Management of Late Preterm PROM at 35+6 Weeks with Active Labor
Proceed with immediate delivery at your current facility with IV antibiotics and GBS prophylaxis—referral to a higher center is NOT required at this gestational age. 1, 2
Immediate Management Protocol
Antibiotic Administration (Start Immediately)
- Initiate IV ampicillin or penicillin for GBS prophylaxis immediately, as the CDC mandates this for all preterm deliveries (<37 weeks) with ruptured membranes, regardless of known GBS colonization status 1, 3
- If penicillin-allergic without anaphylaxis risk, use IV cefazolin as an alternative 1
- The standard regimen is IV ampicillin and erythromycin for 48 hours, followed by oral amoxicillin and erythromycin for 5 days (total 7-day course) for latency prolongation, though at 35+6 weeks with active labor, focus on GBS prophylaxis 1, 3
- Critical pitfall: Do NOT use amoxicillin-clavulanic acid (Augmentin), which increases necrotizing enterocolitis risk in neonates 1, 3
Labor Management
- Proceed with vaginal delivery unless there are specific obstetric indications for cesarean section 1
- Continue continuous fetal heart rate monitoring given the preterm status 1
- At 35+6 weeks, the risks of expectant management (infection, hemorrhage) outweigh the minimal benefits of continued pregnancy 1, 4
- The patient is already 3 cm dilated and in active labor—delivery is the appropriate management 1, 5
Monitoring for Complications
Signs of Chorioamnionitis (Monitor Closely)
- Maternal fever ≥38°C 1, 2
- Maternal tachycardia 1, 2
- Fetal tachycardia (baseline >160 bpm) 1, 2
- Uterine tenderness on palpation 1, 2
- Purulent or malodorous vaginal discharge 1, 2
- Critical consideration: Infection may present without fever, especially at preterm gestational ages—do not wait for fever to diagnose infection 1, 2
Referral Decision: NOT Required
Rationale for Local Management
- At 35+6 weeks gestation, neonatal outcomes are excellent with standard Level II nursery care 1, 4
- The fetus is at a viable gestational age with favorable survival rates and minimal risk of significant prematurity complications 1
- Referral would be indicated if this were <34 weeks or if there were specific maternal/fetal complications requiring tertiary care (e.g., severe fetal anomalies, maternal cardiac disease, anticipated need for NICU beyond standard preterm care) 2, 5
- With normal vitals and reassuring FHS, there is no indication for transfer 1, 5
Neonatal Preparation
Anticipated Neonatal Issues
- Alert pediatrics/neonatal team for delivery room attendance 6
- Potential for mild respiratory distress (though uncommon at this gestational age) 6
- Risk of early-onset neonatal sepsis is reduced by 86-89% with appropriate intrapartum antibiotic prophylaxis 1
- Most neonates at 35+6 weeks do well with routine newborn care or brief observation 4, 6
Critical Pitfalls to Avoid
- Do NOT delay antibiotic administration—start immediately upon diagnosis of PROM in preterm labor 1, 3
- Do NOT perform cesarean section based solely on prematurity or PROM without clear obstetric indication 1
- Do NOT wait for maternal fever to diagnose infection—clinical symptoms may be subtle at preterm gestational ages 1, 2
- Do NOT use expectant management at this gestational age with active labor and 3 cm dilation—the infection risk outweighs any theoretical benefit of pregnancy prolongation 1, 4
- Do NOT transfer to a higher center unless there are specific maternal or fetal complications beyond routine late preterm PROM 2, 5