premature rupture of membranes

Premature Rupture of Membranes

Definition

Premature rupture of membranes (PROM) is an event that occurs during pregnancy when the sac containing the developing baby (fetus) and the amniotic fluid bursts or develops a hole prior to the start of labor.

Description

During pregnancy, the unborn baby (fetus) is surrounded and cushioned by a liquid called amniotic fluid. This fluid, along with the fetus and the placenta, is enclosed within a sac called the amniotic membrane. The amniotic fluid is important for several reasons. It cushions and protects the fetus, allowing the fetus to move freely. The amniotic fluid also allows the umbilical cord to float, preventing it from being compressed and cutting off the fetus's supply of oxygen and nutrients. The amniotic membrane contains the amniotic fluid and protects the fetal environment from the outside world. This barrier protects the fetus from organisms (like bacteria or viruses) that could travel up the vagina and potentially cause infection.Although the fetus is almost always mature at between 36-40 weeks and can be born without complication, a normal pregnancy lasts an average of 40 weeks. At the end of 40 weeks, the pregnancy is referred to as being "term." At term, labor usually begins. During labor, the muscles of the uterus contract repeatedly. This allows the cervix to begin to grow thinner (called effacement) and more open (dilatation). Eventually, the cervix will become completely effaced and dilated. In the most common sequence of events (about 90% of all deliveries), the amniotic membrane breaks (ruptures) around this time. The baby then leaves the uterus and enters the birth canal. Ultimately, the baby will be delivered out of the mother's vagina. In the 30 minutes after the birth of the baby, the placenta should separate from the wall of the uterus and be delivered out of the vagina.Sometimes the membranes burst before the start of labor, and this is called premature rupture of membranes (PROM). There are two types of PROM. One occurs at a point in pregnancy before normal labor and delivery should take place. This is called preterm PROM. The other type of PROM occurs at 36-40 weeks of pregnancy.PROM occurs in about 10% of all pregnancies. Only about 20% of these cases are preterm PROM. Preterm PROM is responsible for about 34% of all premature births.

Causes and symptoms

The causes of PROM have not been clearly identified. Some risk factors include smoking, multiple pregnancies (twins, triplets, etc.), and excess amniotic fluid (polyhydramnios). Certain procedures carry an increased risk of PROM, including amniocentesis (a diagnostic test involving extraction and examination of amniotic fluid) and cervical cerclage (a procedure in which the uterus is sewn shut to avoid premature labor). A condition called placental abruption is also associated with PROM, although it is not known which condition occurs first. In some cases of preterm PROM, it is believed that bacterial infection of the amniotic membrane causes it to weaken and then break. However, most cases of PROM and infection occur in the opposite order, with PROM occurring first followed by an infection.The main symptom of PROM is fluid leaking from the vagina. It may be a sudden, large gush of fluid, or it may be a slow, constant trickle of fluid. The complications that may follow PROM include premature labor and delivery of the fetus, infections of the mother and/or the fetus, and compression of the umbilical cord (leading to oxygen deprivation in the fetus).Labor almost always follows PROM, although the delay between PROM and the onset of labor varies. When PROM occurs at term, labor almost always begins within 24 hours. Earlier in pregnancy, labor can be delayed up to a week or more after PROM. The chance of infection increases as the time between PROM and labor increases. While this may cause doctors to encourage labor in the patient who has reached term, the risk of complications in a premature infant may cause doctors to try delaying labor and delivery in the case of preterm PROM.The types of infections that can complicate PROM include amnionitis and endometritis. Amnionitis is an infection of the amniotic membrane. Endometritis is an infection of the innermost lining of the uterus. Amnionitis occurs in 0.5-1% of all pregnancies. In the case of PROM at term, amnionitis complicates about 3-15% of pregnancies. About 15-23% of all cases of preterm PROM will be complicated by amnionitis. The presence of amnionitis puts the fetus at great risk of developing an overwhelming infection (sepsis) circulating throughout its bloodstream. Preterm babies are the most susceptible to this life-threatening infection. One type of bacteria responsible for overwhelming infections in newborn babies is called group B streptococci.

Diagnosis

Depending on the amount of amniotic fluid leaking from the vagina, diagnosing PROM may be easy. Some doctors note that amniotic fluid has a very characteristic musty smell. A pelvic exam using a sterile medical instrument (speculum) may reveal a trickle of amniotic fluid leaving the cervix, or a pool of amniotic fluid collected behind the cervix. One of two easy tests can be performed to confirm that the liquid is amniotic fluid. A drop of the fluid can be placed on nitrazine paper. Nitrazine paper is made so that it turns from yellowish green to dark blue when it comes in contact with amniotic fluid. Another test involves smearing a little of the fluid on a slide, allowing it to dry, and then viewing it under a microscope. When viewed under the microscope, dried amniotic fluid will be easy to identify because it will look "feathery" like a fern.Once PROM has been diagnosed, efforts are made to accurately determine the age of the fetus and the maturity of its lungs. Premature babies are at great risk if they have immature lungs. These evaluations can be made using amniocentesis and ultrasound measurements of the fetus' size. Amniocentesis also allows the practitioner to check for infection. Other indications of infection include a fever in the mother, increased heart rate of the mother and/or the fetus, high white blood cell count in the mother, foul smelling or pus-filled discharge from the vagina, and a tender uterus.

Treatment

Treatment of PROM depends on the stage of the patient's pregnancy. In PROM occurring at term, the mother and baby will be watched closely for the first 24 hours to see if labor will begin naturally. If no labor begins after 24 hours, most doctors will use medications to start labor. This is called inducing labor. Labor is induced to avoid a prolonged gap between PROM and delivery because of the increased risk of infection.Preterm PROM presents more difficult treatment decisions. The younger the fetus, the more likely it may die or suffer serious permanent damage if delivered prematurely. Yet the risk of infection to the mother and/or the fetus increases as the length of time from PROM to delivery increases. Depending on the age of the fetus and signs of infection, the doctor must decide either to try to prevent labor and delivery until the fetus is more mature, or to induce labor and prepare to treat the complications of prematurity. However, the baby will need to be delivered to avoid serious risks to both it and the mother if infection is present, regardless of the risks of prematurity.A variety of medications may be used in PROM:

Medication to induce labor (oxytocin) may be used, either in the case of PROM occurring at term or in the case of preterm PROM and infection.
Tocolytics may be given to halt or prevent the start of labor. These may be used in the case of preterm PROM, when there are no signs of infection. Delaying the start of labor may give the fetus time to develop more mature lungs.
Steroids may be used to help the fetus' lungs mature early. Steroids may be given in preterm PROM if the fetus must be delivered early because of infection or labor that cannot be stopped.
Antibiotics can be given to fight infections. Research is being done to determine whether antibiotics should be given prior to any symptoms of infection to avoid the development of infection.

Prognosis

The prognosis in PROM varies. It depends in large part on the maturity of the fetus and the development of infection.

Prevention

The only controllable factor associated with PROM is smoking. Cigarette smoking should always be discontinued during a pregnancy.

Resources

Organizations

American College of Obstetricians and Gynecologists. 409 12th Street, S.W., P.O. Box 96920

Key terms

Amniocentesis — A medical procedure during which a long, thin needle is inserted through the abdominal and uterine walls, and into the amniotic sac. A sample of amniotic fluid is withdrawn through the needle for examination.Amniotic fluid — The fluid within the amniotic sac; the fluid surrounds, cushions, and protects the fetus.Amniotic membrane — The thin tissue that creates the walls of the amniotic sac.Cervical cerclage — A procedure in which the cervix is sewn closed; used in cases when the cervix starts to dilate too early in a pregnancy to allow the birth of a healthy baby.Placenta — The organ that provides oxygen and nutrition from the mother to the fetus during pregnancy. The placenta is attached to the wall of the uterus, and leads to the fetus via the umbilical cord.

premature rupture of membranes (PROM),

rupture of the amniotic sac before onset of labor.

premature rupture of membranes

Premature rupture of fetal membranes, PROM Obstetrics The leakage of amniotic fluid before the onset of labor; PROM occurs in 8% to 10% of term pregnancies, 15-20% of preterm pregnancies and associated with ↑ M&M Etiology Unknown, possibly due to bacterial and/or internal enzymes Complications Respiratory distress syndrome, fetal and neonatal infections–eg, congenital pneumonia or septicemia, fetal wastage, intraventricular hemorrhage Management Deliver baby within 36 hrs. See Amnion, Chorion.

pre·ma·ture rup·ture of mem·branes

(PROM) (prē'mă-chŭr' rŭp'chŭr mem'brānz) Rupture of the amnionic sac before onset of labor.

Premature Rupture of Membranes

DRG Category:	765
Mean LOS:	4.8 days
Description:	SURGICAL: Cesarean Section With CC or Major CC
DRG Category:	775
Mean LOS:	2.4 days
Description:	MEDICAL: Vaginal Delivery Without Complicating Diagnoses

Premature rupture of membranes (PROM) is the spontaneous rupturing of the amniotic membranes (“bag of water”) before the onset of true labor. While it can occur at any gestational age, PROM usually refers to rupture of the membranes (ROM) that occurs after 37 weeks’ gestation. Preterm premature rupture of membranes (PPROM) occurs between the end of the 20th week and the end of the 36th week. PPROM occurs in 33% of all preterm births and is a major contributor to perinatal morbidity and mortality owing to the lung immaturity and respiratory distress. PROM can result in two major complications. First, if the presenting part is ballotable when PROM occurs, there is risk of a prolapsed umbilical cord. Second, the mother and fetus can develop an infection. The amniotic sac serves as a barrier to prevent bacteria from entering the uterus from the vagina; once the sac is broken, bacteria can move freely upward and cause infection in the mother and the fetus. Furthermore, if the labor must be augmented because of PROM and the cervix is not ripe, the patient is at a higher risk for a cesarean delivery.

Causes

Although the specific cause of PROM is unknown, there are many predisposing factors. An incompetent cervix leads to PROM in the second trimester. Infections such as cervicitis and amnionitis—and also placenta previa, abruptio placentae, and a history of induced abortions—may be involved with PROM. In addition, any condition that places undue stress on the uterus, such as multiple gestation, polyhydramnios, or trauma, can contribute to PROM. Fetal factors involved are genetic abnormalities and fetal malpresentation. A defect in the membrane itself is also a suspected cause.

Genetic considerations

PROM may occur with some of the hereditary connective tissue disorders such as Ehlers-Danlos syndrome, a class of six conditions resulting in skin fragility, skin extensibility, and joint hypermobility, that can be inherited in either an autosomal dominant or an autosomal recessive pattern.

Gender, ethnic/racial, and life span considerations

While estimates vary, PROM occurs in approximately 3% to 10% of all deliveries. It also occurs in 30% to 40% of preterm deliveries in the United States and Western Europe. It is not associated with maternal age or with ethnicity or race.

Global health considerations

The World Health Organization states that PROM occurs in 3% of all pregnancies.

Assessment

History

Ask the patient the date of her last menstrual period to determine the fetus’s gestational age. Ask her if she has been feeling the baby move. Review the prenatal record if it is available or question the patient about problems with the pregnancy, such as high blood pressure, gestational diabetes, bleeding, premature labor, illnesses, and trauma. Have the patient describe the circumstances leading to PROM. Determine the time the rupture occurred, the color of the fluid and the amount, and if there was an odor to the fluid. Patients may report a sudden gush of fluid or a feeling of “always being wet.” Inquire about any urinary, vaginal, or pelvic infections. Ask about cigarette, alcohol, and drug use and exposure to teratogens.

Physical examination

The most common sign is rupture of the membranes and gushing, leaking, or pooling of amniotic fluid. The priority assessment is auscultation of the fetal heart rate (FHR). Fetal tachycardia indicates infection. FHR may be decreased or absent during early pregnancy or if the umbilical cord prolapsed. If bradycardia is noted, perform a sterile vaginal examination to check for an umbilical cord. If a cord is felt, place the patient in Trendelenburg’s position, maintain manual removal of the presenting part off of the umbilical cord, and notify the physician immediately.

Note the frequency, duration, and intensity of any contractions. With PROM, contractions are absent. Perform a sterile vaginal examination if the patient is term (> 37 weeks) and note the dilation and effacement of the cervix and the station and presentation of the fetus. If the patient is preterm, notify the physician before doing a vaginal examination, which is often deferred in preterm patients to decrease the likelihood of introducing infection.

It is important in the initial examination to determine if PROM actually occurred. Often, urinary incontinence, loss of the mucous plug, and increased leukorrhea, which are common occurrences during the third trimester, are mistaken for PROM. Inspect the perineum and vaginal vault for presence of fluid, noting the color, consistency, and any foul odor. Normally, amniotic fluid is clear or sometimes blood-tinged with small white particles of vernix. Meconium-stained fluid, which results from the fetus passing stool in utero, can be stained from a light tan to thick green, resembling split pea soup. Take the patient’s vital signs. An elevated temperature and tachycardia are signs that infection is present as a result of PROM. Auscultate the lungs bilaterally. Palpate the uterus for tenderness, which is often present if infection is present. Check the patient’s reflexes and inspect all extremities for edema.

Psychosocial

If the pregnancy is term, most patients are elated with the occurrence of ROM, even though they are not having contractions. If the patient is preterm, PROM is extremely upsetting. Assess the patient’s relationship with her significant other and available support.

Diagnostic highlights

Test	Normal Result	Abnormality With Condition	Explanation
Nitrazine test tape	Yellow to olive green indicates acidic and intact membranes	Blue-green to deep blue indicates alkaline, membranes probably ruptured	Amniotic fluid is alkaline and thus turns the yellow paper blue
Speculum examination and fern test	No fluid is seen in vaginal vault, fern pattern is not noted on slide	Fluid is visualized at cervical os; microscope slide reveals fern pattern	Amniotic fluid possesses ferning capacity evident by microscopic examination of a prepped slide

Other Tests: Complete blood count, cervical cultures for infections, amniocentesis (to check lung maturity if the patient is preterm when PPROM occurs), ultrasound

Primary nursing diagnosis

Diagnosis

Risk for infection related to loss of protective barrier

Outcomes

Risk control; Risk detection; Knowledge: Infection control

Interventions

High-risk pregnancy care; Infection control; Labor induction: surveillance; Electronic fetal monitoring: Intrapartum

Planning and implementation

Collaborative

Treatment varies, depending on the gestational age of the fetus and the presence of infection. If infection is present, the fetus is delivered promptly regardless of gestational age. Delivery can be vaginal (induced) or by cesarean section. Intravenous (IV) antibiotics are begun immediately. The antibiotics cross the placenta and are thought to provide some protection to the fetus.

If the patient is preterm (< 37 weeks) and has no signs of infection, the patient is maintained on complete bedrest. A weekly nonstress test, contraction stress test, and biophysical profile are done to continually assess fetal well-being. If the gestational age is between 28 and 32 weeks, glucocorticoids are administered to accelerate fetal lung maturity. Use of tocolysis to stop contractions if they begin is controversial when ROM has occurred. Some patients are discharged on bedrest with bathroom privileges if the leakage of fluid ceases, no contractions are noted, and there are no signs and symptoms of infection; however, most physicians prefer to keep the patient hospitalized because of the high risk of infection.

If the patient is term and PROM has occurred, the labor can be augmented with oxytocin. It is always desirable to deliver a term infant within 12 hours of ROM because the likelihood of infection increases significantly at 12 and 16 hours. Some patients and physicians prefer to wait 24 to 48 hours and let labor start on its own without the use of oxytocin. If this is the case, in-patient monitoring for signs and symptoms of infection and fetal well-being is recommended. Follow the physician’s protocol for oxytocin administration, as each may be different. When administering oxytocin, monitor the frequency, duration, intensity, and pattern of contractions; resting tone; blood pressure; intake and output; and response to pain.

Determine the patient’s preference for pain relief during labor. If IV narcotics are used, assess the effects of these drugs on the respiratory status of the neonate upon birth. The neonatal nurse or nurse practitioner should be on hand to reverse respiratory depression at delivery. Many patients who receive oxytocin request an epidural because IV narcotics do not provide effective pain relief.

If the patient has an epidural, turn her from side to side hourly to ensure adequate distribution of anesthesia. Use pillows to support the back and abdomen and between the knees to maintain proper body alignment. Most patients are unable to void and require a straight catheter every 2 to 3 hours to keep the bladder empty; if a long labor is anticipated, sometimes a urinary catheter is inserted. Maintain the infusion of IV fluids to prevent hypotension, which can result from regional anesthesia.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Ampicillin, or other antibiotics (ampicillin, erythromycin)	1–2 g q 6 hr IV piggyback (PB); dosage varies with drug	Antibiotic	Prophylaxis; treatment for infection
Oxytocin (Pitocin)	Mix 10 U in 500 mL of IV solution, begin infusion at 1 mU/min and increase 1–2 mU/min q 30 min	Oxytocic	Stimulates labor contractions to begin
Dinoprostone (Cervidil insert or Prepidil gel)	Varies with drug	Prostaglandin	Ripens the cervix to facilitate dilation and stimulates contractions
Meperidine (Demerol)	25 mg IV push (IVP) q 3–4 hr	Opioid analgesic	Pain relief of labor contractions
Butorphanol tartrate (Stadol)	1–2 mg q 3–4 hr IVP	Analgesic	Pain relief of labor contractions

Independent

Teach every prenatal patient from the beginning to call the physician if she suspects ROM. If ROM occurs, monitor for signs and symptoms of infection and the onset of labor. Maintain the patient in the left lateral recumbent position as much as possible to provide optimal uteroplacental perfusion. Vaginal examinations should be held to an absolute minimum and strict sterile technique should be used to avoid infection.

Assist the patient who is having natural childbirth in breathing and relaxation techniques. Often, the coach plays a significant role in helping the patient deal with the contractions. The nurse should become involved only when necessary. If a preterm delivery is expected, educate the patient and family on the expected care of the newborn in the neonatal intensive care unit (NICU). If possible, allow the patient to visit the NICU and talk to a neonatologist.

Hospital stay is 48 hours for a vaginal delivery and 72 hours for a cesarean section. Teach the patient as much as possible about self-care and newborn care while in the hospital. Arrange for a follow-up home visit by a perinatal nurse. If the baby is retained in the NICU after the patient is discharged, support and educate the family as they return to the hospital to visit their newborn.

Evidence-Based Practice and Health Policy

Singla, A., Yadav, P., Vaid, N.B., Suneja, A., & Faridi, M.M. (2010). Transabdominal amnioinfusion in preterm premature rupture of membranes. International Journal of Gynecology and Obstetrics, 108(3), 199–202.

Investigators conducted a randomized controlled trial to determine the effectiveness of transabdominal amnio-infusion in cases of PROM. Sixty pregnant women between 26 and 34 weeks' gestation, whose amniotic fluid index (AFI) fell below the fifth percentile, were equally divided between a treatment group (amnio-infusion at baseline and weekly thereafter if AFI fell below the fifth percentile again) and a control group (routine management).
Among women in the treatment group, the AFI increased from a mean of 3.66 cm (SD, ± 2.05 cm) to a mean of 11.21 cm (SD, ± 2.1 cm) and the biophysical score increased from 4.07 (SD, ± 1.23) to 7.53 (SD, ± 0.96) after the initial amnio-infusion (p < 0.001).
Infants of women in the treatment group were less likely to experience adverse neonatal outcomes, including fetal distress (10% versus 37%; p = 0.03), neonatal sepsis within 72 hours of birth (17% versus 63%; p = 0.04), and neonatal mortality (17% versus 63%; p < 0.01). Sepsis was the cause of death in all of the cases in the control group and none of the cases in the treatment group (p = 0.04).
Seven percent of the women in the treatment group developed postpartum sepsis compared to 33% of women in the control group (p = 0.02).

Documentation guidelines

Time of ROM, color of fluid, amount of fluid, presence of any odor
Contractions: Frequency, duration, intensity, pattern, patient’s response
Fetal heart rate assessment: Baseline, accelerations, decelerations, variability
Patient’s comfort level in labor, response to medications, vital signs
Signs and symptoms of infection: Elevated maternal heart rate and temperature; malodorous amniotic vaginal discharge/fluid; fetal tachycardia

Discharge and home healthcare guidelines

home care if undelivered.

The patient should maintain bedrest, check her temperature four times per day, abstain from intercourse, not douche or use tampons, and have a white blood cell count drawn every other day. Tell her to notify the physician immediately of any fever, uterine tenderness or contractions, leakage of fluid, or foul vaginal odor.

home care if delivered.

Teach the patient to be aware of signs and symptoms that indicate postpartum complications. Teach her not to lift anything heavier than the baby and not to drive until after the postpartum checkup with the physician.