Pathophysiology
The rupture of fetal membranes (water breaks) before the beginning of labor is considered a complication of pregnancy known as premature rupture of membranes. This can happen at any gestational age, even full term. Despite what movies may depict, this sudden gush or steady trickle of fluid only occurs in about 10% of term pregnancies and 4% of preterm pregnancies. When the membranes rupture prior to 37 weeks gestation, it is considered preterm premature rupture of membranes (PPROM). Regardless of gestational age, when the membranes rupture, the protective barrier between the vagina and the fetus is lost and increases the risk of maternal and fetal infection.
Etiology
There is no specific cause, but there are many factors that may increase the risk of PROM. Maternal or intra-amniotic infection and chronic disease, such as systemic lupus erythematosus, direct abdominal trauma, nutritional deficiencies, smoking and placenta abruption all increase the risk of PROM. Multiple pregnancy (twins or more) and a history of previous PROM also indicate an increased risk.
Desired Outcome
Patient will be free from infection (maternal and fetal); viable birth
Premature Rupture of Membranes (PROM) / Preterm Premature Rupture of Membranes (PPROM) Nursing Care Plan
Subjective Data:
- Sudden gush or steady trickle of clear fluid from vagina
Objective Data:
- Blue nitrazine paper test – turns dark blue if positive for amniotic fluid
- Visual pooling of amniotic fluid in vagina
Nursing Interventions and Rationales
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Assess for signs of infection
Maternal and fetal infection may prompt PROM and must be treated quickly to avoid fetal compromise.
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Perform single digital or sterile speculum vaginal exam
Vaginal exam may be required to confirm diagnosis, but avoid multiple digital vaginal exams to reduce the risk of infection. Reserve these exams for when delivery is imminent.
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Obtain history from patient regarding complications and status of pregnancy.
- Treatment depends on gestational age and existing complications
- Patient may need to remain on bed rest to continue pregnancy if preterm, or labor may be induced.
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Initiate fetal monitoring
PROM may be an indicator of fetal distress. Monitor for signs of fetal compromise to include changes in fetal heart rate.
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Administer medications and IV fluids as appropriate
- Prophylactic antibiotics
- Corticosteroids
- Tocolytics
- Magnesium sulfate
- PPROM may indicate a need for corticosteroids to speed up the fetal lung maturity
- Antibiotics are given prophylactically to prevent infection
- Tocolytics may be given to stop preterm labor
- Magnesium sulfate may be given if prior to 32 wks gestation to prevent fetal neurological dysfunction
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Prepare patient for induction of labor and delivery
If indicated, labor will likely be induced if it does not spontaneously begin within 12-24 hours. Explain process to patient to reduce fears.
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Provide patient education if preterm
- Pelvic rest
- Avoid tampons and intercourse
- Avoid tub baths (showers ok)
- If delivery is not indicated(<34 wks gestation), patient will likely remain in the hospital until delivery is an option.
- Regardless of location, patient will be required to remain on bed rest and antibiotics will continue prophylactically until delivery.
References
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
For more information, visit www.nrsng.com/cornell
