I.

Introduction:

Premature rupture of membranes (PROM) at term is rupture of membranes prior to the

onset of labor at or beyond 37 weeks' gestation. The membranes that hold amniotic fluid

(the water surrounding the baby) usually break at the end of the first stage of labor.

However, in about 10% of pregnancies after 37 weeks, the membranes will break before

labor. PROM occurs in about 10 percent of all pregnancies. PPROM (before 37 weeks)

occurs in about 2 percent of all pregnancies

The cause of PROM is often unknown. Some causes are thought to be: uterine or genital

tract infections, including sexually transmitted diseases , poor nutrition, overstretching of

the uterus and amniotic sac, which sometimes occurs with multiple fetuses or too much

amniotic fluid (hydramnios), cigarette smoking, increased susceptibility if it occurred in

previous pregnancies, previous cervical surgery, including cone biopsies or cerclage

suture to hold the cervix closed, most women whose membranes rupture before labor

don’t have a risk factor.

The most important symptom of PROM is fluid leaking from the vagina. It may leak

slowly or may gush out. Sometimes when it leaks out slowly, women mistake it for urine.

Although some of the fluid is lost when the membranes rupture, the baby continues to

produce more, so it may continue to leak.

PROM is a complicating factor in as many as one third of premature births. A significant

risk of PPROM is that the baby is very likely to be born within one week of the

membrane rupture. Another major risk of PROM is development of a serious infection of

the placental tissues called chorioamnionitis, which can be very dangerous for mother

and baby. Other complications that may occur with PROM include placental abruption

(early detachment of the placenta from the uterus), compression of the umbilical cord,

cesarean birth, and postpartum (after delivery) infection.

Treatment for premature rupture of membranes may include: hospitalization, expectant

management (in some cases of PPROM, the membranes may seal over and the fluid may

stop leaking without treatment.), monitoring for signs of infection such as fever, pain,

increased fetal heart rate and/or laboratory tests, giving the mother medications called
corticosteroids that may help mature the lungs of the fetus (lung immaturity is a major

problem of premature babies). However, corticosteroids may mask an infection in the

uterus, antibiotics (to prevent or treat infections), tocolytics - medications used to stop

preterm labor, and delivery (if PROM endangers the well-being of the mother or fetus,

then an early delivery may be necessary to prevent further complications).

Unfortunately, there is no way to actively prevent PROM. However, this condition does

have a strong link with cigarette smoking and mothers should stop smoking as soon as

possible.

This case study is conducted with the following aims and objectives of the study:

• To have a thorough assessment on the patient

• To obtain patient’s data to have a better bonding with my patient

• To gain knowledge on premature rupture of membranes, its causes, symptoms and

prevention of the case.

• To plan necessary care to be rendered to the patient while in the hospital and also

to give health teachings.

My Patient, Jesary Espiritu, has been hospitalized last June 22, 2008 at 2 am in Gabriela

Silang General Hospital with the chief complains of lumbosacral pain and according to

her it is also because of continuous leaking of vaginal fluid (amniotic fluid) that she

thought as water. She was rushed in the hospital for all they knew is that she will already

deliver the baby. Her Admitting diagnosis was Premature rupture of membranes and the

admitting physician was Dra. Eugenio. It was June 23 when she delivered a baby girl

through a caesarean section. She was then discharged after staying one week in the

hospital.
VI. Anatomy and Physiology:

(Female Reproductive Parts)

Affected Parts: (Amnion and the Chorion)

The Amnion

- in the human embryo the earliest stages of the formation of the amnion have not been

observed; in the youngest embryo which has been studied the amnion was already present

as a closed sac and appears in the inner cell-mass as a cavity. This cavity is roofed in by a

single stratum of flattened, ectodermal cells, the amniotic ectoderm, and its floor consists

of the prismatic ectoderm of the embryonic disk - the continuity between the roof and

floor being established at the margin of the embryonic disk. Outside the amniotic

ectoderm is a thin layer of mesoderm, which is continuous with that of the somatopleure

and is connected by the body-stalk with the mesodermal lining of the chorion.

When first formed the amnion is in contact with the body of the embryo, but about the

fourth or fifth week fluid (liquor amnii) begins to accumulate within it. This fluid

increases in quantity and causes the amnion to expand and ultimately to adhere to the

inner surface of the chorion, so that the extra-embryonic part of the celom is obliterated.

The liquor amnii increases in quantity up to the sixth or seventh month of pregnancy,

after which it diminishes somewhat; at the end of pregnancy it amounts to about 1 liter. It

allows of the free movements of the fetus during the later stages of pregnancy, and also

protects it by diminishing the risk of injury from without. It contains less than 2 per cent.

of solids, consisting of urea and other extractives, inorganic salts, a small amount of

protein, and frequently a trace of sugar. That some of the liquor amnii is swallowed by

the fetus is proved by the fact that epidermal debris and hairs have been found among the

contents of the fetal alimentary canal.

The Chorion

- the chorion consists of two layers: an outer formed by the primitive ectoderm or

trophoblast, and an inner by the somatic mesoderm; with this latter the amnion is in

contact. The trophoblast is made up of an internal layer of cubical or prismatic cells, the

cytotrophoblast or layer of Langhans, and an external layer of richly nucleated

protoplasm devoid of cell boundaries, the syncytiotrophoblast. It undergoes rapid

proliferation and forms numerous processes, the chorionic villi, which invade and destroy

the uterine decidua and at the same time absorb from it nutritive materials for the growth

of the embryo. The chorionic villi are at first small and non-vascular, and consist of
trophoblast only, but they increase in size and ramify, while the mesoderm, carrying

branches of the umbilical vessels, grows into them, and in this way they are vascularized.

Blood is carried to the villi by the branches of the umbilical arteries, and after circulating

through the capillaries of the villi, is returned to the embryo by the umbilical veins. Until

about the end of the second month of pregnancy the villi cover the entire chorion, and are

almost uniform in size, but after this they develop unequally. The greater part of the

chorion is in contact with the decidua capsularis, and over this portion the villi, with their

contained vessels, undergo atrophy, so that by the fourth month scarcely a trace of them is

left, and hence this part of the chorion becomes smooth, and is named the chorion læve;

as it takes no share in the formation of the placenta, it is also named the non-placental

part of the chorion. On the other hand, the villi on that part of the chorion which is in

contact with the decidua placentalis increase greatly in size and complexity, and hence

this part is named the chorion frondosum.

Primary chorionic villi. Diagrammatic.

Transverse section of a chorionic villus. (Modified from Bryce.)
External Parts of Female Reproductive Organ:

Internal Parts of Female Reproductive Organ :

LOCATION &
STRUCTURE FUNCTION
DESCRIPTION

Breasts Upper chest one on each side Lactation milk/nutrition for newborn.

containing alveolar cells (milk

production), myoepithelial cells

 (contract to expel milk), and

duct walls (help with extraction

of milk).

During childbirth, contractions of the

uterus will dilate the cervix up to 10 cm

The lower narrower portion of
Cervix in diameter to allow the child to pass
the uterus.
through. During orgasm, the cervix

convulses and the external os dilates

Small erectile organ directly in

Clitoris Sexual excitation, engorged with blood.
front of the vestibule.

Extending upper part of the Egg transportation from ovary to uterus

Fallopian tubes
uterus on either side. (fertilization usually takes place here).

Thin membrane that partially

Hymen covers the vagina in young

females.

Outer skin folds that surround

Labia majora Lubrication during mating.
the entrance to the vagina.

Inner skin folds that surround

Labia minora Lubrication during mating.
the entrance to the vagina.

Mound of skin and underlying

Mons fatty tissue, central in lower

pelvic region

Provides an environment for maturation

Ovaries (female Pelvic region on either side of
of oocyte. Synthesizes and secretes sex
gonads) the uterus.
hormones (estrogen and progesterone).
 Short stretch of skin starting at

Perineum the bottom of the vulva and

extending to the anus.

Pelvic cavity above bladder,

Urethra Passage of urine.
tilted.

To house and nourish developing

Uterus Center of pelvic cavity.
human.

Receives penis during mating. Pathway

through a womans body for the baby to

take during childbirth. Provides the

Canal about 10-8 cm long going
route for the menstrual blood (menses)
Vagina from the cervix to the outside of
from the uterus, to leave the body. May
the body.
hold forms of birth control, such as an

IUD, diaphragm, neva ring, or female

condom

Surround entrance to the

Vulva reproductive tract.(encompasses

all external genitalia)

The innermost layer of uterine Contains glands that secrete fluids that
Endometrium
wall. bathe the utrine lining.

Myometrium Smooth muscle in uterine wall. Contracts to help expel the baby.
VIII. Management

A. Medical Surgical

- the patient undergone caesarean section last June 23, 2008 and began at 1:40

p.m. and ended at 2:25 p.m. a baby girl was delivered at 1:45 p.m. with Dra. Eugenio as

the surgeon. Induction of anesthesia started at 1:30 p.m. by Dr. Baniqued.

Caesarean Section

-(surgery done)

A caesarean section, or c-section, is a form of childbirth in which a surgical

incision is made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to

deliver one or more babies. It is usually performed when a vaginal delivery would lead to

medical complications, although it is increasingly common for otherwise normal births as

well.

There are several types of caesarean sections (CS):

• The classical caesarean section involves a midline longitudinal incision

which allows a larger space to deliver the baby. However, it is rarely

performed today as it more prone to complications.

• The lower uterine segment section is the procedure most commonly used

today; it involves a transverse cut just above the edge of the bladder and

results in less blood loss and is easier to repair.

• An emergency caesarean section is a caesarean performed once labour has

commenced.

• A crash caesarean section is a caesarean performed in an obstetrical

emergency.
 • A caesarean hysterectomy consists of a caesarean section followed by the

removal of the uterus. This may be done in cases of intractable bleeding or

when the placenta cannot be separated from the uterus.

• Traditionally other forms of CS have been used, such as extraperitoneal CS or

Porro CS.

• repeat caesarean section is done when a patient had a previous section.

Typically it is performed through the old scar.

Indications

Caesarean section is recommended when vaginal delivery might pose a risk to the mother

or baby. Reasons for caesarean delivery include:

• prolonged labour or a failure to progress (dystocia)

• apparent fetal distress

• apparent maternal distress

• complications (pre-eclampsia, active herpes)

• catastrophes such as cord prolapse or uterine rupture

• multiple births

• abnormal presentation (breech or transverse positions)

• failed induction of labour

• failed instrumental delivery (by forceps or ventouse)

• the baby is too large (macrosomia)

• placental problems (placenta previa, placenta abruption,or placenta accreta)

• contracted pelvis

• prior problems with the healing of the perineum (from previous childbirth or

Crohn's Disease)

However, different providers may disagree about when a caesarean is required. For

example, one obstetrician may feel that a woman is too small to deliver her baby, another

might well disagree. Similarly, some care providers may be much quicker to cite "failure
to progress" than others. Disagreements like this help to explain why caesarean rates for

some physicians and hospitals are much higher than are those for others. The medico-

legal restrictions on VBAC, vaginal birth after caesarean, have also increased the

caesarean rate.

As scheduled caesarean sections have become a rather safe operation, there has been a

movement to perform caesarean delivery on maternal request (CDMR). There is also a

consumer-driven movement to support VBAC as an alternative for repeat caesareans in

the face of increased medico-legal restrictions on vaginal birth.

Risks

Statistics from the 1990s suggest that less than one woman in 2,500 who has a caesarean

section will die, compared to a rate of one in 10,000 for a vaginal delivery. However the

mortality rate for both continues to drop steadily. The UK National Health Service gives

the risk of death for the mother as three times that of a vaginal birth. However, it is not

possible to directly compare the mortality rates of vaginal and caesarean deliveries as

women having the surgery are often those who were at a higher risk anyway.

A study published in the June 2006 issue of the journal Obstetrics and Gynecology found

that women who had multiple caesarian sections were more likely to have problems with

later pregnancies, and recommended that women who want larger families should not

seek caesarian section as an elective. The risk of placenta accreta, a potentially life-

threatening condition, is 0.13% after two c-sections, and increases to 2.13% after four

and then to 6.74% after six or more surgeries. Along with this is a similar rise in the risk

of emergency hysterectomies at delivery. The findings were based on outcomes from

30,132 cesarean deliveries.

Babies born by caesarean sometimes have some initial trouble breathing. In addition,

because the baby may be drowsy from the pain medication administered to the mother,

and because the mother's mobility is reduced, breastfeeding may be difficult.

A caesarean section is a major operation, with all that it entails, including the risk of post-

operative adhesions. Pain at the incision can be intense, and full recovery of mobility can
take several weeks or more. A prior caesarean section increases the risk of uterine rupture

during subsequent labour.

If a CS is performed under emergency situations, the risk of the surgery may be increased

due to a number of factors. The patient's stomach may not be empty, increasing the

anesthesia risk.

Anaesthesia

The mother has the option of receiving regional anaesthesia (spinal or epidural) or

general anaesthesia for caesarean section. Regional anaesthesia has the advantage of

allowing her to remain awake for the delivery and avoids sedation of the newborn. Pain

relief after the caesarean is also improved.

General anaesthesia for caesarean section is becoming less common as scientific research

has now clearly established the benefits of regional anaesthesia for both the mother and

baby. General anaesthesia tends to be reserved for emergencies where the mother or

baby's life is immediately threatened or other high-risk cases. The risks of general

anaesthesia for mother and baby are still extremely small overall.

If the mother already has an epidural in this epidural can often be used for the caesarean

section. Multiple recent studies have now shown that epidurals in labour do not increase

the caesarean section rate (Meta analysis 2005 Anim-Somuah, Cochrane Review) but

they may increase the risk of a forceps or instrumental delivery. At least one study

however, has found that the risk of c-section doubles if the epidural is placed before the

mother has reached 5cms cervical dilation. For this reason many UK hospitals are

reluctant to give epidural anaesthesia before this stage. Epidurals placed after 5cms

dilation is achieved do not affect chance of c-section. Epidurals traditionally have been

known to slow down the progress of labour, but recent work has shown that they may

actually speed up the labour process (COMET Study, Lancet 2001). This is because in

women who are tense, exhausted and in pain labour can slow, and the "break" provided

by the epidural which allows many women to sleep for a few hours, allowing her to relax

enough to dilate fully and gather strength for the second (pushing) stage of labour. Deep

transverse arrest, where the baby's head becomes lodged in the birth canal, can be a
complication of epidural anaesthesia because the tone of the pelvic floor, which helps to

turn the baby's head as it passes through the pelvic bones, can be reduced or lost. To

avoid this complication (which always results in forceps/ventouse/c-section delivery)

experienced care-givers will often instruct the labouring woman not to push until the

head is visible during contractions, ensuring it has already turned to pass under the pubic

arch.
XII. Bibliography:

Book Sources:

Doenges, Marilyn E. et al. Nurse’s Pocket Guide. F.A. Davis Company, 2004.

Doenges, Marilyn E. et al. Nursing Care Plans. F.A. Davis Company, 2002.

Pillitteri, Adele. Maternal and Child Health Nursing: Care of the Childbearing and

Childrearing Family. Lippincot Williams and Wilkins, 207.

Sia, Maria Loreto J. Outline in Obstetrics A Textbook and a Reviewer. Quezon City:

RMSIA Publishing, 2005.

Internet Sources:

http://en.wikipedia.org/wiki/Caesarian_section

http://search.yahoo.com/search?p=diagnostic+procedure+for+Premature+rupture+of+membrane

&vc=&fr=yfp-t-501&toggle=1&cop=mss&ei=UTF-8&fp_ip=PH

http://www.caesarian.eu/

http://www.emedicine.com/med/topic3246.htm

http://www.merck.com/mmpe/index.html

http://www.moondragon.org/obgyn/pregnancy/placenta.html

http://www.moondragon.org/obgyn/pregnancy/prom.html
V. Diagnostic Procedures

A. Ideal

• Ultrasound

- a diagnostic imaging technique which uses high-frequency. sound waves and a

computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to

view internal organs as they function, and to assess blood flow through various vessels.

• Amniocentesis

-a medical procedure during which a long, thin needle is inserted through the

abdominal and uterine walls, and into the amniotic sac. A sample of amniotic fluid is

withdrawn through the needle for examination.

• Cervical cerclage

-a procedure in which the cervix is sewn closed; used in cases when the cervix starts

to dilate too early in a pregnancy to allow the birth of a healthy baby.

• Complete Blood Count

-a complete blood count (CBC), also known as full blood count (FBC) or full blood

exam (FBE) or blood panel, is a test requested by a doctor or other medical professional

that gives information about the cells in a patient's blood. A lab technician (diploma

holder) or technologist (bachelor holder) performs the requested testing and provides the

requesting Medical Professional with the results of the CBC. A CBC is also known as a

"hemogram".
The cells that circulate in the bloodstream are generally divided into three types: white

blood cells (leukocytes), red blood cells (erythrocytes), and platelets or thrombocytes.

Abnormally high or low counts may indicate the presence of many forms of disease, and

hence blood counts are amongst the most commonly performed blood tests in medicine,

as they can provide an overview of a patient's general health status. A CBC is routinely

performed during annual physical examinations.

Methods

• Samples

A phlebotomist collects the specimen, in this case blood is drawn in a test tube containing

an anticoagulant (EDTA, sometimes citrate) to stop it from clotting, and transported to a

laboratory.

In the past, counting the cells in a patient's blood was performed manually, by viewing a

slide prepared with a sample of the patient's blood under a microscope (a blood film, or

peripheral smear). Nowadays, this process is generally automated by use of an automated

analyzer, with only specific samples being examined manually.

• Automated blood count

The blood is well mixed (though not shaken) and placed on a rack in the analyzer. This

instrument has many different components to analyze different elements in the blood. The

cell counting component counts the numbers and types of different cells within the blood.

The results are printed out or sent to a computer for review.

Blood counting machines aspirate a very small amount of the specimen through narrow

tubing. Within this tubing, there are sensors that count the number of cells going through

it, and can identify the type of cell; this is flow cytometry. The two main sensors used are

light detectors, and electrical impedance. One way the instrument can tell what type of

blood cell is present is by size. Other instruments measure different characteristics of the

cells to categorize them.

Because an automated cell counter samples and counts so many cells, the results are very

precise. However, certain abnormal cells in the blood may be identified incorrectly, and

require manual review of the instrument's results and identify any abnormal cells the

instrument could not categorize.

In addition to counting, measuring and analyzing red blood cells, white blood cells and

platelets, automated hematology analyzers also measure the amount of hemoglobin in the

blood and within each red blood cell. This information can be very helpful to a physician

who, for example, is trying to identify the cause of a patient's anemia. If the red cells are

smaller or larger than normal, or if there's a lot of variation in the size of the red cells, this

data can help guide the direction of further testing and expedite the diagnostic process so

patients can get the treatment they need quickly.

Automated blood counting machines include the Beckman Coulter LH series, Sysmex

XE-2100, Siemens ADVIA 120 & 2120, and the Abbott Cell-Dyn series.

• Manual blood count

Counting chambers that hold a specified volume of diluted blood (as there are far too

many cells if it is not diluted) are used to calculate the number of red and white cells per

litre of blood.

To identify the numbers of different white cells, a blood film is made, and a large number

of white cells (at least 100) are counted. This gives the percentage of cells that are of each

type. By multiplying the percentage with the total number of white blood cells, the

absolute number of each type of white cell can be obtained.

The advantage of manual counting (using helper tools like Grid cell counter) is that blood

cells that may be misidentified by an automated counter can be identified visually. It is,

however, subject to human error and sampling error because so few cells are counted

compared with automated analysis.

A complete blood count will normally include:

Red cells
 • Total red blood cells - The number of red cells is given as an absolute number per

litre.

• Hemoglobin - The amount of hemoglobin in the blood, expressed in grams per

decilitre. (Low hemoglobin is called anemia.)

• Hematocrit or packed cell volume (PCV) - This is the fraction of whole blood

volume that consists of red blood cells.

• Red blood cell indices

o Mean corpuscular volume (MCV) - the average volume of the red cells,

measured in femtolitres. Anemia is classified as microcytic or macrocytic

based on whether this value is above or below the expected normal range.

Other conditions that can affect MCV include thalassemia and

reticulocytosis.

o Mean corpuscular hemoglobin (MCH) - the average amount of

hemoglobin per red blood cell, in picograms.

o Mean corpuscular hemoglobin concentration (MCHC) - the average

concentration of hemoglobin in the cells.

• Red blood cell distribution width (RDW) - a measure of the variation of the RBC

population

White cells

• Total white blood cells - All the white cell types are given as a percentage and as

an absolute number per litre.

A complete blood count with differential will also include:

• Neutrophil granulocytes - May indicate bacterial infection. May also be raised in

acute viral infections.Because of the segmented appearance of the nucleus,

neutrophils are sometimes referred to as "segs." The nucleus of less mature

neutrophils is not segmented, but has a band or rod-like shape. Less mature

neutrophils - those that have recently been released from the bone marrow into the

bloodstream - are known as "bands" or "stabs". Stab is a German term for rod.
 • Lymphocytes - Higher with some viral infections such as glandular fever and.

Also raised in lymphocytic leukaemia CLL. Can be decreased by HIV infection.

In adults, lymphocytes are the second most common WBC type after neutrophils.

In young children under age 8, lymphocytes are more common than neutrophils..

• Monocytes - May be raised in bacterial infection, tuberculosis, malaria, Rocky

Mountain spotted fever, monocytic leukemia, chronic ulcerative colitis and

regional enteritis

• Eosinophil granulocytes - Increased in parasitic infections, asthma, or allergic

reaction.

• Basophil granulocytes- May be increased in bone marrow related conditions such

as leukemia of lymphoma.

A manual count will also give information about other cells that are not normally present

in peripheral blood, but may be released in certain disease processes.

Platelets

• Platelet numbers are given, as well as information about their size and the range

of sizes in the blood.

Interpretation

Certain disease states are defined by an absolute increase or decrease in the number of a

particular type of cell in the bloodstream. For example:

Type of Cell Increase Decrease

erythrocytosis or
Red Blood Cells (RBC) anemia or erythroblastopenia
polycythemia

White Blood Cells

leukocytosis leukopenia
(WBC):

-- lymphocytes -- lymphocytosis -- lymphocytopenia

 -- granulocytopenia or
-- granulocytes: -- granulocytosis
agranulocytosis

-- --neutrophils -- --neutrophilia -- --neutropenia

-- --eosinophils -- --eosinophilia -- --eosinopenia

Platelets thrombocytosis thrombocytopenia

All cell lines --- pancytopenia

Many disease states are heralded by changes in the blood count:

• leukocytosis can be a sign of infection.

• thrombocytopenia can result from drug toxicity.

• pancytopenia is generally as the result of decreased production from the bone

marrow, and is a common complication of cancer chemotherapy.

B. Actual

Complete Blood Count Results:

Diagnostic Result Reference Interpretation Significant Value

Test Values
WBC 12.4 x 10^ 9/L 4 – 10 High If high,

leukocytosis

If low, leukopenia

If high,
Lymph# 1.1 x 10 ^ 9/L .8 – 4.0 Normal
lymphocytosis

If low,

lymphocytopenia

Mid# 1.6 x 10^9/L .1- .9 High

Gran# 9.7 x 10^9/L 2.0-7.0 High If high,

granulocytosis

If Low,

granulocytopenia

Lymph% 8.6 % 20-40 Low

If high,

leukocytosis

If low, leukopenia

Mid% 13 % 3.0-9% High

Gran% 78.4% 50-70% High If high,

granulocytosis

If Low,
 granulocytopenia

Hemoglobin 131 g/L 110-150 Normal

RBC 4.36x10^ 12/L 3.5-5.0 Normal If high,

erythrocytosis or

polycythemia

If low, anemia or

erythroblastopenia

Hematocrit 40.6% 37-48 Normal If high,

Erythrocytosis

If low, anemia
MCV 93.2fL 82 – 95 Normal

MCH 30.0 pg 27-31 Normal

MCHC 322 g/L 320-360 Normal

RDW-SD 46.8 fL 35-56.0 Normal

Platelet 319x10^9L 100-300 High

If high,

thrombocytosis

If low,

thrombocytopenia

MPV 7.0fL 7 – 11 Normal

PDW 15.3 15- 17 Normal

PCT .223% .108-.282 Normal

BLOOD TYPE: O
IV. PERSON ASSESSMENT:

JUNE 23, 2008

Jesary Espiritu, 23 and at the early

P adulthood stage of development,

admitted due to lumbosacral pain and

continuous leakage of vaginal fluid. She

is

lives at Cabaroan Daya, Vigan with her

parents, four siblings and her partner.

Before hospitalization, she works at

Benjo’s drugs as a saleslady and does some

household chores like cleaning, washing

the clothes and cooking their foods. When I

handled her as my patient, she appears

weak and complains pain on her abdomen

that radiates to her back. During

orientation, she speaks in Ilokano and

restless. She has a little knowledge about

her condition as evidenced by the

verbalization of the patient as: “Apai gamin

ta kastoy, nakasaksakit met haan mo man

pay lang ikabkabil dayta ah (stethoscope).”

-During my shift, (she was transferred to
E/A DR At 9:05a.m.) she did not defecate nor

urinated.

-With time of sleep less than 1 hour due to

R labor pain.

-instructed patient to have bed rest to

prevent cord prolapse.

 -with no known allergies to food and drugs.

S -with medication (Hydralazine, Tramadol)

taken regularly as prescribed.

-BP-130/90mmHg

-Temp-36.6oC per axilla.

-with fair but dry skin

-with IVF of D5LR

-no wounds

-WBC count-12.4 x 10^ 9/L

-Lymphocyte count-1.1 x 10 ^ 9/L

- rapid breathing, clear breath sounds with

O no cough.

-respiration-37 cycles per minute

-pulse rate-61 beats per minute

-Hgb count-131 g/L

-Hct count-40.6%

N -with an IVF of D5LR 1L regulatef at 25

gtts/min at right basilic vein

-on NPO.

June 24,2008
 -During orientation, she lies on her bed and

P gradually changes her position.

-still weak in appearance

-complains post-operative pain.

-with an IFC at 100 cc level at 9:00 a.m.

E with yellowish color of urine and at 250 cc

level when pulled out at 11:30 a.m.

-(-) bowel movement

-with lochial discharge.

- (+) Difficulty in moving and complains

A/R pain when moving but increased activity

tolerance.

-had 5 hours of sleep.

-she does walking as tolerated in the

afternoon.
-no allergies to food and drugs.

S -with medications taken regularly as

prescribed.

-with post operative wound at the

abdominal area.

-BP-130/90mmHg

-Temperature-37.90C per axilla with fever

and taken PRN meds (Paracetamol 1 amp,

IV)

-WBC count-12.4 x 10^ 9/L

-Lymphocyte count-1.1 x 10 ^ 9/L

 -clear breath sounds

O -rapid breathing

-Respiration- 37cpm

-Pulse rate- 91 bpm

-Hgb count-131 g/L

-Hct count-40.6%

-with an IVF of D5Lr 1L regulated at 28

N gtts/min inserted at right cephalic vein.

-still on NPO in the morning and shifted to

liquid diet in the afternoon.

II. Patient’s Profile:

Name: Jesary Espiritu

Age:23 years old

Address: Cabaroan Daya, Vigan City

Civil Status: Single

Educational Attainment: High School Graduate at Vigan National High School West

Elementary: Cabaroan Daya Elementary School

Date of Birth: June 22, 1985

Occupation: Saleslady

Religion: Roman Catholic

Hospital Profile:

Date Admitted: June 23, 3008

Agency: Gabriela Silang General Hospital

Ward: OB Ward

Chief Complaint: Lumbosacral Pain

Admitting Diagnosis: Premature Rupture of Membarane

Admitting Physician: Dr. Judylyn Eugenio

OB History: G1P0

LMP: September ?, 2008

EDC: June ?, 2008

Vital Signs:

June 23, 2008: June 24, 2008

BP: 130/90 mmHg 130/90 mmHg

PR: 61 bpm 91 bpm

RR: 37 cpm 37 cpm

Temp: 36.6 oC per axilla 37.9oC per axilla

FHT: 138

III. History of Past and Present Illness:

Past Illnesses:
 My patient, Jesary Espiritu has an OB history of G1P0, started to have

menstruation when she was 14 years old and according to her she received complete

immunization, “adda gamin center diay barangay mi ading su ti nagpatudukan ni nanang

kinyak.” During assessment, she told me that there were no severe diseases that she

experienced before but just simple headache and fever and during her childhood years,

she had had chicken pox and measles, she also added that she never experienced to be

confined in the hospital. When I asked the patient if there are diseases relating to

pregnancy or reproductive system in their family, she answered none and added, “ni

tatang ko lang ti malagip ko nga nagasaksakit idi ngem asthma met ken adda TB na,

naconfine idi ngem diay ngato (medical ward) ken ni manong ngem gapu met diay saka

ta nu pinagsiksikog awan met problema ken diay pamilya mi.”

Past Illnesses Medications taken Consulted Not Consulted

1) Fever Paracetamol 
2) Headache Paracetamol, Alaxan 

Present Illnesses:

It was afternoon of June 21, 2008 (Saturday) when my patient experienced pain

on the part of her abdomen radiating on her back. She then rested for a while thinking

that it would relieve the pain and told me, “idi Sabado ket nasakit ngem haan unay ngem

di dumteng ti Domingon ket alla kumaro metten diay sakit nan.” According also to her it

was still Thursday 4 days before she was admitted she experienced leakage of fluid from

her vagina and experienced continuous urination. Due to persisting pain and leakage of

fluid she thought that she will already deliver her baby so her mother rushed her at

Gabriela Silang General Hospital last June 23 at dawn and admitted at the same day.

When I handled her as my patient, June 23, morning, she was already in labor and

experiencing increased episodes of lumbosacral pain. During assessment, she told me that

she experienced drinking alcohol but only in a little amount and told me, “bassit met

laeng ken diay sigarilyo diak met pinadpadas.” She had experienced prenatal check-up

twice during her pregnancy and regarding her diet, she eats everything. She also does

some heavy works before like washing their clothes and lifting heavy objects. She was

transferred to Delivery room at 9:05 am on the same day she was admitted but transferred
to Operating Room qt 1:40 p.m. and delivered a baby girl at 1:45 p.m. trough a caesarean

section.
VII. Pathophysiology:

A. Algorithm
RISK FACTORS:

Infection of the membranes

Idiopathic cause (Chorioamnionitis)
Cigarette Smoking during
pregnancy
Overdistention in multiple
pregnancy
Hydramnios
Over distention of the membranes Abruptio Placenta

Rupture of Amnion and Chorionic membranes

Leakage of Amniotic Fluid amount of Amniotic Fluid

pH of Vagina

increased risk for infection pressure between Compression of Cord

Signs and Symptoms: the membranes and umbilical cord by Prolapse

*Fever fetal parts fetal parts

* Increased WBC

Pulmonary Potter like

Hypoplasia Syndrome Fetal Circulation

Impairment

Fetal Hypoxia
XI. Summary and Copy of Updates:

Premature rupture of membranes is a rupture of fetal membranes with loss of amniotic

fluid during pregnancy between 36-40 weeks. The cause of PROM is unknown but the

most common cause is infection, Hydramnios, overdistention uterus in multiple

pregnancy and smoking. Signs and symptoms of PROM include:

• Leakage of fluid in the vagina (main manifestation of PROM)

• Constant wetness in the underwear

• The passage of fluid is followed by signs of labor: cervical dilatation, uterine

clamping, and pelvic pressure.

Complications of PROM:

• Premature labor and delivery of fetus

• Infections

• Cord Prolapse that may cause fetal hypoxia.

Management of PROM:

• Hospitalization

• Mother is put into bed rest

• If PROM occurred at term and labor does not begin in 24 hours, labor induction is

performed to prevent infection from prolonged rupture of membranes.

Frequency:

• Prom occurs in about ten percent of all pregnancies.

- My patient Jesary Espiritu was admitted because of Premature rupture of membranes,

and the signs of PROM like leakage of vaginal fluid was first experienced 4 days before
she was run in the hospital. She gave birth to a baby girl last June 23, 2008 thru a

caesarean section and discharged after one week of staying at the hospital.

B. Explanation:

Premature Rupture of Membranes is rupture of fetal membranes with loss of amniotic

fluid during pregnancy between 36-40 weeks of pregnancy. The cause of Premature

rupture of membranes is unknown but it is usually associated with infection of

membranes (Chorioamnionitis). It occurs 5-10% of pregnancies. Premature rupture of

membranes results from over distention of the membranes and this causes leakage of

Amniotic Fluid and that causes many complications. This leakage causes an alteration on

the pH of vagina because the amniotic fluid is alkaline and in turn increases risk for

maternal infection. Amniotic fluid serves as the cushion between the fetal parts and the

fetal membranes so the decreased amount of it causes an increase pressure between the

membranes and fetal parts that leads to potter like syndrome on the fetus when delivered.

Yet another complication for the fetus to stay in the non-fluid environment is the

compression of umbilical cord by fetal parts and also cord prolapse (extension of the cord

out of uterine cavity into the vagina) a condition that can interfere with fetal circulation

thereby causing fetal hypoxia.

If PROM is diagnosed without infection, they prolong pregnancy to provide more time

for fetal lungs to develop and mature. But if PROM is diagnosed with infection mother

goes antibiotic therapy and labor induction to prevent fetal infection and sepsis.
C. Promotive and Preventive:

To prevent PROM and other complications of Labor, a pregnant woman should:

• Have Pre-natal check up with the following schedules:

*From first visit to 32 weeks: every 4 weeks

*From 32 to 36 weeks: every 2 weeks

*from 36 weeks until delivery: every week

• Must complete her immunization of Tetanus Toxoid:

*TT1: Anytime during pregnancy (usually on the second trimester)

*TT2: One month after TT1. gives 3years protection to the mother and protects

infant from neonatal tetanus

*TT3: Six months after TT2. gives 5 years protection to the mother anom

neonatal tetanus.

*TT4: One year after TT3/next pregnancy. Gives ten years protection to the

mother and prevents neonatal tetanus.

*TT5: One year after TT4 and gives lifetime protection to the mother and infants

are protected.

• Refrain from drinking and smoking.

• Consult her health care provider if she feels any unusual signs of pregnancy

(severe bleeding, leakage of fluid in the vagina)

• If there is any leakage of fluid, hospitalization is necessary.

• If PROM is diagnosed, put mother on bed rest to prevent cord prolapse.

• Stop exercising if diagnosed with PROM already.

• Undergo labor induction if PROM occurred at term and labor does not begin in 24

hours to prevent infection from prolonged rupture.

DIET:

Daily Food Guide for Filipino Pregnant Women

Rice and alternatives 5 ½-6 cups of cooked rice where:

1 cup of cooked rice is equivalent to any of the

following:

• 4pcs pandesal of about 17 grams each

• 4 slices of loaf bread of about 17 grams each

• 1 pack of 30g instant noodles

• 1 cup cooked macaroni or spaghetti

• 1 small-sized root crop, about 180g or 1 cup

cooked, diced root crop

Fish, meat, poultry, dried At least 3 ½ servings where:

beans or nuts
1 serving of cooked meat is equivalent to:

• 30g or 30 cm cube

• 2 pieces medium-sized (55-60g each or about 16

inches long) fish

• 1 ½ cup cooked dried beans or nuts at least 3x a

week
Egg 1piece 3-4 times a week
Milk 1 glass whole milk (equivalent to 4 tablespoons of

powdered whole milk or ½ cup of evaporated milk

diluted with ½ cup of water.

Vegetables
Green leafy 3/4 cup cooked
Others 1 cup cooked
Fruits
Vitamin C-rich 1 medium size fruit or 1 slice of a big fruit
Others 1 medium size fruit or 1 slice of a big fruit
Fats and oils 7 teaspoons
Sugar 6 teaspoons
Water and beverages 6-8 glasses, 240 ml per glass

*Source: Nutritional Guidelines for Filipinos, 2000. Food and Nutrition Research

Institute-Department of Science and Technology

X. Discharge Plan:

M- edications:

-continue medications as prescribed by the physician

-take antibiotics for presence of infection if prescribed.

E- xercise

- active range of motion on extremities (flexion and extension) since patient undergone

major operation and these prevent contractures on the muscles.

- gradual ambulation without strenuous activities.

- deep breathing and coughing exercises to prevent hypostatic pneumonia.

- turning exercises in bed to prevent pressure ulcers.

T- reatment:

- must continue medications and should follow all the orders of the physician.

H- ealth Teachings:

- support the incision site.

- take a rest.

- commit self in diversional activities to alleviate pain.

 - upon resuming normal diet, eat foods rich in protein and Vitamin C for faster wound

healing and prevent infection.

O- PD

- have follow up check up every 2 weeks for the first month with her baby after

hospitalization and once a month for the succeeding months.

- She must complete her baby’s immunization.

D- iet

Foods to Eat more Foods to take in moderation

Green Leafy vegetables Fatty foods
High in protein foods Raw foods
High in Vitamin C foods
Have a balanced diet and a variety of nutritious foods.
IX. Drug Study

Name Ordered Dose Mechanism of Action Indication Contraindication Adverse Reaction Nursing

Responsibility
Tramadol -100mg slow IV every -centrally acting -relief of moderate to -contraindicated in -potential for abuse -reassess patient’s level

Hydrochloride 8 hours synthetic analgesic not moderately severe patients with -anaphylactoid of pain at least 3o

chemically related to pains. hypersensitivity to reactions minutes after

opioids. tramadol or other -Nausea and Vomiting administration.

opioids or acute -Seizures -Monitor CV and

intoxication with -dizziness respiratory status. With

alcohol or psychoactive hold dose if

drugs. respirations decrease or

-use cautiously in rate is below 12

pregnancy, lactation, breaths/minute.

sezures, contaminant -for better analgesic

use of CNS depressants effect, give drug before

or MAOI’s, renal onset of intense pain.

dysfunction, or hepatic -monitor risk for drug

impairment. dependence.
 Name Ordered Dose Mechanism of Action Indication Contraindication Adverse Effects Nursing

Responsibility
Hydralazine 25mg IV Acts directly on Parenteral: severe -contraindicated with -headache -assess hypersensitivity

Hydrochloride vascular smooth essential hypertension hypersensitivity to -orthostatic to hydralazine.

muscle to cause when drug can be hydralazine hypotension -give oral drug with

vasodilatation, primary given orally or when -use cautiously with -nausea and vomiting food to increase

arteriolar, maintains or need to lower Bp is CVAs or severe renal -rashes bioavailability (drug

increases renal and urgent. impairment and in -lupuslike syndrome should be given in a

cerebral blood flow. those taking other constant relationship to

antihypertensives. ingestion of food for

consistent response to

therapy)

-use parenteral drug

immediately after

opening ampule.
Hydralazine changes

color after contact with

metal and discolored

solutions should be

discarded.

-withdraw drug

gradually especially

from patients who have

experienced marked BP

reduction. Rapid

withdrawal may cause

a possible sudden

increase in BP.
 Name Ordered Dose Mechanism of Action Indication Contraindication Adverse Effects Nursing

Responsibility
Paracetamol 1 ampule IV PRN -thought to produce -relief of mild pain or -contraindicated in -rashes -many OTC and

analgesia effect. fever. patient’s hypersensitive -hypoglycemia prescription products

to drugs. contain acetaminophen.

-use cautiously in -use liquid form for

patients with long term patients who have

alcohol use because difficulty of

therapeutic doses cause swallowing.

epatotoxicity in these

patients.

B. Nursing Care Plan

 Assessment Nursing Diagnosis Scientific Background Nursing Nursing Interventions Rationale Evaluation

Objectives
Cues: -after 30 minutes Independent: June 23,2008 8:50

S: Pain due to uterine contractions, of rendering >assessed pain reports, >indicates need for a.m.
P: Chronic Pain
“Nagsakit met stretching of cervix and perineum nursing noting location, intensity, interventions and may After 30 minutes

ditoy ayan ti and due to pressure of fetal interventions to frequency and time of signal development of of rendering

tiyan ko apti toy

E: Related to
presenting part on surrounding the patient, she onset. Note nonverbal complications. nursing
uterine contractions
likod ko, haan ko organs. would experience cues. interventions,
and tissue
kayan aganak lesser pain as >Instructed patient to >efficacy of comfort patient still
stretching.
nak san!” as manifested by report pain as it develops measures and complains of pain

verbalized by the
S: Lumbosacral
decreased pain rather that waiting until medications is improved but was slightly

patient. and reports of level is severe. with timely intervention. decreased due to
pain
O: decreased >Performed palliative >promotes relaxation/ nursing
Facial Grimace
>facial grimace intensity of pain measures like massage on decreases muscle tension. interventions done

>weak in the affected area. as evidenced by

appearance >instructed patient with >promotes relaxation and lesser reports of

>complains deep-breathing to assist muscle. pain. Goal was

Lumbosacral techniques. partially met.

pain Collaborative:

Increased >Administer >provides relief from

Respiratory Rate analgesics/antipyretics. pain.

(Tachypnea): 37

cpm
 Assessment Nursing Diagnosis Scientific Background Nursing Objectives Nursing Interventions Rationale Evaluation
Cues: Independent June 25, 2008 7:45

S: After a day > Promoted surface > Cold application entails a.m.
P: Hyperthermia
“Nagbara toy of rendering nursing cooling by means of heat dissipation via After a day of

mairkriknak,” as interventions, the tepid sponge bath, evaporation and rendering nursing

verbalized by the
E: Related to
client’s body immersion, application conduction. Thus, heat is interventions, the
infection secondary
patient. temperature will of local ice packs lost thereby subsiding client’s body
to preterm rupture of
O: subside as would be especially on the groin or fever. temperature subsided
membranes without
>Fever- 37.9oC at manifested by a body axilla. as manifested by a
accompanying labor.
8 a.m. 38.10C at temperature ranging > Provided proper body temperature of

10:00 a.m.
S: >fever from 36.5 to 37.5 ventilation (opening > to create a cool 37.4 degrees Celsius,

(temperature taken degrees Celsius, windows) environment and as a absence of flushed

last June 24,2008) >Increased absence of flushed > Placed the client on means of convection. and warm-to-touch

WBC count and warm-to-touch bed rest. skin, and

>Increased WBC
skin, and > Placing the client on verbalization of the
count: 12.4 x 10^
 verbalization of the bed rest promotes client, “Haan unay
9/L
client, “Haan unay relaxation that would nabara ti riknakon.”

nabara ti riknakon.” cause decreased oxygen Goal was met.

demand by the body

Collaborative: furthermore decreasing

> Administered basal metabolic rate and

medications as achieving decreased body

prescribed by the temperature.

physician such as

antipyretic (Paracetamol

1 ampule). > Reduces fever by acting

directly on the

hypothalamic heat-

regulating center to

cause vasodilation and

sweating, which helps

dissipate heat.
 Assessment Nursing Diagnosis Scientific Background Nursing Objectives Nursing Interventions Rationale Evaluation
Cues: Independent:

S: Insufficient After 1-2 days of >Assisted patient in all > to preserve strength June 24, 2008 11:40
P: Activity
Reports of fatigue: physiological energy to rendering Nursing her activities an and prevent injury. Bed a.m.
Intolerance
“Nagsakit met gamin, endure daily activities interventions, patient instituted bed rest. rest is encouraged to After 1 day of

agkakapsotak payen E: Related to due to weakness and can already report prevent cord prolapse. rendering nursing

diak pay makapigsa generalized weakness labor pains. measurable increase in >Promoted comfort > enhances ability to interventions, patient

nga aggarawen,”as and Bed rest. activity tolerance as measures and provide participate in activities. reported measurable

verbalized by the evidenced by relief from pain. increase in activity

patient.
S: Verbalization of
verbalization of >Provided positive > helps to minimize tolerance e.g. sitting,
weakness
O: strength, “kayak met ti atmosphere while frustration and walking in near
Tachycardia
Increased Respiratory agpagna pagnan.” acknowledging rechannel energy. distance and verbalized
Weak in appearance
Rate (Tachypnea): 37 difficulty of situation “ kayak et ti agpagnan
Presence of pain
cpm for the client. ti asideg.” Goal was

Weak in appearance >Monitored Vital signs > to monitor maternal met.

Restlessness every 30 minutes. and fetal distress.

Complaints of > Extremities ate > exercise is helpful in

lumbosacral pain passively exercised preventing venous

through a full range of stasis which may

motion. predispose the patient

to thrombosis and

pulmonary embolus.

> Position changed > to prevent pressure.

gradually
 Assessment Nursing Diagnosis Scientific Background Nursing Objectives Nursing Interventions Rationale Evaluation
Cues: Independent:
P: Knowledge
S: Knowledge deficit due After 1-2 days of >Verified client’s level > provides opportunity June 24, 2008 8:00
Deficit
Inadequate knowledge to unfamiliarity of her rendering nursing of knowledge about her to assure accuracy and a.m.

on her condition as condition interventions, her condition completeness of After 1 day of

evidenced by the E: Related to first knowledge about her knowledge base for rendering nursing

verbalization of patient time of pregnancy and condition will increase future learning. interventions, her

as: “Apai gamin ta unfamiliarity on her to be evidenced by >Determined >provides insight knowledge about her

kastoy, nakasaksakit condition. cooperation to nursing motivation/expectations useful in developing condition is increased

met haan mo man pay interventions and for learning. goals and identifying as evidenced by

lang ikabkabil dayta ah

S: Verbalization of
participate in learning information needs. cooperation in nursing
inadequacy of
(stethoscope).” process. >Ascertained preferred >identifies best interventions and
knowledge.
methods of learning. approaches to facilitate learning process. Goal

learning process. was met.

>Identified/provided >use of multiple

information in varied formats increases

formats appropriate to learning and retention

client’s learning style. of material.

>Reviewed disease >provides knowledge

process and future base from which

expectations. patient can make

informed choices.

Collaborative:

>Identify available >provides additional

community opportunities for role-

resources/support modeling, skill

groups. training, anticipatory

problem solving.