PREMATURE RUPTURE OF MEMBRANE

- Premature rupture of membranes (PROM) is when the amniotic sac (membrane)

ruptures before labor starts. Preterm premature rupture of membranes (PROM) is the
term used when PROM occurs before 37 weeks of pregnancy (PPROM). About 8 to 10
percent of pregnancies result in PROM. Between one-fourth and one-third of all
preterm births occur before 37 weeks.
A natural thinning of the membranes or the force of contractions may result in
membrane rupture close to the end of pregnancy (term). PPROM before term is
frequently brought on by a uterine infection.

FOCUS ASSESSMENT (Signs and Symptoms)

- Unless difficulties arise, leakage or a sudden flow of fluid from the vagina is typically the
only indication of PROM. An intra-amniotic infection is strongly suggested by fever,
copious or unpleasant vaginal discharge, abdominal pain, and fetal tachycardia,
especially if they are not proportional to the mother's temperature.

DIAGNOSTIC AND LABORATORY TEST

- A comprehensive history, physical examination, and chosen laboratory tests are

necessary for the diagnosis of PROM. Patients frequently describe a sudden surge of
fluid followed by ongoing leaks. Physicians should inquire if the patient is feverish,
contracting, ovulating, or bleeding vaginally. The patient's expected due date must be
confirmed because it will guide any additional treatment.

 Vaginal pooling of amniotic fluid or visible vernix or meconium

 Evaluation of vaginal fluid showing ferning or alkalinity (blue color) on Nitrazine
paper
 Sometimes ultrasound-guided amniocentesis with dye for confirmation

- Sterile speculum examination is done to verify PROM, estimate cervical dilation, and
obtain samples for cervical cultures. Digital pelvic examination, particularly multiple
examinations, increases risk of infection and is best avoided unless imminent delivery is
anticipated.
  Fetal position should be assessed.
- If subclinical intra-amniotic infection is a concern, amniocentesis (obtaining amniotic
fluid using sterile technique) can confirm this infection.

 Pearls & Pitfalls

- If prelabor rupture of membranes is suspected, avoid doing digital pelvic examinations
unless delivery seems imminent.

RISK FACTORS

 Rupture of the membranes near the end of pregnancy (term) may be caused by a
natural weakening of the membranes or from the force of contractions. Before term,
PPROM is often due to an infection in the uterus. Other factors that may be linked to
PROM include the following:

 Low socioeconomic conditions (as women in lower socioeconomic conditions are less
likely to receive proper prenatal care)
 Sexually transmitted infections, such as chlamydia and gonorrhea
 Previous preterm birth
 Vaginal bleeding
 Cigarette smoking during pregnancy

PATHOPHYSIOLOGY (Diagram)
NURSING DIAGNOSIS BY PRIORITY (3 with rationale)

NURSING MANAGEMANT / INTERVENTION

 Explain the procedures, nursing interventions, and treatment regimen.

Information and knowledge of the reasons for these activities can decrease fear of the
unknown. Clients desire honest and complete information, an opportunity to answer questions,
and an explanation of medical terms, procedures, and expectations of care conferred in the
language they understand and at the appropriate literacy level (Griggs et al., 2020).

 Encourage verbalization of fears or concerns.

The nurse should assess the client’s views of their pregnancy at the time of preterm labor.
Incorporating this type of assessment will help provide individualized empathetic care (Griggs et
al., 2020). Saisto et al., (2006) found that support interventions for pregnant women, which
included discussions of concerns and feelings about birth, taught positive birth imagery (Kao et
al., 2017).

 Provide relaxation-focused nursing care to the client.

Relaxation-focused nursing care (RFNC) was created using Hypnobirthing and the Transactional
Model. Hypnobirthing philosophy aims to reduce stress, fear, and tension in the pregnant
woman by creating positive thoughts and emotions using the laws of mind. The Transactional
Model defines stress as a special relationship between a person and the environment. It
identifies the stressors of the person and indicates how they should be handled. RFNC is formed
by using these two models and comprises positive language, a positive environment, and
reducing stressors. RFNC may reduce the client’s state of anxiety, lower cortisol levels, and thus
prevent preterm labor by lowering the severity of uterine contractions (Özberk et al., 2020).

MEDICAL / SURGICAL MANAGEMENT

- Management of patients with prelabor rupture of membranes is determined by

gestational age.

 Early term and term patients (37 0/7 weeks of gestation or more): proceed to delivery
and Group B Streptococcus prophylaxis should be administered as indicated
 Late Preterm (34 0/7- 36 6/7 weeks of gestation): same for early term and term
 Preterm (24 0/7 – 33 6/7 weeks of gestation): expectant management, latency
antibiotics, single course of corticosteroids, GBS prophylaxis as indicated
Less than 24 weeks of gestation: patient counseling, expectant management or
induction of labor, antibiotics can be considered as early as 20 0/7 weeks of gestation,
GBS prophylaxis/corticosteroids/tocolysis/magnesium sulfate are not recommended
before viability
 Nonreassuring fetal status and chorioamnionitis are indications for delivery. If the
patient presents with vaginal bleeding, there may be a concern for a placental abruption
and delivery should be considered. The decision for delivery should be made based on
fetal status, amount of bleeding, the stability of mother, and gestational age. In a term
patient, if spontaneous labor does not occur near the time of presentation, labor should
be induced.