Premature Rupture of Membrane

By:
Ferry, Savina Thalitha Cumi
Pajares, Jan Resty
Napolitano, Arriane Yessamin
Sumiller, Jayson Neil
 Definition
• Premature Rupture of
Membranes (PROM) is
defined as rupture of
membranes before the
onset of labor. When
membrane rupture
occurs before labor
and before 37 weeks
of gestation, it is
referred to as preterm
PROM (PPROM).
 Prevalence and
Statistics
• The incidence of PROM
ranges from about 5%
to 10% of all deliveries,
and PPROM occurs in
approximately 3% of all
pregnancies.
• Approximately 70% of
cases of PROM occur in
pregnancies at term,
but in referral centers,
more than 50% of
cases may occur in
preterm pregnancies.
 Anatomy and Physiology
The fetal membranes consist of the chorion and the
amnion.
 Terms
• Amnion is the inner membrane that surrounds
the embryo. It is filled with amniotic fluid that
holds the embryo in suspension
• Chorion surrounds the embryo, the amnion, and
other membranes. It also acts as a protective
barrier during the embryo's development.
• Chorioamnionitis (also known as intra-amniotic
infection (IAI) is an inflammation of the fetal
membranes (amnion and chorion) due to a
bacterial infection.)
 Pathophysiology
• Low socioeconomic conditions (as women in
lower socioeconomic conditions are less likely to
• Smoking (especially < 28 weeks gestation).Previous
receive proper prenatal care)
PROM/ pre-term delivery.

• Sexually transmitted infections, such as chlamydia

• Vaginal bleeding during pregnancy.
and gonorrhea

• Lower genital tract infection.

• Previous preterm birth

• Vaginal bleeding

• Cigarette smoking during pregnancy

• Unknown causes

Chorioaminionitis Uterine and fetal infections Pressure to the umbilical cord or cord Potter-like syndrome
relapse

• Maternal fever (this is the most important clinical sign of the infection)
• Diaphoresis (excessive sweating)
• Fever • Bradycardia • Widely separated
• Uterine Tenderness
• Hypotension (low blood pressure)
• Foul-smelling amniotic
• Fetal distress eyes with epicanthal

• Uterine tenderness fluid •

folds

• Significant maternal tachycardia (heart rate > 120 beats/min.)

• Purulent cervical •
broad nasal bridge
• Fetal tachycardia (heart rate > 160 – 180 beats/min.) Purulent discharge, •
low set ears

• or foul-smelling amniotic fluid or vaginal discharge Maternal • Maternal or fetal •

receding chin

• leukocytosis (high white blood cell count) tachycardia

Difficultybreathing

DEATH/DELIVERY
 Assessment
Clinical Manifestation
• a typical history is of ‘broken
waters’ – with women experiencing
a painless popping sensation,
followed by a gush of watery fluid
leaking from the vagina.
• However, the symptoms can often
be more non-specific, such
as gradual leakage of watery fluid
from the vagina
• On speculum examination, fluid
draining from
the cervix and pooling in
the posterior vaginal fornix may be
seen.
• Additionally, a lack of normal
vaginal discharge (‘washed clean’)
can be suggestive of rupture of
membranes.
 Diagnostic Findings
• Urinary
incontinence.
Normal vaginal
secretions of
pregnancy.
• Increased sweat/
moisture around
perineum.
 Management
Pharmacologic Therapy
• Future hope is stem cell
engineering
• Immediate delivery or bed rest if
the fetus is not at a point of
viability.
• corticosteroid- if she reaches
viability
• Prophylactic- to delay onset of
labor and reduce infection
– broad spectrum antibiotic
• Tocolytic- if no sign of infection
• Amnioinfusion- reduce pressure
on the fetus or cord and allow a
safer term birth
 Surgical
Management
• Ultrasound is not used
routinely, but may
facilitate diagnosis in
cases where it remains
unclear.
• In all cases of
premature membrane
rupture, a high vaginal
swab should be taken.
 Other test
Ferning test – placing cervical secretion onto a
glass slide and allowing it to dry (forming fern-
patterned crystals if there is PROM/PPROM).
Actim-PROM (Medix Biochemica) – uses a
swab test looking for IGFBP-1 (insulin-like
growth factor binding protein-1) in vaginal
samples.
 Other test
• Amnisure (QiaGen) – looks for Placental Nitrazine testing – measures the pH of vaginal
alpha microglobulin-1 (PAMG-1) which is fluids and has previously been used to
present in the blood, amniotic fluid (in large diagnose PROM and PPROM (amniotic fluid pH
concentrations) and cervico-vaginal is higher than vaginal fluids).
discharge of pregnant women (in low
concentrations with membranes intact).
 Prevention
• 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.
 If labor doesn’t start, it is important to consider the risks and
benefits of expectant management versus induction of
labor (IOL) when formulating an appropriate management plan
for women with PROM:

• <34 weeks gestation – the balance would normally be in favour of

aiming for increased gestation.
• >36 weeks gestation – if labor does not start, induction of labor
ought to be considered at 24–48 hours. This is because the risk of
infection outweighs any benefit of the fetus remaining in utero.
• 34 – 36 weeks – Historically the aim was to get the pregnancy to 36
weeks if there was no evidence of infection. However, with
improvements in neonatal care (and evidence for poorer outcomes
in babies if there is maternal infection), management has shifted
towards 34 weeks and induction of labor once there has been a
course of steroids.
Nursing Process
NURSING PROCESS : ASSESSMENT

Sudden gush of fluid from vagina

Foul smelling
Elevated temperature
Uterus tenderness
Diminished fetal movement
Tachycardia
Hypertension
Changes in fetal heart rate
palpable and visible cord
NURSING PROCESS : DIAGNOSIS

Risk for infection related to preterm rupture of membrane without

accompanying labor

Potential of fetus injury related to interruption of blood due to

prolapsed cord

Anxiety related to outcome of pregnancy and health of unborn child

as witnessed by mother’s frequent doubts about the pregnancy
outcome
NURSING PROCESS : PLANNING

Maternal infection does not occur, the

white blood cell count remains below
20,000/mm³

Fetal heart rate will return to normal

with 120 – 160 beats per minute

Alleviate the anxiousness of the mother

 NURSING PROCESS : INTERVENTION

• Perform initial vaginal examination, when the contraction pattern repeats, or maternal
behavior indicates progress.
• Monitor temperature, pulse, respiration, and white blood cells as indicated
• Initiate fetal monitoring
•Give prophylactic antibiotics when indicated.
• Assist to position woman head down with hips elevated
• Auscultate FHR and initiate EFM if immediate cesarean section is not possible
• Draw blood for CBC
• Prepare for vaginal birth if cervix is fully dilated
• Be prepared to perform neonatal resuscitation
• Collect cord gases at delivery
• Approach and discuss the mother’s worry in a calm manner
• Administer in dexemethasone6 as ordered
• Allow her to ask questions and clear her doubt
• Assure that the neonate will be kept in the hospital
NURSING PROCESS : EVALUATION

Maternal white blood cell count remains

below 20,000/mm³; Maternal
temperature is less than 38.0°C while
awaiting fetal maturity

Mother shows less anxiousness about the

outcome of the labor

Mother shows less anxiousness about the

outcome of the labor
 References
•Children's Hospital. (2014, August 24). Premature Rupture of Membranes
(PROM)/Preterm Premature Rupture of Membranes (PPROM). Retrieved from
https://www.chop.edu/conditions-diseases/premature-rupture-membranes-
prompreterm-premature-rupture-membranes-pprom

•Kelly, T. (1995, April). The pathophysiology of premature rupture of the

membranes. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/7787124

•Premature Rupture of Membranes and P-PROM. (n.d.). Retrieved from

https://teachmeobgyn.com/labour/delivery/premature-rupture-membranes/

•Silbert-Flagg, J. & Pillitteri, A. (2018). Nursing Care of a Family Experiencing a

Sudden Pregnancy Complication. L, Pecarich (Ed.). Preterm Rupture of Membranes
(8th ed., 546-547). Philippines: Absolute Service, Inc.