Relationship Between Premature Rupture Of Membranes And Caesarean Section Delivery Analytical Observational Study at Sultan Agung Islamic Hospital Semarang

Background: Premature rupture of membranes (PROM) is a rupture of the membranes before delivery which poses a serious threat in the form of an increased risk of cesarean delivery. The risk of greater morbidity and mortality needs to be considered in cesarean delivery compared to vaginal delivery. Objective: This study aims to determine the relationship between premature rupture of membranes and delivery by cesarean section at Sultan Agung Islamic Hospital, Semarang. Methods: This research is an analytic observational study with a cross sectional research design. The population of this study was pregnant women with inpatient deliveries at the Sultan Agung Islamic Hospital, Semarang in 2018-2020. The study sample size was 50 patients. The research instrument used medical records from the Obstetrics and Gynecology section at Sultan Agung Islamic Hospital, Semarang. The sampling technique of this study is a non-probability sampling technique with purposive sampling method and meets the inclusion and exclusion criteria. Data were analyzed by Chi Square Test (X2). Results: The results of the study from a total of 50 samples obtained were 19 patients (38%) with PROM, of which 10 were delivered by cesarean section (52.6%) and 9 patients had vaginal delivery (47.4%). Patients who did not experience PROM were 31 patients (62%) of which 26 were delivered by cesarean section (83.9%) and 5 patients delivered vaginally (16.1%). The results of the Chi Square test (X2) obtained a significance value or Asymptotic Significance (2-sided) of 0.039. Conclusion: The conslusion of this study is that there is a relationship between premature rupture of membranes and delivery by cesarean section.


Introduction
Premature rupture of membranes (PROM) is an obstetric problem due to rupture of the membranes that can occur before 37 weeks of gestation which is called preterm PROM. The membranes that rupture at or more than 37 weeks of gestation are called term PROM. 10 PROM is a condition that poses a serious threat in the form of an increased risk of cesarean delivery. Oligohydramnios and fetal distress conditions to intrauterine infection in preterm and term PROM affect the well-being of the mother and fetus if not managed properly so it is necessary to terminate pregnancy, one of which is by caesarean section delivery. 1 Sectiocaesarea delivery needs attention because of the greater risk of postoperative morbidity and longer hospitalization recovery time than vaginal delivery. 5 The problem of premature rupture of membranes requires great attention because the incidence is quite high. According to in 2013 the incidence of PROM in the world was 50-60% while in Indonesia it was 35% of 17,665 births. 15 The incidence of PROM at term occurs around 6.46-15.6% of term pregnancies. The incidence of preterm PROM occurs in the range of 2-3% of all singleton pregnancies. These data show that the incidence of term PROM is higher than that of preterm PROM. 10 The incidence of PROM is associated with adverse maternal and perinatal outcomes. The immediate risks of PROM include Correspondence to: umbilical cord prolapse, placental abruption, and cord compression. Further risks are in the form of neonatal and maternal infections and delivery by cesarean section. 14 The incidence of PROM without risk depends on the way of management and complications that occur. The greater the complications, the smaller the incidence of PROM without risk. 8 The incidence of potentially severe infections occurs in about 1/3 of pregnant women who experience preterm PROM. 10 Increased cases of PROM can result in an increase in the number of caesarean sections. 3 From the background above, the author wants to examine the relationship between premature rupture of membranes and delivery by cesarean section so that maternal care with PROM can be managed properly and minimize sectiocaesarea delivery. 16 The author wants to examine this with the consideration that there has been no similar research in Semarang, especially at the Sultan Agung Islamic Hospital, Semarang. The purpose of this study was to determine the relationship between PROM and sectiocaesarea delivery. The benefits of this study are expected to increase knowledge about the relationship between PROM and sectiocaesarea delivery and as an evaluation of delivery management and the basis for policy making in order to improve hospital services, especially at Sultan Agung Islamic Hospital, Semarang. The hypothesis of this study is that there is a relationship between PROM and delivery by cesarean section.

Material and Methods
This type of research is an observational analytic study with a cross sectional research design. The statistical test used is the Chi square test (X2). This research was conducted at the Islamic Hospital Sultan Agung Semarang from June to July 2021. The population in this study were pregnant women with inpatient deliveries at the Islamic Hospital Sultan Agung Semarang in 2018-2020. The population was determined by non-probability sampling with purposive sampling method and met the inclusion and exclusion criteria and then included in the research sample until the number was met. The number of samples taken was 50 patients. The research instrument was the medical record of the Obstetrics and Gynecology section at the Sultan Agung Islamic Hospital, Semarang. The inclusion criteria for this study were mothers who gave birth by sectiocaesarea because the primary diagnosis of premature rupture of membranes at term was with the head position and mothers who gave birth through vaginal delivery due to the primary diagnosis of premature rupture of membranes at term with the head position.Exclusion criteria for this study included pregnant women with a primary diagnosis of malpresentation, pregnant women with multiple or multiple pregnancies, and incomplete medical record data.The sample data was processed using the Statistical Package for the Social Sciences (SPSS) application. Data analysis used univariate analysis and bivariate analysis.

Univariate Analysis
Univariate analysis is a description of the research sample that presents the frequency distribution of the number of cases of PROM and cesarean delivery. The distribution of the frequency of PROM events at Sultan Agung Islamic Hospital Semarang can be seen in Table 1.Based on the results of the study on the frequency distribution of PROM, 50 samples were obtained with the number of cases of PROM 19 patients and 31 patients without PROM. The results of this study indicate that the incidence of PROM is 38% of the total research sample. This figure is much larger than the figure estimated which is around 6.46-15.6%. 10 The incidence of PROM at 38% is also higher than the incidence of PROM in Indonesia which is 35% of 17,665 births. The difference in the proportion of the incidence of PROM can be caused by differences in the number of patients experiencing PROM and differences in the number of populations studied. The characteristics of the sample in this study were seen from the age of pregnant women and gravida status. The distribution of the frequency of PROM events based on gravida status at Sultan Agung Islamic Hospital Semarang can be seen in Table 2.  The distribution of the frequency of PROM events based on maternal age at Sultan Agung Islamic Hospital Semarang can be seen in Table3.
Based on table 3, mothers who experience PROM often occur in mothers of age who are not at risk (20-35 years). This study is in line with other studiesthat mothers giving birth with PROM are more than 20-35 years old. This is because the age of 20-35 years is a productive age for pregnancy. 11 However, this is not in line with the theory which states that age < 20 years or > 35 years is at risk of PROM. 9 These different results can be caused by good antenatal care management.
The distribution of the frequency of delivery types at the Sultan Agung Islamic Hospital in Semarang is shown in Table 4. Based on table 4, it shows that from a total sample of 50 patients, 36 were delivered by cesarean section and 14 were delivered vaginally. These data indicate that the total incidence of cesarean section deliveries is 72%, which exceeds the national incidence of cesarean section deliveries. According to the Ministry of Health of the Republic of Indonesia in 2018, the incidence of sectiocaesarea in Indonesia is 17.6% of the total number of deliveries. 6 The high rate of cesarean section deliveries at the Sultan Agung Hospital, Semarang as a Type B Hospital is due to being an obstetrical referral from various health facilities such as clinics and health centers in the local area as well as referrals from district hospitals. Efforts to minimize sectiocaesarea can be done by providing education to pregnant women for routine antenatal care as an early detection of risk factors for sectiocaesarea.
Sectiocaesarea delivery is carried out based on certain indications. Indications for cesarean section delivery in 36 patients with cesarean section are shown in Table5.  The study showed that 9 people with PROM experienced vaginal delivery (47.4%). Vaginal delivery is performed in PROM patients due to success in labor induction. Induction of labor is done in an effort to stimulate the onset of his. PROM patients who had vaginal delivery were also caused by the absence of other complications, so there was no indication for sectio caesarea. 12 This study showed that there were 26 patients without PROM who underwent cesarean section delivery (83.9%). This shows that sectiocaesarea is not only performed in PROM conditions. Delivery by cesarean section is carried out on maternal and fetal indications. There were 5 patients without PROM who experienced vaginal delivery (16.1%). This shows that the patient is a spontaneous parturition without other complications so that there is no indication for caesarean section. Sectiocaesarea delivery is performed when the mother or fetus is at high risk and vaginal delivery is not possible. 3

Conclusion
The results showed that there was a relationship between PROM and delivery by cesarean section (p = 0.039).