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Friday, August 5, 2011

sleep and PROM - prelabour rupture of membranes

Sleep is elusive.


I want it, but it doesn't come. too many thoughts running through my head.


it has been a productive day. a sad day. a day filled with seeing lovely people, a nap and a good amount of school work. i should be sleeping.


i'm thinking a lot about PROM. no. not that american tradition i am still trying to understand (is it only important in  your senior year, or every year?), but premature/prelabour rupture of membranes.


i've been reading the washington state guidelines and i'm exited to see that there are three levels of considerations a midwife has.


1. discussion
2. consultation
3. transport


in regards to PROM, in AZ midwives must have active labour within 24hrs. this is pretty limiting to say the least and is more in line with the obstetric model, though better to an extent than what is offered in hospitals.


i've been reading a lot on PROM and i have no idea where AZ got their information from, but they may want to get with the times. in 1996, 1996 the TermPROM study was published. in this study women were allowed to labour for up to 96 hours. FOUR DAYS!!! in a HOSPITAL. granted all the data comes from outside of the USA, but still. i am simply amazed at this.


they did find there was an increase in neonatal and maternal infection the longer birth occurred after ROM, but this was more a factor of GBS status and the number of vaginal exams that occurred...not ROM itself. also the only significant finding in regards to the latency period after ROM was the frequency of neonatal admittance into the NICU unit...and this was based on hospital protocol, not on an increased occurrence of neonatal sepsis or other infections. 


----


so back to washington, reading their guidelines, midwives must have a "discussion" at 48 hours and transport at 72 hours.


i haven't figured out what "discussion" means, i.e. with the client or physician, but the fact that women are allowed to actually go into labour naturally is fantastic. by 72hours most women will be in labour (i'll write a more detailed post on PROM later). with these guidelines, midwives and mothers don't need to be worried about a clock.


all this though brings up questions.

  1. at what point should a midwife start monitoring clients- with ROM or active labour?
  2. do we put mothers and babies at risk if left unmonitored (expect for mothers taking their own temperatures) or is it better to leave things alone and wait for active labour?
  3. what affect does a midwife and clinical monitoring have on the labour process?
  4. at what point should we consider home inductions/augmentations of labour, and what are the best methods?
  5. do midwives (CPM) or should they have access to prostaglandin gels to help ripen an unfavaourable cervix?

anyways...it's things like these that keep me awake.
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2 comments:

  1. Louisa WalesAugust 5, 2011 at 8:46 AM

    A discussion is a conversation with a doc. ACOG's word, not ours. I'll have to dig out the ACOG statement on discussion/consultation. A consult is when we actually send records in to the doc and the client has a meeting with them. This is often en route to outright transfer of care. Hope that's a bit more enlightening. Often discussion is simply the doc saying "not comfortable discussing this" and in the context of PROM "Bring her in and we'll start and induction". This recommendation is charted, then discussed with the client, and may, or may not be acted upon.

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  2. labrador teaAugust 5, 2011 at 9:24 AM

    ack. i was really hoping that the relationship was more friendly there. i was trying to convince myself it was at least.

    I'm pretty sure i have never seen the term "discussion" used for AZ, it is either consult or transfer, which intrapartumly are synonymous. In regards to PROM at least, in WA women are given a good opportunity to go into labour without being messed around with, before even a discussion is required.

    thanks for the info.

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