravenous antibiotics per local protocol, intravenous access and bloods, continuous fetal monitoring, and expedite the birth by the safest route. Chorioamnionitis itself is not an indication for caesarean."[5]
• "Practical detail: minimise further vaginal examinations, tell the neonatal team, send the placenta for histopathology, and plan for a higher risk of postpartum haemorrhage and endometritis."[4][5]
• "And I would go back to her and explain, kindly, that the plan has changed and why — she chose to wait with good information, and this is not a moment for 'I told you so'."[9]

Probe 5 — "How would you audit your unit's practice in term PROM?"

• "Three measurable things: the proportion of women with a documented time of rupture; the number of digital vaginal examinations before established labour; and the proportion of colonised women who received at least 4 hours of intrapartum prophylaxis before birth."[4][6]
• "Outcome measures: clinical chorioamnionitis, early-onset neonatal sepsis, and neonatal unit admissions after term PROM."[2][7]
• "I would also audit whether women were offered both options and whether that discussion was documented, because that is a consent standard, not a preference."[9]