In a 35‑week‑gestation pregnant woman with six‑hour ruptured membranes, stable vital signs, no uterine activity, and meconium‑stained amniotic fluid, what is the appropriate management?

Management of 35-Week Gestation with 6-Hour Ruptured Membranes and Meconium-Stained Fluid

Induction of labor with prophylactic antibiotics is the appropriate management for this patient.

Rationale for Active Management

At 35 weeks gestation with ruptured membranes, this patient is in the preterm but not periviable range where active management is clearly indicated. The presence of meconium-stained amniotic fluid at this gestational age is concerning and warrants expedited delivery rather than expectant management 1.

Key Management Components

Immediate antibiotic prophylaxis is mandatory because:

• The membranes have been ruptured for 6 hours, approaching the critical threshold where infection risk increases 2
• For preterm premature rupture of membranes (PPROM) at ≥24 weeks gestation, antibiotics are strongly recommended (GRADE 1B evidence) 2
• The standard regimen is IV ampicillin and erythromycin for 48 hours, followed by oral amoxicillin and erythromycin for 5 additional days 2
• Group B Streptococcus prophylaxis is indicated for all women with ruptured membranes in the preterm setting regardless of colonization status 1, 2

Induction of labor is preferred over cesarean section because:

• There are no absolute contraindications to vaginal delivery in this scenario 3
• The patient is stable with no uterine contractions, suggesting no acute fetal distress requiring immediate cesarean delivery 3
• Meconium-stained fluid alone at 35 weeks, while concerning, does not mandate cesarean delivery in a stable patient 4
• The fundal height discrepancy (30 cm at 35 weeks) may reflect oligohydramnios from prolonged rupture rather than growth restriction, but does not change the delivery route 5

Expectant management is inappropriate because:

• At 35 weeks, the risks of prematurity are substantially lower than the risks of ascending infection with continued expectancy 3, 5
• The majority of women with PPROM will deliver within 7 days, and delaying delivery increases maternal infectious morbidity 6
• Meconium passage suggests some degree of fetal stress that warrants expedited delivery 4

Clinical Pitfalls to Avoid

• Do not delay antibiotic administration: Failing to administer antibiotics promptly is a critical error, especially as the patient approaches the 18-hour threshold where infection risk significantly increases 2
• Do not perform cesarean section reflexively: The presence of meconium does not automatically require cesarean delivery in a stable patient without evidence of acute fetal compromise 3
• Do not choose pure expectant management: At 35 weeks with meconium, the balance has shifted toward delivery rather than pregnancy prolongation 3, 5

Monitoring During Induction

• Anticipate potentially long latent phases during induction at this gestational age 7
• Minimize vaginal examinations to reduce infection risk 7
• Monitor closely for signs of chorioamnionitis: maternal fever, uterine tenderness, fetal tachycardia, and purulent discharge 2
• Continuous fetal monitoring is essential given the meconium-stained fluid 4

The correct answer is C: Induction of labor + prophylactic antibiotics.