Nursing Care of

the High Risk

Prenatal Client
NCM109A: Care of Mother, Child and Adolescent At
Risk or with Problems
(Acute & Chronic)

Harlene Rose Razote-Cayat, RN

Preterm Premature Rupture
of Membranes (PPROM)

Premature Rupture
of Membranes
(PROM)
 ❑ CAUSES
1. Infection
2. Other risk factors that have been linked to PROM are:
✓ Low socioeconomic conditions

✓ STI

✓ Previous preterm birth

✓ Overdistention of the uterus

✓ Cigarette smoking
 ❑ CAUSES ❑ COMPLICATIONS
3. Obstetrical procedures:
1. Premature labor and
✓ Application of cerclage
delivery of the fetus
✓ Amniocentesis
2. Infections
4. Unknown causes
3. Cord prolapse and
compression
 ❑ SIGNS and SYMPTOMS
1. Leakage of fluid in the vagina
2. Diagnostic Tests:
a. Fern Test c. Ultrasound
b. Vaginal speculum examination
3. Constant wetness
4. Signs of labor
• In TERM PROM: labor often begins within 24 hours after
the BOW ruptured
• In PRETERM PROM: labor can be delayed up to a week or
more after PROM
 ❑ MANAGEMENT
1. Report to the health care provider passage of fluid from her
vagina
2. Hospitalization
3. Labor induction
• If PROM occurred at term and labor does not begin in 24
hours
a. Put client on bedrest
b. Monitor:
✓ Maternal VS ✓ FHT
 ❑ MANAGEMENT
b. Monitor:
✓ Character of vaginal discharge
✓ Uterine contractions

c. Allay fears of the mother

d. Provide comfort measures for painful uterine contractions
e. Administer prescribed medications and monitor
patient’s response
f. Discourage bearing down until cervix is fully dilated
 ❑ MANAGEMENT
4. If a woman is diagnosed with preterm premature rupture of
membranes with infection present:
✓ Antibiotic therapy: mother
✓ Labor induction: fetus

5. Expectant Management
a. Avoid routine digital examination
b. Proper perineal care
c. Bedrest
 ❑ MANAGEMENT
5. Expectant Management
d. Administer prescribed medications:
✓ Tocolytics ✓ Betamethasone
✓ Prophylactic antibiotics
e. Monitor for:
✓ Signs of infection ✓ Uterine contractions
✓ Fetal well-being
f. Report to physician assessments that deviate from normal
g. Intrauterine amnioinfusion
Preterm
Labor
 PRETERM LABOR (PTL)
➢ characterized by regular uterine contractions that are strong
enough to cause significant cervical dilation and effacement

❑DEFINITION OF TERMS:
▪ Low birth weight infant ▪ Appropriate for gestational
age
▪ Very low birth weight infant
▪ Extremely low birth weight infant ▪ Small for gestational
age (SGA)
▪ Large for gestational age (LGA)
 ❑ RISK OF PREMATURE BIRTH TO
INFANTS
1. Respiratory Distress Syndrome (RDS)
2. Pathologic apnea 8. Anemia
3. Infections 9. Jaundice
4. Congenital heart defects
10. Increased
5. Thermoregulation problems susceptibility to
6. Feeding difficulties infection

7. Neurologic disorders
 ❑ CAUSES/RISK FACTORS
1. A history of previous PTL with an early delivery
2. One or more spontaneous 2nd-3rd trimester abortions
3. Epidemiological factors. Higher incidence among women in:

✓ Low socioeconomic status

✓ Low pre-pregnancy weight
✓ Pregnancy age of <18 years or >40
✓ Maternal smoking
 ❑ CAUSES/RISK FACTORS
3. Epidemiological factors. Higher incidence among women in:
✓ Use of cocaine
✓ Stressful living conditions
✓ Job that requires physical labor
✓ Teenage primigravida
✓ Multiparity

4. Overdistention of the uterus

5. Uterine abnormalities
✓ Unicornuate or bicornuate uterus
 ❑ CAUSES/RISK FACTORS
5. Uterine abnormalities
✓ Fibroid tumors
✓ Cervical incompetence
✓ Previous uterine surgery
✓ Shorter cervix

6. Maternal infections:
✓ STD
✓ Asymptomatic bacterial infections
 ❑ CAUSES/RISK FACTORS
6. Maternal infections:

✓ Untreated acute pyelonephritis, pneumonia

✓ Bacterial vaginosis
7. Serious maternal conditions:
✓ Dehydration
✓ Chronic hypertension
✓ Diabetes
✓ Poor maternal nutrition
 ❑ CAUSES/RISK FACTORS
8. Premature rupture of membranes
9. Infection of amniotic fluid
10. Congenital malformation of the fetus and placenta
11. Fetal death
12. Abnormal placentation
13. Retained IUD
14. Complication of pregnancy that requires immediate
delivery of the fetus regardless of gestational age
15. Unknown causes
 ❑ SIGNS and SYMPTOMS
1. Regular uterine contractions accompanied by:
✓ Progressive cervical changes
✓ Cervical dilation of 2cm or more
✓ Cervical effacement of 80% or more
✓ Duration of at least 30 seconds
2. Menstrual like cramping
3. Watery or bloody vaginal discharge
4. Low back pain
 ❑ SIGNS and SYMPTOMS
5. Intestinal cramps with or without diarrhea
6. Pelvic pressure
7. Biochemical markers of PTL:
a. Fetal Fibronectin Enzyme
✓ intact membranes
✓ less than 3cm dilated
✓ swab between 22 and 34 weeks gestation
b. Salivary estriol
 ❑ MANAGEMENT
1. Regular prenatal check-up
2. Prenatal screening
3. Provide patient education on the following areas:
✓ Lifestyle modification
✓ Signs and symptoms of PTL

✓ Teach how to palpate for contractions, the importance of

this twice-a-day exercise
 ❑ MANAGEMENT
3. Provide patient education on the following areas:
✓ Contact healthcare provider
✓ Effects of a preterm birth to the neonate
4. When PTL occurs, an attempt to stop the uterine contractions is
made if:
a. fetus is <32 weeks and will benefit from further intrauterine
stay
b. Membranes are intact
c. There is no fetal distress
 ❑ MANAGEMENT
4. When PTL occurs, an attempt to stop the uterine contractions is
made if:
d. There is no vaginal bleeding
e. Cervical dilatation is not >4cm
f. effacement is not >50%

5. NST is performed on a regular basis

6. Place client on bedrest on left side lying position
7. Hydration
 ❑ MANAGEMENT
8. Administer prescribed medications:
✓ Prophylactic antibiotic therapy
✓ Drug to hasten lung maturity
✓ Tocolytic therapy
a. Magnesium Sulfate
b. Terbutaline
• Side effects: tachycardia, hypotension,
dysrhythmias, chest pain, nervousness, n/v,
headache & hyperglycemia
 ❑ MANAGEMENT
8. Administer prescribed medications:
✓ Tocolytic therapy
a. Magnesium Sulfate
b. Terbutaline
• This drug should be used WITH CAUTION in clients
with thyroid disease and DM and CONTRAINDICATED
in patients with cardiac disease
• Terbutaline should be administered in a piggy back
method using microdrip tubing and an infusion
pump.
 ❑ MANAGEMENT
8. Administer prescribed medications:
✓ Tocolytic therapy
a. Magnesium Sulfate
b. Terbutaline
• Monitor BP and PR every 15 minutes then every 30
minutes
• Monitor FHT every 30 minutes
• Report PR >120bpm, BP below 90/60, dyspnea, rales,
chest pain and cardiac arrhythmias
 ❑ MANAGEMENT
8. Administer prescribed medications:
✓ Tocolytic therapy
a. Magnesium Sulfate
b. Terbutaline
• Tocolytic therapy is continued for 24 hours after
uterine contractions stopped and oral
administration is begun 30 minutes before
discontinuing IV tocolytic therapy
c. Ritodrine
d. Prostaglandin inhibitors
 ❑ MANAGEMENT
9. Home Management

a. Prenatal visit is weekly

b. Bedrest, avoidance of fatigue, strenuous activities
psychological stress
c. Abstinence from sexual activity
d. Maintenance of proper hydration
e. Advice woman to stop cigarette smoking and alcohol
consumption
 ❑ MANAGEMENT
9. Home Management

f. Tocolytic therapy continued at home

✓ Take medications STRICTLY on time
✓ If she MISSED A DOSE—take the drug as soon as
she remembers it but she should not double the
dose
✓ Call health provider if PR >120bpm
 ❑ MANAGEMENT
9. Home Management
g. Instruct client that if strong uterine contractions occur at
home:
✓ Empty her bladder
✓ Drink 2-3 glasses of water
✓ Lie down on her left side
✓ If uterine contractions continue after an
hour—notify health care provider
 ❑ MANAGEMENT
9. Home Management

h. Instruct to monitor fetal well being

i. Home Uterine Activity Monitoring(HUAM)

 ❑ MANAGEMENT
10. If delivery cannot be prevented:

✓ Sedatives and analgesics are kept to minimum

✓ If fetus is VERY IMMATURE, delivery is by CS

✓ Amniotomy
✓ The cord of preterm infant is cut immediately without
waiting for pulsations to stop
 THANK
YOU NCM109A
Sources:
Pillitteri, A. & Silbert-Flagg, J. (2018). Maternal and Child Health Nursing: Care
of the Childbearing & Childbearing Family (8th edition). Lippincott Williams &
Wilkins.

Evangelista-Sia, M. (2011). Outline In Obstetric for Nurses and Midwives (4th

edition). MESIA Publishing.

•Murray, S., McKinney, E., Holub, K. & Jones, R. (2019). Foundations of Maternal-
Newborn and Women’s Health Nursing (7th edition). Elsevier.