Premature rupture of membranes (PROM) refers to the spontaneous rupturing of the amniotic membranes (“bag of water”) before the onset of true labor. While it can occur at any gestational age, PROM ususally refers to rupture of the membranes (ROM) that occurs after 37 weeks’ gestation. Preterm premature rupture of membranes (PPROM) occurs between the end of the 20th week and the end of the 36th week. PPROM occurs in 33% of all preterm births and is a major contributor to perinatal morbidity and mortality owing to the lung immaturity and respiratory distress. PROM can result in two major complications. First, if the presenting part is ballotable when PROM occurs, there is risk of a prolapsed umbilical cord. Second, the mother and fetus can develop an infection. The amniotic sac serves as a barrier to prevent bacteria from entering the uterus from the vagina; once the sac is broken, bacteria can move freely upward and cause infection in the mother and the fetus. Furthermore, if the labor must be augmented because of PROM, and the cervix is not ripe, the patient is at a higher risk for a cesarean delivery.
Although the specific cause of PROM is unknown, there are many predisposing factors. An incompetent cervix leads to PROM in the second trimester. Infections such as cervicitis and amnionitis—and also placenta previa, abruptio placentae, and a history of induced abortions— may be involved with PROM. In addition, any condition that places undue stress on the uterus, such as multiple gestation, polyhydramnios, or trauma, can contribute to PROM. Fetal factors involved are genetic abnormalities and fetal malpresentation. A defect in the membrane itself is also a suspected cause.
Nursing care plan assessment and physical examination
Ask the patient the date of her last menstrual period to determine the fetus’s gestational age. Ask her if she has been feeling the baby move. Review the prenatal record if it is available, or question the patient about problems with the pregnancy, such as high blood pressure, gestational diabetes, bleeding, premature labor, illnesses, and trauma. Have the patient describe the circumstances leading to PROM. Determine the time the rupture occurred, the color of the fluid and the amount, and if there was an odor to the fluid. Patients can report a sudden gush of fluid or a feeling of “always being wet.” Inquire about any urinary, vaginal, or pelvic infections. Ask about cigarette, alcohol, and drug use and exposure to teratogens.
The priority assessment is auscultation of the fetal heart rate (FHR). Fetal tachycardia indicates infection. FHR may be decreased or absent during early pregnancy or if the umbilical cord prolapsed. If bradycardia is noted, perform a sterile vaginal examination to check for an umbilical cord. If a cord is felt, place the patient in Trendelenburg’s position, maintain manual removal of the presenting part off of the umbilical cord, and notify the physician immediately.
Note the frequency, duration, and intensity of any contractions. With PROM, contractions are absent. Perform a sterile vaginal examination if the patient is term ( 37 weeks), and note the dilation and effacement of the cervix and the station and presentation of the fetus. If the patient is preterm, notify the physician before doing a vaginal examination, which is often deferred in preterm patients to decrease the likelihood of introducing infection.
It is important in the initial examination to determine if PROM actually occurred. Often, urinary incontinence, loss of the mucous plug, and increased leukorrhea, which are common occurrences during the third trimester, are mistaken for PROM. Inspect the perineum and vaginal vault for presence of fluid, noting the color, consistency, and any foul odor. Normally, amniotic fluid is clear or sometimes blood-tinged with small white particles of vernix. Meconium-stained fluid, which results from the fetus passing stool in utero, can be stained from a light tan to thick green, resembling split pea soup. Take the patient’s vital signs. An elevated temperature and tachycardia are signs that infection is present as a result of PROM. Auscultate the lungs bilaterally. Palpate the uterus for tenderness, which is often present if infection is present. Check the patient’s reflexes, and inspect all extremities for edema.
If the pregnancy is term, most patients are elated with the occurrence of ROM, even though they are not having contractions. If the patient is preterm, PROM is extremely upsetting. Assess the patient’s relationship with her significant other and available support.
Nursing care plan primary nursing diagnosis: Risk for infection related to loss of protective barrier.
Nursing care plan intervention and treatment plan
Treatment varies, depending on the gestational age of the fetus and the presence of infection. If infection is present, the fetus is delivered promptly, regardless of gestational age. Delivery can be vaginal (induced) or by cesarean section. Intravenous (IV) antibiotics are begun immediately. The antibiotics cross the placenta and are thought to provide some protection to the fetus.
If the patient is preterm ( 37 weeks) and has no signs of infection, the patient is maintained on complete bedrest. A weekly nonstress test, contraction stress test, and biophysical profile are done to continually assess fetal well-being. If the gestational age is between 28 and 32 weeks, glucocorticoids are administered to accelerate fetal lung maturity. Use of tocolysis to stop contractions if they begin is controversial when ROM has occurred. Some patients are discharged on bedrest with bathroom privileges if the leakage of fluid ceases, no contractions are noted, and there are no signs and symptoms of infection; however, most physicians prefer to keep the patient hospitalized because of the high risk of infection.
If the patient is term and PROM has occurred, the labor can be augmented with oxytocin. It is always desirable to deliver a term infant within 24 hours of ROM because the likelihood of infection is decreased. Some patients and physicians prefer to wait 24 to 48 hours and let labor start on its own without the use of oxytocin. If this is the case, monitoring for signs and symptoms of infection and fetal well-being is critical. Follow the physician’s protocol for oxytocin administration, as each may be different. When administering oxytocin, monitor: the frequency, duration, intensity and patterm of contractions; resting tone; blood pressure; intake and output; and response to pain.
Determine the patient’s preference for pain relief during labor. If IV narcotics are used, assess the effects of these drugs on the respiratory status of the neonate upon birth. The neonatal nurse or nurse practitioner should be on hand to reverse respiratory depression at delivery. Many patients who receive oxytocin request an epidural because IV narcotics do not provide effective pain relief.
If the patient has an epidural, turn her from side to side hourly to ensure adequate distribution of anesthesia. Use pillows to support the back and abdomen and between the knees to maintain proper body alignment. Most patients are unable to void and require a straight catheter every 2 to 3 hours to keep the bladder empty; if a long labor is anticipated, sometimes a urinary catheter is inserted. Maintain the infusion of IV fluids to prevent hypotension, which can result from regional anesthesia.
Teach every prenatal patient from the beginning to call the physician if she suspects ROM. If ROM occurs, monitor for signs and symptoms of infection and the onset of labor. Maintain the patient in the left lateral recumbent position as much as possible to provide optimal uteroplacental perfusion. Vaginal exams should be held to an absolute minimum, and strict sterile technique should be used to avoid infection.
Assist the patient who is having natural childbirth in breathing and relaxation techniques. Often, the coach plays a significant role in helping the patient deal with the contractions. The nurse should become involved only when necessary. If a preterm delivery is expected, educate the patient and family on the expected care of the newborn in the neonatal intensive care unit (NICU). If possible, allow the patient to visit the NICU and talk to a neonatologist.
Hospital stay for a vaginal delivery is 48 hours and for a cesarean section 72 hours. Teach the patient as much as possible about self-care and newborn care while in the hospital. Arrange for a follow-up home visit by a perinatal nurse. If the baby is retained in the NICU after the patient is discharged, support and educate the family as they return to the hospital to visit their newborn.