JOMAR B.

MONTEZA
JULIANNE KRISTINE O. MOLINA

Premature Rupture of Membrane

Premature rupture of the membranes refers to spontaneous rupture of the amniotic membranes before the
onset of labor. Gestational age usually determines the plan and intervention. When the rupture of membranes
is before term and birth will be delayed, infection becomes a risk.

• If PROM occurs before 37 weeks of pregnancy, it is called preterm premature rupture of membranes
(PPROM). PPROM (before 37 weeks) accounts for one fourth to one third of all preterm births.
• Preterm rupture of membranes is rupture of fetal membranes with loss of amniotic fluid during
pregnancy before 37 weeks (Mercer et al., 2007). The cause of preterm rupture is unknown, but it is
associated with infection of the membranes (chorioamnionitis). It occurs in 5% to 10% of pregnancies.
Preterm labor may follow rupture of the membranes and end the pregnancy.
• PPROM is when the sac (amniotic membrane) surrounding your baby breaks (ruptures) before 37 weeks
of pregnancy. The cause of PPROM is unknown in most cases.

Prolonged rupture of membranes is when membrane rupture occurs more than 24 hours before the birth of
the baby.

ANATOMY AND PHYSIOLOGY

Fetal membranes
▪ Also known as amniochorionic membranes. Fetal membranes comprised of yolk sac, amnion, allantois,
and chorion. They function in the embryo’s protection, nutrition, respiration, and excretion. It cushions
the embryo, protecting it against bump and against pressure of maternal organs. And it permits fetal
movements. It protects from injury and provides lubrication for parturition.

Amniotic fluid is a clear, slightly yellowish liquid that surrounds the unborn baby (fetus) during pregnancy. It is
contained in the amniotic sac, the membranes or layers of tissue that hold the fluid. Amniotic fluid is responsible
for:

• Protecting the fetus: The fluid cushions the baby from outside pressures, acting as a shock absorber.
• Temperature control: The fluid insulates the baby, keeping it warm and maintaining a regular
temperature.
• Infection control: The amniotic fluid contains antibodies.
• Lung and digestive system development: By breathing and swallowing the amniotic fluid, the baby
practices using the muscles of these systems as they grow.
• Muscle and bone development: As the baby floats inside the amniotic sac, it has the freedom to move
about, giving muscles and bones the opportunity to develop properly.
• Lubrication Amniotic fluid prevents parts of the body such as the fingers and toes from growing together;
webbing can occur if amniotic fluid levels are low.
• Umbilical cord support: Fluid in the uterus prevents the umbilical cord from being compressed. This cord
transports food and oxygen from the placenta to the growing fetus.

WHAT CAUSES PREMATURE RUPTURE OF MEMBRANES?

In most cases, the cause of PROM is unknown. 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:

RISK FACTORS

• Low socioeconomic conditions (as women in lower socioeconomic conditions are less likely to receive
proper prenatal care).
• Sexually transmitted infections
• Cigarette smoking during pregnancy
• Having a preterm birth in a previous pregnancy
 • History of premature rupture of membranes
• Having an infection in your reproductive system
• Vaginal bleeding during pregnancy
• Overdistention of the uterus in multiple pregnancy and hydramnios
• Abruption placenta
• Obstetrical procedures:
▪ Application of cerclage
▪ Amniocentesis

CLINICAL MANIFESTATIONS (SIGNS AND SYMPTOMS)

• A sudden gush of fluid from your vagina.

• Leaking of fluid from your vagina.
• Constant wetness in underwear.
• The passage of fluid is followed by signs of labor: cervical dilatation, uterine cramping, and pelvic
pressure.

POSSIBLE COMPLICATIONS OF PREMATURE RUPTURE OF MEMBRANES

▪ Infections: endometritis, amnionitis, chorioamnionitis.

• Chorioamnionitis- is an infection of the placenta and the amniotic fluid. It happens more often
when the amniotic sac is broken for a long time before birth. The major symptom is fever. Other
symptoms include a fast heart rate, sore or painful uterus, and a bad smell from the amniotic fluid.
• Endometritis is an inflammation and infection of the uterus.
• Amnionitis- is an infection of the uterus, the amniotic sac (bag of waters), and in some cases, of the
fetus.
▪ Increased pressure on the umbilical cord from the loss of amniotic fluid, inhibiting the fetal nutrient
supply. Cord compression that may cause fetal hypoxia.
▪ Cord prolapse (extension of the cord out of the uterine cavity into the vagina), a condition that could
also interfere with fetal circulation. Cord prolapse is most apt to occur when the fetal head is still too
small to fit the cervix firmly.
▪ Separation of the placenta from the uterus (PLACENTAL ABRUPTION).
▪ Another risk to the fetus of remaining in a non-fluid-filled environment is the development of a Potter-
like syndrome or distorted facial features and pulmonary hypoplasia from pressure (Hofmeyr, 2009).
▪ Potter syndrome is a fatal congenital disorder characterized by the changes in physical
appearances of neonate due to oligohydramnios caused by renal agenesis and
impairment.
▪ Pulmonary hypoplasia is a condition in which the lungs are abnormally small, and do
not have enough tissue and blood flow to allow the baby to breathe on his or her own.
This can be a life-threatening condition.
▪ Primary antepartum hemorrhage.

DIAGNOSTIC CONSIDERATION

In addition to a complete medical history and physical examination, PROM may be diagnosed in several ways,
including the following:

• An examination of the cervix (may show fluid leaking from the cervical opening)
• Sterile vaginal speculum examination
• Testing the fluid using Nitrazine paper. Amniotic fluid causes an alkaline reaction on the paper (appears
blue) and urine causes an acidic reaction (remains yellow). Amniotic fluid typically has a pH of 7.1–7.3,
while normal vaginal secretions have a pH of 4.5–6.0.
• Looking at the dried fluid under a microscope (may show a characteristic fern-like pattern). The typical
appearance of a high-estrogen fluid on microscopic examination (amniotic fluid shows this; urine does
not).
• The presence of a high level of alpha-fetoprotein (AFP) in the vagina is also diagnostic (Shahin & Raslan,
2007).
 • Ultrasound. A diagnostic imaging technique that 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 how much fluid is around the baby. It will assess the amniotic fluid index.

MANAGEMENT/ TREATMENT

Treatment for premature rupture of membranes may include:

• If PROM occurred at term and labor does not begin in 24 hours, labor induction is performed to deliver
the baby and prevent infection from prolonged rupture. Put mother on bedrest to prevent cord prolapse.

▪ Monitor: maternal vital signs; FHT every hour; character of vaginal discharge: smell, color,
amount; uterine contractions: duration, intensity, frequency, and interval.
▪ Allay fears of the mother by informing her of the progress of labor and the condition of the fetus.
▪ Provide comfort measures for painful uterine contractions such as sacral pressure, back rub,
frequent changes of position, breathing techniques and frequent emptying of the bladder if the
woman is not catheterized.
▪ Discourage bearing down until cervix is fully dilated.

• If a woman is diagnosed with PPROM with infection present, the mother is put on antibiotic therapy and
the fetus is delivered with labor induction, regardless of the age of gestation to prevent fetal infection
and sepsis.
• If a woman is diagnosed with PPROM without evidence of infection, active labor, or fetal compromise,
the current standard management is to prolong pregnancy to provide more time for fetal lungs to
mature. In some cases of PPROM, the membranes may seal over spontaneously and the fluid may stop
leaking without treatment.
• Hospitalization
• Expectant management (in very few cases of PPROM, the membranes may seal over and the fluid may
stop leaking without treatment, although this is uncommon unless PROM was from a procedure, such as
amniocentesis, early in gestation).
• 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.
• Women with PPROM usually deliver at 34 weeks if stable. If there are signs of abruption,
chorioamnionitis, or fetal compromise, then early delivery would be necessary).

Medicines:

▪ Corticosteroids: these medicines can help your baby’s lungs grow and mature. If your baby is born early,
their lungs may not be able to work on their own.
▪ Antibiotics: to prevent or treat and infection.
▪ Tocolytic medicines: these are used to stop preterm labor.

Note: If a fetus is estimated to be mature enough to survive in an extrauterine environment at the time of
rupture and labor does not begin within 24 hours, labor contractions are usually induced by intravenous
administration of oxytocin so the infant is born before infection can occur.

Therapeutic Management
• If labor does not begin and the fetus is not at a point of viability, a woman is placed on bed rest either in
the hospital or at home and administered a corticosteroid to hasten fetal lung maturity.
• Prophylactic administration of broad-spectrum antibiotics during this period may both delay the onset
of labor and reduce the risk of infection in the newborn sufficiently to allow the corticosteroid to have
its effect.
 • Women positive for Streptococcus B need intravenous administration of penicillin or ampicillin to reduce
the possibility of this infection in the newborn.
• A woman with no signs of infection may be administered a tocolytic agent if labor contractions begin
(Mercer, 2007). Although its effectiveness is not well documented, a woman might be given an
amnioinfusion to reduce pressure on the fetus or cord and allow a term birth (Hofmeyr, 2009).
• Following endoscopic intrauterine procedures, membranes can be resealed by use of a fibrin-based
commercial sealant so they are again intact. This is a future possibility for premature rupture of the
membranes also.

NURSING DIAGNOSES AND RELATED INTERVENTIONS

Nursing Diagnosis: Risk for infection related to preterm rupture of membranes without accompanying labor.

Nursing Interventions:

• If at home, a woman is asked to take her temperature twice a day and to report a fever (a temperature
greater than 100.4° F [38.0° C]), uterine tenderness, or odorous vaginal discharge.
• Advice the patient to refrain from tub bathing, douching, and coitus because of the danger of introducing
infection.
• The white cell count will need to be assessed frequently, perhaps as often as daily. A count of more than
18,000 to 20,000/mm3 suggests infection. The normal number of WBCs in the blood is 4,500 to 11,000
WBCs per micro liter. Normal value ranges may vary slightly among different labs.
• Before a woman is discharged to home care, be certain she knows how to read a thermometer, she has
specific instructions regarding what degree of temperature she should report, and she
understands what degree of bed rest is expected of her. Help her make arrangements for a daily white
blood cell count through a laboratory service or home care nurse.

Nursing Diagnosis: Risk for infection related to loss of protective barrier as evidence by positive fern test.

Nursing Interventions:

• Assist the patient in a comfortable position for her to be able to rest.

• Assess the patient from any signs and symptoms of infection every 4 hours while hospitalized.
• Initiate fetal monitoring every 4 hours.
• Educate the patient on 6 signs and symptoms of infection the patient should watch for.

Nursing Diagnosis: Risk for infection related to invasive procedures, recurrent vaginal examination, and amniotic
membrane rupture.

Nursing Interventions:

• Perform initial vaginal examination, when the contraction pattern repeat, or maternal behavior indicates
progress.
• Monitor temperature, pulse, respiration, and white blood cells as indicated.
• Give prophylactic antibiotics when indicated.

Nursing Diagnosis: Anxiety related to perceived threat to self and fetus as evidence by apprehension.

Nursing Interventions:

• Assess patient’s level of anxiety.

• Acknowledge awareness of patient’s anxiety.
• Explain the procedures, nursing interventions, and treatment regimen. Keep communication open;
discuss with the patient the possible side effects and outcomes while maintaining an optimistic
attitude.
• Orient patient and partner to labor suite environment.
Prevention of premature rupture of membranes
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.

Fetal membranes are comprised of:

Yolk sac originates from fetal midgut. Nutrient supply for early embryo. Absorbs uterine secretions from
endometrium to stimulate early embryonic development.

Amnion is an innermost membrane directly surrounding the fetus. Protects from injury and provides lubrication
for parturition. Prevents lung collapse and opens digestive tract.

Allantois originates from the gut and forms the umbilicus. Support the blood vessels. Reservois of the nutrients
and wastes.

Chorion- outermost membrane in direct contact with uterine tissue. Becomes vascularized by allantoic vessels.
site of hormone production, nutrient and gas exchange.