What is the best next step for a patient at 34 weeks gestation with ruptured membranes (premature rupture of membranes), no contractions, and meconium-stained liquor, with a fundal height of 30 weeks and no signs of infection or fetal distress?

Management of PPROM at 34 Weeks with Meconium-Stained Liquor

Administer prophylactic antibiotics immediately and proceed with induction of labor (Option C). 1, 2

Immediate Management Algorithm

Step 1: Antibiotic Administration

• Start broad-spectrum antibiotics immediately using the standard PPROM regimen: IV ampicillin and erythromycin for 48 hours, followed by oral amoxicillin and erythromycin for 5 additional days 1, 2
• This reduces chorioamnionitis risk from 38% (with expectant management) to 13% (with immediate intervention) 1, 2
• Azithromycin can substitute for erythromycin if unavailable, but avoid amoxicillin-clavulanic acid due to necrotizing enterocolitis risk 2

Step 2: Corticosteroid Administration

• Administer betamethasone 12 mg IM × 2 doses, 24 hours apart for fetal lung maturity 1, 3
• This is appropriate for PPROM at 32-34 weeks gestation and reduces neonatal respiratory morbidity and NICU admissions 1, 3

Step 3: Proceed with Induction of Labor

• At 34 weeks gestation, the balance shifts decisively toward delivery rather than expectant management 1
• Induction at this gestational age is safe for the neonate and avoids maternal-neonatal infectious complications 4
• The presence of meconium-stained liquor does not change this recommendation but requires neonatal team notification 1

Why Not Wait Until 37 Weeks (Option D)?

Expectant management at 34 weeks with ruptured membranes significantly increases infection risk without meaningful neonatal benefit:

• Chorioamnionitis occurs in 38% of expectant management cases versus 13% with immediate intervention 1, 2
• Maternal sepsis occurs in up to 6.8% of cases with expectant management 2
• Infection can progress rapidly without obvious symptoms, and vigilant monitoring alone is insufficient 2
• At 34 weeks, most centers can effectively manage neonatal complications, making the risk-benefit calculation favor delivery 1

Why Not Immediate Cesarean Section (Option B)?

There is no indication for cesarean delivery in this clinical scenario:

• The fetus is at -1 station with no signs of fetal distress 5
• Meconium-stained liquor alone is not an indication for cesarean section 6
• Induction of labor at 34 weeks does not increase cesarean section rates compared to later gestational ages 7
• Multiple studies demonstrate cesarean section rates of only 2-14% with induction at this gestational age 8, 4, 5

Critical Meconium Management Points

Do NOT perform routine laryngoscopy with tracheal suctioning for meconium:

• For nonvigorous newborns delivered through meconium-stained amniotic fluid, immediate resuscitation without direct laryngoscopy is recommended over routine suctioning 6, 1
• This applies to infants ≥34 weeks gestation 6
• Have trained personnel and equipment for intubation readily available, but do not delay resuscitation for suctioning 1

Additional Monitoring Considerations

While proceeding with induction, monitor for:

• Signs of chorioamnionitis: fever, maternal tachycardia, uterine tenderness, foul-smelling discharge 1, 2
• Fetal heart rate patterns indicating compromise 2
• Note that intraamniotic infection may present without maternal fever, especially at earlier gestational ages 2

Common Pitfall to Avoid

Do not delay delivery based on fundal height discrepancy (30 weeks vs. 34 weeks gestational age):

• This suggests possible intrauterine growth restriction but does not change the management at 34 weeks with PPROM 1
• The neonatal team should be notified of both the prematurity and potential growth restriction 1