REPORT INTRODUCTION AND NURSING WITH MATERNITY

PREMATURE RUPTURE OF MEMBRANES (PROM)

I.

BASIC CONCEPTS OF DISEASE

A. Definition
Premature Rupture of membranes (PROM) is rupture of /
rupture of the amniotic membranes prior to the commencement of
true labor or rupture of the amniotic membranes before the
pregnancy reaches 37 weeks with or without contractions
(Hamilton, G. M. 2009).
Premature rupture of membranes or preterm rupture of
membranes (PROM) is rupture of membranes before inpartu ie
when the opening of the primiparous less than 3 cm and in
multiparas less than 5 cm (Mitayani, 2012).
Premature rupture of membranes characterized by being water
discharge water from the vagina after 22 weeks gestation. Rupture
of amniotic membranes can occur in preterm pregnancies atauptun
term pregnancies Nugroho, T. 2011.
The time between, the rupture with his starts the delivery
process as latency period. Also called premature rupture when a
latency period of more than 1 hour.

B. Etiology
The exact cause of the PROM is not yet clear. However, there are
several factors associated with the occurrence of this KPD, which
are as follows.
1. Trauma: amniocentesis, pelvic examination, and sexual
intercourse.

2. Increased

intrauterine

polihidroamnion.
3. Infections of the

pressure,

vagina,

twin

cervix

or

pregnancy,

or

karioamnionitis

streptococci, as well as vaginal bacteria.

4. 4. The amniotic membrane has a weak structure / membrane is
too thin.
5. The abnormal state of the fetus as malpresentation.
6. Abnormalities in the cervix or genital apparatus such as the
size of a short cervix (<25 cm).
7. Multipara and increased maternal age.
8. Nutritional deficiencies.
Another factor causes are:
a. Factors blood type Due to the blood group of mothers and
children who do not fit can cause inherent weaknesses
including jarinngan weakness skin membranes.
b. Factors disproportion between the fetal head and the
mother's pelvis.
c. Factors multi

gravidity,

smoking

and

antepartum

haemorrhage.
d. Defisiesnsi nutrition of copper or ascorbic acid (Miranie,
Hanifa, and Desy Kurniawati. 2009).

C. Pathophysiology
Infection and inflammation can cause premature rupture of
membranes by inducing uterine contractions or focal weakness
skin and membranes. Many microorganisms ovaginal cervix,
produce phospholipids phospholipids A2 and C that can locally
increase the concentration of arachidonic acid, and further causes
the release of PGE2 and PGF2 alpha and further causes contraction
of the myometrium. On infection also produced secretory products
due to activation of monocytes / macrophages, ie cytokines,
interleukin 1, tumor necrosis factor and interleukin 6. Platelet
activating factor produced by the fetal lungs and kidneys of the
fetus that is found in the amniotic fluid, also synergistically

activate the formation of cytokines , Endotoxin into the amniotic

fluid will also stimulate cells to produce cytokines decidua and
then prostaglandins that lead to the commencement of delivery.
Local weakness or changes in the membranes of skin is another
mechanism the premature rupture of membranes due to infection
and inflammation. And a bacterial enzyme that is secreted or
products host response to infection can cause weakness and skin
rupture of membranes. Many cervicovaginal commensal and
pathogenic flora has the ability to produce protease and collagenase
which

lowers

the

tensile

strength

of

skin

membranes.

Polymorphonuclear leukocyte elastase specifically can break

kolagentipe III in humans, proving that the amniotic fluid
leukocyte infiltration of the skin that occurs due to bacterial
colonization or infection can cause a reduction in collagen type III
and

cause

premature

rupture

of

membranes.

Hidrolitiklain enzymes, including katepsin B, katepsin N, and

collagenase produced by neutrophils and macrophages, the skin
appears to weaken the membranes. Human inflammatory cells also
outlines plasminogen activator that converts plasminogen to
plasmin, a potential cause premature rupture of membranes.
D. Diagnostic Examination
1. Complete blood count to determine the presence of anemia,
infection.
2. Blood type and Rh factor.
3. The ratio of lecithin to spingomielin (the ratio of US):
determine fetal maturity.
4. Test ferning and paper nitrazine: ensure rupture of membranes.
5. Ultrasound: determining gestational age, fetal size, fetal heart
motion, and the location of the placenta.
6. pelvimetry: identification of the fetal position.
7. Clinical Manifestations Pregnant women usually present with
the release of amniotic fluid / amniotic fluid through the
vagina. Furthermore, if the long latency period, can occur

chorioamnionitis. To know that there have been infections are

initially with fetal tachycardia. Maternal tachycardia appeared
later, when the mother started a fever. If the mother's fever, the
diagnosis karioamnionitis can be enforced, and reinforced by
the visible presence of pus and smell the secretions.
Signs and gejela according to Dr. Typhoon can be:
a) The exit of amniotic fluid seeping through the vagina.
b) The smell of sweet-smelling amniotic fluid and do not
like the smell of ammonia, the liquid may still seeping
or dripping, with the characteristic pale and striped
color of blood.
c) This liquid will not stop atu dry as it continues to be
produced until birth. But when you sit or stand, the
head of the fetus that has been taken is usually "prop"
or "clog" leak for a while.
d) Fever, vaginal spotting many, abdominal pain, rapid
heart rate of the fetus beramba are signs of infection
occur

(Nugroho,

Dr.

hurricane.

2010).

Signs and gejela According to Arif Mansjoer, et al

include:
1. Exit the waters murky white, clear, yellow,
green or brownish piecemeal or all at once
much.
2. It can be accompanied by fever when there is an
infection.
3. Fetal easily palpable.
4. At check in the membranes does not exist, the
amniotic fluid is dry.
5. inspekulo: visible amniotic fluid flow or no
membranes

and

amniotic

(Mansjoer, Arif, dkk.2002)

E. Complications.

fluid

is

dry.

1. intra partum infection (chorioamnionitis) ascendens from

vagina to intrauterine.
2. Preterm delivery, if it occurs in preterm gestational age.
3. umbilical cord prolapse, fetal distress and can be up to fetal
death due to hypoxia (common in breech or transverse
layout).
4. Oligohydramnios, often dry parturition (labor cleaning) due
to amniotic fluid runs out.
F. Therapeutic Management
Therapeutic management of pregnancy and if there are any
signs of infection or not. The first step is to determine whether
amniotic membrane rupture completely. Urinary incontinence and
vaginal spending increase is a sign to suspect the occurrence of
rupture

rupture

of

the

amniotic

membranes.

To prove it, by using a sterile speculum in order to see amnioan

fluid collection around the cervix, or can also look directly
amniotic

fluid

that

comes

out

through

the

vagina.

Analysis of the paper will signify state nitiozine alkali from

amniotic fluid. Vaginal secretion of pregnant women have a pH
value between 7.0 to 7.2. If the paper does not show discoloration,
meaning negaatif test results that indicate membrane is not
ruptured membranes. If the test result is positive, then the color
changes of paper. This may indicate the occurrence of poisoning
due to urine, blood, and the provision of anti-septic that cause
cervical secretions become alkaline, so as to have a pH that is
nearly

equal

to

the

pH

of

amniotic

fluid.

Can also use the ferning test. Ferning tests used in conjuction
with a bit of amniotic fluid over the glass, then add a little sodium
chloride and protein. The result will be shaped like a fern. Results
of the test will be negative in the leakage that has occurred a few
days.
Can also be used test combinations, namely speculum

examination, tests with paper nitrazin, or ferning tests, making

diagnosis more accurate.
In the preterm pregnancy, the cervix is usually not good for
induction. Factors such as gestational age, the remaining amount of
amniotic fluid fetal lung maturity, should be taken into
consideration. Moreover, it should also be noted the presence of
infection in the mother and fetus.
Currently between 32-35 weeks gestational age need dlakukan
fetal lung maturity test and fluid in the vagina. Among these tests is
the test that measures the ratio of surfactant to albumin. Tests using
Phosphatidyl glycerol, or tests that calculate the ratio of lecithin to
spingomielin. Aminiosintesis and culture of bacteria is often done
if there are signs of infection. This test is useful to prevent
Respiratory Distress Syndrome (RDS) in infants if a baby is born.
Liggins and Howie (1972) showed that administration of
glucocorticoids

(betamethasone)

will

accelerate

fetal

lung

maturation and will reduce the incidence of RDS. However, due to

the increased incidence of neurological disorders and the potential
to increase the incidence of infection in newborns who were given
corticosteroids, then corticosteroids can not be recommended.
If the fetus is viable (less than 36 weeks) and want to maintain
pregnancy, mothers were asked to bed rest (bedrest). Give drugs
such as antibiotic prophylaxis to prevent infection also spasmolitik
to step up to the child variable. Tests of fetal lung maturity needs to
be done periodically, observation of infection and the onset of
labor, then labor may be done after the fetal lungs mature.
If the fetus was viable (more than 36 weeks) and the cervix is
ripe, do the induction of labor with oxytocin 2-6 hours after a latent
period, and given antibiotic prophylaxis. If the cervix is immature,
finalize the cervix with a prostaglandin and oxytocin infusion. In
the cases when the induction of parturition fails, then the operative
action.

Risk of infection in premature rupture of membranes is very

high, this is usually caused by organisms that exist in the vagina,
such as E. Colli, fastafis Streptococcus, Streptococcus hemoliticus,
Proteus, klebsietta, pseudomonas and stafilococcus. But fortunately
the incidence of infection is still low. This Because although
resikoinfeksi for inspection and delivery are very high, but the
amniotic

fluid

has

bacteriostatic

function.

If there korioamnitis, given antibiotics and will be better jiika

given intravenously. The most effective antibiotics, namely:
gentamicin,

cephalosporine,

and

ampiciline.

Management of patients with premature rupture indication by

Hamilton (2009: 391), Hidayat, Asri (2009: 17) and Nugroho
(2011: 7), among others:
1. Prevention
a. Treat gonococcal infection, chlamydia, and bacterial
vaginosis.
b. Discuss effects of smoking during pregnancy and support
efforts to reduce or stop.
c. Motivation to add enough weight during pregnancy.
d. Encourage your partner to stop coitus in the last trimester
when there presdisposisi factor.
2. Free anticipate: explain to patients who have a history of
following the current prenatal that they should immediately
report when rupture.
a. Conditions that cause rupture can lead to prolapse of the
umbilical cord:
- Location of the head in addition to vertex
- Polyhydramnios
b. Active herpes
c. History of prior infection streptokus beta hemolytic
3. If
the
membranes
have
ruptured
a. Instruct the patient to go to the hospital or clinic
b. Record the occurrence of rupture

1) Perform a thorough assessment. Strive to know the

time of the rupture.
2) If the membranes tear seemed rude:
- When the patient is lying on his back, hit the
fundus to look for bursts of fluid from the vagina
- Moisten a cotton swab with liquid and do smear
on a slide to examine under a microscope ferning
- Most of the fluid rubbed into Nitrazene paper.
- If positive, consider a diagnostic test when the
patient had not had sexual intercourse, no
bleeding, and no vaginal examination using KY
jelly
- When rupture of membranes and / or possible
signs of infection are unclear, do sterile speculum
examination.
- Assess the value of cervical Bishop (see the value
of bishops)
- Perform cervical culture only when there are signs
of infection
- Get another fluid specimen with a sterile swab is
daubed on the slides to examine under a
microscope ferning.
3) If the rate of gestational age less than 37 weeks
or patients infected with herpes type 2, refer to a
physician.
4. Conservative management
a. Most labor begins within 24-72 hours after the rupture.
b. The possibility of infection is reduced when there is no
tool inserted into the vagina, except sterile speculum; do
not do a vaginal examination.
c. While waiting, still monitor patients closely.
1) Measure the body temperature four times a day; when
2) the temperature rises significantly, and / or reach 38
C, give two kinds of antibiotics and delivery should
be completed.
3) Observation of vaginal discharge: a pungent odor,
purulent or yellowish indicate infection.
4) Note if there is tenderness and uterine irritability and
report any changes.
5. Management of Aggressive

a. Prostaglandin gel or Misoprostol (though not approved

for use) can be given after consultation with the doctor
b. It may take a series of Pitocin induction when the cervix
is unresponsive
c. Some experts waited 12 hours for the delivery. If there
is

no

mark,

began

giving

Pitocin

d. Give fluids by IV, fetal monitor

d. Increased risk of cesarean section if the induction is not
effective
e. When the decision depends on the feasibility of the
cervix to be induced, assess the value Bishop after
speculum examination. When it was decided to wait for
delivery, no more checks are carried out, either by hand
or manipulation of the speculum, until labor begins and
induction begins
f. Examination of the complete blood count when the
membranes rupture. Repeat the examination the next
day until delivery, or more often if there are signs of
infection
g. Perform NST (nonstress test) after rupture; watchful
presence of fetal tachycardia which is one of the signs
of infection
h. Start induction after consultation with a doctor if:
- The mother's body temperature to rise significantly
- There fetal tachycardia
- Lochea looks cloudy
- Irritability or significant uterine tenderness
- Culture vagina shows streptokus beta hemolytic
- Complete blood count showed an increase of white
blood cells
6. Management of labor more than 24 hours after the rupture
a. Spontaneous labor
1) Measure the patient's temperature every two hours,
give antibiotics when fever
2) Encourage internal fetal monitoring

3) Tell obstetrician and special child or neonatal nurse

practitioner
4) Perform the appropriate culture guide
Labor induction
1. Perform routine after consultation with the doctor
2. Take temperature every 2 hours
3. Antibiotics: antibiotics have various guidelines,
many of which provide 1-2 g of ampicillin per IV or
1-2 g mefoxin per IV every 6 hours as prophylaxis.
As for after the birth the need for nursing care in
newborns with a common goal:
a. Maintain BreathingImmediately aft er birth, the
baby is placed with the head lower than the body
so that the mucus out of the mouth and prevent
mucus and sometimes - sometimes blood and
meconium entered kesaluran breathing.
b. Aspiration of mucus must be done quickly and
gently Normal baby in a few seconds up to one
minute to clean the mouth and nose of mucus will
soon arise spontaneously breathing
c. Prevent Infection The most effective efforts to
prevent infection in newborns is to wash your
hands before handling the baby and supplies used
to care for the baby, isolating the sick infants and
wear clean clothes.
d. Pay
attention

to

body

temperature

Environmental temperature affects the life and

health of newborns, because if the ambient
temperature does not exist; baby's metabolism
and oxygen consumption will increase. Soon after
the baby is born to be dried and placed in a warm.
After the baby's body temperature stable usually

1-2 hours after birth, the baby was cleaned or

washed.
e. Know

the

signs

of

illness

The baby's condition can change rapidly because

it needs to be watched continuously. Some signs
of abnormalities that harts note for example the
skin, forehead on the first tire difficulty
breathing,

increase

or

decrease

in

body

temperature, blue or pale, bloated disease, eating

problems, vomiting, convulsions, not Chapter for
12 hours and Bak in 12 hours The first life and
decrease infant bodies lot.
II.

BASIC CONCEPTS NURSING

A. Assessment
1. Identity of the mother
2. Disease history
a. Current medical history: the mother comes to rupture before the
pregnancy reaches 37 weeks with or without complications
b. Advance medical history
o The existence of previous trauma due to the effect of
o
o
o
o
o
o

amniotic examination
Synthesis, pelvic examination and relationships seksusal
Multiple pregnancy, polyhydramnios
Infections of the vagina / cervix by germs streptikokus
Amniotic membrane weak / thin
Abnormal fetal position
Abnormalities in the cervix or genital muscles as short

cervical length
o Multiparity and increased maternal age and nutritional
deficiencies
c. Family health history: whether there is a complaint that another
mother who never conceive twins or twins derivatives
3. Physical examination
a. Head and neck
- The eyes should be examined at the sclera, konjugtiva

Nose: presence / absence of the nasal turbinate swelling.

Presence / absence of mucous hypersecretion. Mouth
dental caries / no, dry mouth mucosa and mucosa color

of teeth
The neck of the examination of the JVP, the KGB, and
thyroid

b. Chest
- Thoracic
Inspection

for

symmetry

chest,

breathing

kind

torakoabdominal, and no retraction of the chest wall. Normal

respiratory rate 26-24 times / min. ICTUS cardiac visible /
not.
Palpation:

no

swelling

breasts.

Auscultation: BJ1 sound IC and II in the left / right. Vesicular

breath sounds normal
Abdomen

Inspection:

no

no

scar,

striae,

and

linea.

Palpation: TFU, contraction is no / no, position, bladder full /

no
Auscultation: DJJ no / no
c. Genitalia
- Inspection: cleanliness, presence / absence of signs REEDA
(Red, Edema, Discharge, Approximately); expenditure
amniotic fluid (number, color, smell); and brownish pink
-

slime.
Palpation: cervical opening (0-4)
Extremities: edema, varicose no / no

B. Nursing Diagnosis
1. High risk of maternal infection associated with invasive procedures,
inspection, recurring vaginal and amniotic membrane rupture
2. Damage to the fetal gas exchange associated with the disease
3. High risk of injury to the fetus associated with premature delivery /
not mature
4. Anxiety related to a crisis situation, the threat to himself / fetus

5. High risk of spread of infection / sepsis associated with an infection,

invasive procedures, and an increased understanding of the
environment.
6. High risk of toxicity due to dose-related toxic / side effects of
tocolytic.
7. High risk of injury to the mother associated with surgical
intervention, the use of tocolytic drugs
8. intolerance activities associated with hypersensitivity muscle
9. High risk of fluid volume deficiency associated with decreased fluid
intake.

DAFTAR PUSTAKA
Asri Hidayat, Mufdilah, & Sujiyanti. 2009. Asuhan Patologi Kebidanan.
Yogyakarta: Nuha Medika.
Hamilton, G. M. 2009. Obstetri dan Ginekologi : Panduan Praktik Ed. 2. Jakarta:
EGC.
Mitayani. Asuhan Keperawatan Maternitas. Jakarta: Salemba Medika
Nugroho, T. 2011. Asuhan Keperawatan Maternitas, Anak, Bedah, Penyakit
Dalam.Yogyakarta: Nuha Medika.
Nugroho, T. 2011. Buku Ajar Obstetri Untuk Mahasiswa Kebidanan. Yogyakarta:
Nuha Medika.