In a 35‑week pregnant woman with preterm premature rupture of membranes for 16 hours, stable vital signs, no uterine contractions, fundal height 30 cm, and meconium‑stained amniotic fluid, what is the appropriate management: induction of labor, cesarean delivery, or induction of labor with prophylactic antibiotics?

Management: Induction of Labor with Prophylactic Antibiotics

At 35 weeks gestation with preterm premature rupture of membranes (PPROM) for 16 hours and meconium-stained amniotic fluid, you should proceed with induction of labor using IV oxytocin combined with immediate GBS prophylaxis antibiotics (IV penicillin or ampicillin). 1

Rationale for This Approach

Why Induction is Mandatory

• At 35 weeks, the risks of expectant management outweigh any benefits of continued pregnancy, as the fetus is at viable gestational age with favorable neonatal survival rates with modern intensive care. 1

• Meconium-stained fluid in the setting of PPROM signals potential fetal compromise requiring delivery, making expectant management contraindicated. 1

• The 16-hour rupture interval creates significant infection risk that escalates rapidly—maternal sepsis can progress to death within 18 hours of symptom onset, and clinical signs may be less overt at preterm gestational ages. 1, 2

• Cesarean delivery is not indicated based solely on meconium presence or preterm status, as GBS colonization and meconium alone are not indications for surgical delivery. 3, 1

Why Antibiotics are Mandatory

• CDC guidelines mandate GBS prophylaxis for all preterm deliveries (<37 weeks) with ruptured membranes, regardless of known GBS colonization status. 3, 1

• Intrapartum antibiotic prophylaxis provides 78-86% effectiveness in preventing early-onset neonatal GBS disease when administered ≥4 hours before delivery in preterm patients. 3, 1

• Antibiotics for PPROM reduce maternal infection, chorioamnionitis, and neonatal morbidity (GRADE 1B recommendation). 1

Specific Management Algorithm

Immediate Actions (Within Minutes)

• Initiate GBS prophylaxis immediately with IV penicillin G (5 million units loading dose, then 2.5-3 million units every 4 hours) or IV ampicillin (2g loading dose, then 1g every 4 hours). 3, 1

• If penicillin-allergic without anaphylaxis risk, use IV cefazolin (2g loading dose, then 1g every 8 hours). 3, 1

• Begin induction of labor with IV oxytocin to minimize the interval from membrane rupture to delivery. 1

• Obtain vaginal-rectal GBS culture if not already done, though treatment should not be delayed pending results. 3, 1

Continuous Monitoring Requirements

• Continuous fetal heart rate monitoring for signs of fetal compromise given meconium presence. 1

• Monitor maternal vital signs closely for fever (≥38°C), tachycardia, uterine tenderness, fetal tachycardia, or purulent discharge as signs of chorioamnionitis. 1

• Do not wait for maternal fever to diagnose infection—intraamniotic infection may present without fever, especially at preterm gestational ages. 1, 2

Antibiotic Regimen Details

• The standard latency antibiotic regimen is IV ampicillin and erythromycin for 48 hours, followed by oral amoxicillin and erythromycin for 5 days (total 7-day course). 1

• However, since you are proceeding with immediate induction rather than expectant management, continue GBS prophylaxis (penicillin/ampicillin) until delivery rather than switching to the full latency regimen. 3, 1

Critical Pitfalls to Avoid

• Never use amoxicillin-clavulanic acid (Augmentin), which increases necrotizing enterocolitis risk in neonates. 1, 2

• Never perform cesarean section reflexively based on meconium or GBS concerns alone without clear obstetric indication (non-reassuring fetal status, failed induction, malpresentation). 3, 1

• Never delay antibiotic administration beyond what is necessary to establish IV access—failing to administer antibiotics promptly when membrane rupture exceeds 6 hours in a preterm patient significantly increases infection risk. 1

• Never wait for fever to develop before treating suspected infection—the absence of fever should not provide false reassurance, as infection can progress rapidly without obvious symptoms. 1, 2

Why Not Cesarean Delivery Alone (Option B)

• Cesarean delivery itself does not prevent mother-to-child GBS transmission, as GBS can cross intact membranes, and surgical delivery carries its own maternal and neonatal risks. 3

• Cesarean delivery without antibiotics would leave both mother and neonate unprotected against GBS infection, which is the primary preventable cause of early-onset neonatal sepsis. 3

• The fundal height of 30 cm at 35 weeks suggests appropriate fetal size without macrosomia, and there is no indication of cephalopelvic disproportion or malpresentation mentioned that would necessitate cesarean delivery. 3