Included studies

A systematic review of the literature was conducted but no studies were identified which were applicable to this review question.

See the literature search strategy in appendix B and study selection flow chart in appendix C.

Excluded studies

Studies not included in this review are listed, and reasons for their exclusion are provided in appendix J.

Included studies

A systematic review of the economic literature was conducted but no economic studies were identified which were applicable to this review question.

The outcomes that matter most

The committee chose maternal admission to intensive therapy unit (ITU) or high-dependency area, mode of birth and requirement for antibiotics as the critical outcomes for this review. As both maternal admission and requirement for antibiotics are common negative outcomes for women associated with PRoM, the committee agreed that these were the best indicators to understand the differential effectiveness of different timeframes between a woman reporting possible PRoM and an in-person clinical review. The committee also wanted to find out whether different timeframes would impact the mode of birth and agreed that this was a meaningful outcome for making recommendations, both in terms of the woman and the health system.

The committee also agreed on the important outcomes for this review. As induction of labour is recommended 24 hours after PRoM due to an increased risk of infection, the committee wanted to include induction of labour and evidence of maternal infection as important outcomes as these are likely to be impacted by different timeframes between a woman reporting PRoM and an in-person face-to-face clinical review. They also agreed that it was also important to find out about women’s experience of labour and birth. The committee recognised the great importance of women’s experience of labour and birth in the presence of suspected PRoM, but they were aware that data on this outcome was likely to be sparse and unlikely to inform decision-making in a meaningful way, so they prioritised other outcomes as critical.

Finally, the committee chose neonatal admission as an important outcome as this would indicate whether there are any risks for the baby associated with different timeframes between a woman reporting PRoM and a face-to-face clinical review.

The quality of the evidence

No evidence was identified which was applicable to this review question.

Benefits and harms

The committee noted that the protocol had included women with preterm PRoM (less than 37 weeks) but that the NICE guidelines on Preterm labour and birth already included recommendations on the management of preterm PRoM and so they restricted their discussions and recommendations to women with PRoM at term (37 to 42 weeks) which is aligned with the scope of the Intrapartum care guidance.

No evidence was identified for the timeframe between a woman reporting possible PRoM and an in-person clinical assessment, so the committee based the recommendations on their experience and expertise. The committee agreed that while the recommendations would reflect current practice in many Trusts, the recommendations would help to reduce variation in practice and reliance on women’s knowledge and perception of risk.

The committee discussed the triage of women reporting possible PRoM and agreed that in practice, the urgency of an in-person clinical assessment should be based on the presence of risk factors. The committee agreed that a list of risk factors would be useful in determining the urgency of an in-person clinical assessment and decided that a woman should be seen immediately if any one of these factors is present. The committee noted that some of these factors would require women to be offered immediate induction, for example, if she has a positive group B streptococcus test, and that recommendations relating to the timing of induction were already present in the NICE guideline on Inducing labour and the NICE guideline on Neonatal infection. The committee therefore included these recommendations in the guideline and cross-referenced to these other relevant NICE guidelines.

The committee agreed that women who do not have any risk factors should be seen within 12 hours or as soon as possible if the woman has any concerns or wishes to be induced immediately. The committee discussed the timeframe and agreed that there was no clinical reason there should be a delay in an in-person clinical assessment, but they agreed that for this lower risk group, the benefits of urgency should be balanced with the preferences of the woman, for example wanting to spend the night at home or taking time to arrange childcare and agreed that within 12 hours would be a reasonable pragmatic time to allow this. The committee agreed that the in-person assessment of a woman without risk factors could be carried out at the woman’s intended place of birth, be that at home, in a midwifery-led unit or an obstetric unit. The committee noted that the deployment of community midwives may be needed in cases where the woman was unable to reach the maternity unit within 12 hours, however, they decided not to make a recommendation on this as this would be determined at the local level.

The committee discussed whether to make a research recommendation as no evidence had been identified but agreed that as a risk assessment was necessary for women presenting with PRoM (as they had advised in their recommendations), and as this was an area where maternal preference and planned place of birth also had a large impact on the decision, a study randomising women to different times for assessment would be unlikely to be conducted.

Cost effectiveness and resource use

The committee agreed that the recommendation for women with risk factors is in line with current practice. However, the recommendation for women without risk factors may result in more women being seen in-person within a shorter timeframe than current practice, as some units currently advise longer delays than this. The committee agreed that this is unlikely to have a significant impact on resources as it is only bringing the time of review for some women earlier by a few hours. However, although no clinical evidence was identified, the committee made a qualitative assessment that the recommendations based on their expertise and experience would represent a cost-effective use of NHS resources.