NG-376

💧 Ruptured membranes, induction & operative birth

PROM and AROM, what oxytocin can do to a uterus, and the difference between forceps and a vacuum — including which newborn injury goes with which.

🚨 The one idea

The moment the membranes rupture — however they rupture — the first thing you assess is the fetal heart rate. Not the fluid, not the clock. Fetal heart rate first.

The cord can wash down with the fluid. A sudden deep variable or prolonged deceleration right after rupture is cord prolapse until proven otherwise.

💧 PROM, PPROM, SROM, AROM — four words, two questions

Every one of these terms answers only two questions: did labor start yet, and how many weeks is she.

Term	What it means	Why it matters
SROM	Spontaneous rupture — it broke on its own	Normal in labor
AROM	Artificial rupture — the provider does it (amniotomy)	Needs an engaged presenting part first
PROM	Rupture before labor starts, at term	Infection clock starts
PPROM	Rupture before labor and before 37 weeks	Prematurity and infection

🧠 The extra P in PPROM is Preterm. Same event, worse week.

📋 What you chart about the fluid

Time, Amount, Color, Odor.

Clear with white flecks — normal
Green or brown — meconium; have the resuscitation team ready
Cloudy or foul-smelling — infection
Port-wine — think abruption

Then take her temperature every 2 hours and limit vaginal exams. Fever, maternal or fetal tachycardia, uterine tenderness and foul fluid together are chorioamnionitis.

🔄 What to do the second the membranes go

Do not push a visible cord back in, and do not take your hand away once it is holding the presenting part up. You go to the operating room like that.

💉 Oxytocin — a high-alert drug on a pump

Oxytocin makes the uterus contract. That is the whole benefit and the whole danger, because the placenta is perfused between contractions.

Always a secondary line piggybacked into a mainline, at the port closest to the patient, so it can be stopped instantly.
Always on a pump. Titrate to a contraction pattern, not to a number on the bag.
Aim for contractions no closer than every 2 minutes, no longer than 90 seconds, with a soft uterus in between.

🧠 You are titrating to the uterus, not to the order. The order is a ceiling, not a target.

🚨 Tachysystole — stop, turn, open, oxygen

Recognize it: more than five contractions in ten minutes, or contractions that will not let the uterus relax.

Order	Action	Why
1	Stop the oxytocin	Removes the cause
2	Turn her to her side	Off the vena cava
3	Open the mainline — fluid bolus	Fills the circulation
4	Oxygen by non-rebreather	Raises what is available
5	Notify; expect terbutaline	Relaxes the uterus

Water intoxication is the other oxytocin risk on a long induction — watch for headache, confusion and a falling sodium.

🪛 Forceps vs vacuum

Both need the same five things first: fully dilated cervix, ruptured membranes, an engaged head, an empty bladder, and adequate anesthesia.

	Forceps	Vacuum
Applied to	Sides of the head	Top of the head
Newborn injury	Facial bruising, facial nerve palsy	Cephalohematoma, scalp lacerations, subgaleal bleed
Mother’s risk	Higher — lacerations	Lower
Time limit	Provider judgment	Yes — and pop-offs are counted

🧠 ForCeps → Face. VaCuum → Cap. Forceps mark the face, the vacuum marks the scalp.

After either: check the newborn’s head and face, and check the mother for a fourth-degree laceration and a full bladder.

🧵 Cesarean birth

Before

Consent, labs, IV, indwelling catheter, antibiotic within the hour before incision
Wedge under the right hip on the table — never flat and supine
Non-particulate antacid to reduce aspiration risk

After — she is a surgical patient and a postpartum patient

Postpartum half	Surgical half
Fundus firm and midline	Incision: clean, dry, approximated
Lochia amount and clots	Pain control so she can move
Bladder emptying after the catheter comes out	Early ambulation, leg exercises — VTE risk
Bonding and feeding support	Breath sounds, incentive spirometry

A cesarean does not protect against hemorrhage. Assess the fundus the same way — gently, supporting the incision.

🚨 The never-do rules

Never assess anything before the fetal heart rate after the membranes rupture.
Never replace a prolapsed cord, and never let go of the presenting part once you are holding it up.
Never run oxytocin as a primary line or without a pump.
Never keep oxytocin going through tachysystole while you wait for a call back.
Never lay a pregnant woman flat on her back — wedge or turn her.

RUPTURE→ ASSESS→ ACT

NG-376 · Maternal & Newborn unit · ADHD-friendly visual edition