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Re: NEJM TERMPROMFrom: CheriVH@aol.comTue Apr 30 11:58:48 1996
><<How could you defend a demise from cord prolapse after sending home a >patient >with SROM?>> I believe practices vary considerably around how soon patients are evaluated in the office or the hospital following SROM. Many practitioners have the woman come immediately for evaluation. Others wait until morning if the SROM occurs at night. I have seen it done both ways, though I have always evaluated the woman as soon as possible following SROM. If the concern about cord prolapse after SROM is so great, it seems that the only possible management would be continuous monitoring with strict bedrest after rupture. I believe that this practice has fallen by the wayside in most communities. My most valued instructor in midwifery school, the late great James Green, MD, felt strongly that a term vertex presentation precluded prolapse if the head was engaged in the pelvis. I was taught that the greatest risk of prolapse was with a malpresentation, a preterm infant, or with a high vertex at time of ROM and that if the cord was going to prolapse it would "wash down" with the initial rupture. This last type of prolapse is most common with AROM and is generally iatrogenic. As regards my institution's PROM protocol, it was based on the standard of care set by a respected teaching institution, the University of California at San Francisco, and was approved by my institution's perinatologists. So if it ever came to having to defend this practice, I'm fairly certain expert witnesses could be found to testify on behalf of this approach to PROM management. It's interesting to me that so many of the comments on this list regarding PROM management have reported increased maternal satisfaction with and desire for induction. We have found just the opposite to be true. Since our protocols for induction require continuous monitoring and (of course) IV's, our women prefer to labor spontaneously, with their options to ambulate, shower, and change postition at will preserved. Cheri Van Hoover, CNM Kaiser Hospital Redwood City, CA
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