Premature Rupture of Membrane

During the early stages of pregnancy and embryonic development the amniotic cavity develops. This amniotic cavity is lined by thick fibrous tissue. This tissue is the amniotic sac which is filled with amniotic fluid. In an uneventful pregnancy, this is an ideal environment for the fetus as it provides temperature control, lubrication, and cushion. It also provides the opportunity to “practice” breathing and elimination. In the event where amniotic fluid is not present; as with anhydramnios, or its quantity is reduced; as in oligohydramnios, the fetus and the mother can be at risk.Premature rupture of membrane or PROM is a condition in which the amniotic sac breaks prior to the onset of labor. According to Hatfield and Klossner, (2014, p. 419), “PROM occurs in approximately 10% of pregnancies at term”. The risks associated with PROM are “African American ethnicity, cigarette smoking, previous preterm delivery, vaginal bleeding, low socioeconomic conditions, sexually transmitted infections, and conditions causing uterine distension” (Hatfield and Klossner, 2014, p. 419).When PROM occurs at 37 weeks gestation or later, a woman can expect imminent delivery of the fetus. If labor does not start spontaneously, induction is ordered.  At this stage of development, the fetus’ lungs are probably mature (Murkoff, Eisenberg, Hathaway, Aubry, & Mazel, 2002, p. 142). The causes of PROM at 37 weeks gestation and later can be attributed to many factors to include weakening of the amniotic sac as it approaches the end of pregnancy, or contractions as it puts additional stress on the amniotic sac. The protocol for most facilities is to deliver the fetus within 24 hours of membrane rupture. Delaying delivery can increase the occurrence of infection and compromise the health of mother and child. Premature preterm rupture of membrane (PPROM) is rupture of the membrane that occurs before 37 weeks gestation. It is a much more serious matter and carries a much greater risk for mother and baby. The article published by the Pakistan Armed Forces Medical Journal states that “PPROM affects 32% to 40% of preterm deliveries, with 60% to 80% of these patients entering spontaneous labor within 48 hours” (Ashraf, ul Haq, Ashraf, Sajjad, & Ahmed 2015, p. 228). Because these pregnancies have not reached full term, the fetus is compromised. Morbidity and mortality rates are much higher the earlier rupture occurs. However, the recommended course of action is either to delay delivery (latent pregnancy) or to terminate the pregnancy. The reason for this early rupture can be numerous, with infection being the leading cause. When infection is present, the recommendation is to terminate the pregnancy because continuing can increase the occurrence of sepsis in the mother and fetus. If there is no infection, the recommended course of action is to delay delivery as long as possible to increase the gestational age of the fetus consequently decreasing the chance of injury and death and decreasing duration of NICU stay. Regardless of the chosen course of action, the longer a woman waits to deliver after PROM the more chances for complications. Labs and DiagnosticsPROM is diagnosed in several ways. A visual assessment of the vagina might show a pooling of fluid or visual evidence of leakage from the cervical os. When such evidence is found, the fluid is tested for confirmation. Two tests can be performed; a nitrazine test and a fern test. With the nitrazine test, nitrazine paper is utilized. The paper determines the pH of the fluid. Amniotic fluid is more alkaline than other vaginal fluids. With the fern test, the provider looks under the microscope to see what pattern is made by the fluid collected after it has dried on a slide. Because amniotic fluid contains sodium chloride it dries in a fern like pattern. In the occasion where these tests show no presence of amniotic fluid but PROM still suspected, “the tampon (amnio dye) test may be used: indigo carmine dye is injected into the amniotic fluid via amniocentesis-blue coloring noted on the vaginally inserted tampon within 30 min of intrauterine dye instillation is considered confirmation of rupture” (Packard & Mackeen, 2015, p. 496).  In addition to the above tests an ultrasound is performed to identify fluid volume, and assess fetus health. Complete blood count, paying special consideration to white blood cells, are obtained in order to check for infections. Vaginal exams are discouraged due to concerns of introducing microorganisms. If necessary, a sterile speculum is used in order to check the cervix.Subjective and Objective DataSubjective data is usually present in a form of report of a fluid gush or leakage. Usually expectant mothers complain of “wetness” or a feeling of excessive fluid exiting the vagina. This complaint can be continuous or an one time event. The objective data is the information collected and observed by the health care team via the tests aforementioned. Other subjective data associated with PROM are fever, when an infection is present, as well as psychosocial manifestations of anxiety and fear. MedicationsSeveral pharmacological interventions can take place when an expectant mother experience PROM. The most commonly used medication is antibiotic. It is prophylactically used as a means of preventing infection. According to Hatfield and Klossner, (2014), “The practitioner often orders a course of IV antibiotics (usually ampicillin and erythromycin) for 48 hours, followed by oral antibiotics for five days to treat preterm PROM. The usual practice is to administer seven days of antibiotic therapy.” For those mothers who have not yet reached full term but has reached viability (24-36 weeks gestation), intramuscular corticosteroids is given. The steroid helps with the fetus outcome. Tocolytics are used in order to slow down or stop labor from progressing. They are usually administered to mothers who have started contraction but needs to buy time in order to receive steroids in the event of premature labor. Finally, oxytocin can be administered to induce labor. In the event of an infection, oxytocin is used after treatment has not been successful and delivery is the most beneficial outcome. Also, when PROM happens at 37 weeks or after, oxytocin can be used when labor has not begun on its own after 24 hours. Collaborative Efforts The health care team has a role of facilitating holistic well being in an individual. As such, many health care professionals are involved in the care of an expectant mother who suffered PROM. Morbidity and mortality can affect all members of a family. Because of this, it is important to take into consideration the emotional and psychological implications this event has on the family.  The obstetrician cares for the mother and her health care needs. The perinatologist cares for high risk expectant mothers. The obstetrician together with the perinatologist employ the assistance of the ultrasound technicians, laboratory technicians, nurses, social worker, pharmacist, and neonatologist. The goal of these professionals is to assure a positive and safe outcome for the mother and baby. Nursing Diagnosis Given that the highest risk after PROM is infection, the risk for infection related to loss of protective barrier as evidenced by positive fern test is very appropriate. The goal is to keep infection away.  Deficient knowledge related to unfamiliarity with the signs and symptoms of PPROM, its effects on the pregnancy and fetus, and guidelines to follow for an optimal outcome as evidenced by erroneous verbalization of disease state and treatment options would be a secondary nursing diagnosis. The focus of this nursing diagnosis is placed on the need to inform the patient in every aspect of the condition its effect and implications. A final but very important nursing diagnosis takes into consideration the psychosocial status of the mother as her pregnancy and fetus are threatened; anxiety related to threat to maternal and/or fetal well being secondary to risk of preterm labor as evidenced by patient reporting feelings of fear and anxiety about possible pregnancy outcome.Nursing Interventions The most important thing to consider is to “focus nursing actions on the woman, her partner, and the fetus” (London, Ladewig, Ball, & Bindler, 2007). Assessment of the amniotic fluid would be the first step. As an advocate for the patient and with the purpose of preventing infection, limiting vaginal exams would be a priority. Good hand washing techniques have to be adopted as it reduces the prevalence of infection. Monitoring temperature is an important step as, often times, it is the first detectable sign of infection. This should be done every two hours. Administer medications as prescribed. In the event of imminent delivery, the nurse can assist on maintaining a relaxed atmosphere together with breathing techniques to reduce anxiety and augment focus. It is important to monitor the fetal heart rate once the mother is admitted into the hospital specially when the possibility of umbilical cord prolapse is at hand. During an event of fetal demise, steps should be taken to comfort the family and possible referral to social work or counseling is adequate. The priority is to prevent problems and enhance positive outcome. Health Promotion & Prevention Prevention of infection takes precedence. Educating patient on proper handwashing techniques are important. Proper nutrition is important as well as proper hydration. Dehydration can lead to early labor. Encourage the mother to continue taking her prenatal vitamins. The goal is to maintain a healthy mother and healthy baby throughout this crisis. 
Patient EducationAn informed patient can better make decisions to ensure the best outcome. Proper knowledge can reduce her anxiety and fear. Teach her about her options. She might choose to terminate her pregnancy if she is aware of the possible prognosis. Teach her about the course of treatment.  Teach her how to care for her body to prevent infection. Teach her to recognize the signs of infection and advise her to report them right away. Advise her on when to return to the clinic. Advise her on when to go to labor and delivery.  Teach her about what is normal and abnormal.PROM and PPROM can be a very traumatic event in an expectant mother’s life. The emotional toll can lead to much anxiety and fear as the mother can do little to prevent labor from coming once PROM has occurred. If PROM happens at or after 37 weeks gestation, in some cases, it can be a joyous event.  In PPROM however, the feelings of failure and despair can be very real. The mother might feel like her body failed to keep her baby safe and no longer serves as an ideal environment for the baby. She might fear future pregnancies as the event of PROM puts her at risk for repeated occurrence. In the event where a child is born extremely early due to PROM, there are possibilities of injury. These injuries can include “fetal growth restriction, neonatal chronic lung disease, and brain injury” (Nayot, Penava, Da Silva, Richardson, & Vrijer, 2012, p. 970). Lifelong impact is felt when these injuries are present. Having to deal with taking care of a premature baby may involve astronomical hospital bills, numerous appointments with specialists and therapists, impact on other children in the family, and risk for caregiver role strain. It is important to find community support as learning other’s outcomes help the expectant mother to plan for the future.