Nursing Care Plan for Premature Rupture of Membranes (PROM) / Preterm Premature Rupture of Membranes (PPROM)

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

Nursing Interventions and Rationales

Assess for signs of infection

Maternal and fetal infection may prompt PROM and must be treated quickly to avoid fetal compromise.

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.

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.

Initiate fetal monitoring

PROM may be an indicator of fetal distress. Monitor for signs of fetal compromise to include changes in fetal heart rate.

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

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.

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

• https://www.merckmanuals.com/professional/gynecology-and-obstetrics/abnormalities-and-complications-of-labor-and-delivery/premature-rupture-of-membranes-prom
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492588/
• https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&ContentID=P02496