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

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Outline

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. When the membranes rupture prior to 37 weeks’ gestation, it is considered preterm premature rupture of membranes (PPROM).  

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

Subjective Data:

  • Sudden gush or steady trickle of clear fluid from vagina

Objective Data:

  • Blue nitrazine paper test- turns dark blue if positive for amniotic fluid 
  • Visual pooling of amniotic fluid in vagina

Nursing Interventions and Rationales

Nursing Intervention (ADPIE) Rationale
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.

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

A Nursing Care Plan (NCP) for Premature Rupture of Membranes (PROM) / Preterm Premature Rupture of Membranes (PPROM) starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

  • https://medlineplus.gov/ency/patientinstructions/000512.htm
  • https://www.chop.edu/conditions-diseases/premature-rupture-membranes-prompreterm-premature-rupture-membranes-pprom
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Transcript

Hi everyone, today, the nursing care plan we’re going to be discussing right now is the premature rupture of the membranes. So, the pathophysiology of this is when the membranes rupture prior to 37 weeks’ gestation, it is considered a premature rupture of the membranes or preterm premature rupture of the membranes, PPROM. Nursing considerations: patients, geological history, vaginal exam, fetal monitoring, assess for signs of infection, IV fluids, or medications, preparing for the delivery, and educating the patient. Some desired outcomes: the patient will be free from infection for maternal and fetal and have a viable birth. 

So, coming into the care plan, we’re going to be going over some subjective data and we’re going to be going over some objective data. So, what are we going to see in the patient? So, there might be a sudden gush or steady trickle of clear fluid from the vagina or some objective, which is going to be super common, is a blue nitrazine paper test. And with this test, if it’s positive for amniotic fluid, it’s going to be turning a dark blue color. And there also might be some visual pooling of amniotic fluid from the vagina. 

Some interventions: we want to make sure that we’re looking for any sort of sign of infection – maternal or fetal infection. It may prompt a premature rupture of the membranes, and it must be treated quickly and able to avoid any sort of fetal compromise. We also want to perform any sort of single digital or sterile speculum vaginal exam. So, any sort of vaginal exam, it may be required to confirm a diagnosis, but you want to avoid multiple digital vaginal exams as that will increase the risk of infection. So, reserve those exams for when delivery is imminent. Another thing you want to make sure that we’re doing is getting a history of the patient. So, this could be the amount of pregnancies the patient has had prior to the current, or any existing complications that the patient may have. They may have to remain on bedrest to be able to continue pregnancy. If preterm labor is induced, we want to initiate fetal monitoring. 

So premature ROM can be an indicator of fetal distress. So, you might want to be monitoring for signs of fetal compromise, to include changes in a fetal heart rate. Some other things that we want to assess are medications and IV fluids. So, some medications that you might be looking at are some corticosteroids or tocolytic or magnesium sulfate and some prophylactic antibiotics, just to make sure we’re preventing any infection from arising. Since it may indicate a need for corticosteroids to speed fetal lung maturity is also very important with steroids, especially if it is a preterm premature, we want to make sure we’re preparing the patient for labor and delivery. 

So, if labor and delivery is imminent and they’re not able to keep the baby from not being born at that moment in time, they will educate the patient and get them to the delivery room. We also want to make sure that we’re doing pelvic rest for the mom. So, you want to avoid any sort of tampons or intercourse during that period, avoiding any tub baths or showers. If delivery is not indicated less than 34 weeks, the patient is likely to remain in a hospital until delivery is an option, but regardless of location, the patient will be required to remain on bedrest and antibiotics will continue prophylactically until delivery. 

So, we’re going to go over some key points here. So, pathology, premature rupture of the membrane time prior to 37 weeks factors include maternal or intra amniotic fluid infection, abdominal trauma, nutritional deficits, smoking, and placental abruption. A steady gush or a steady trickle of clear fluid from the vagina blue nitric paper that turns dark blue will be positive for amniotic fluid and any visual pooling of amniotic fluid in the vagina. So, these are going to be things you’re going to see in the patient. You want to assess, perform fetal monitoring, get a full history from the patient, assess for any sort of signs of infection, and vaginal exams. Using a fetal monitor to monitor the fetus to make sure that there is no fetal compromise. You want to give eye meds, perform education, and initiate any sort of IV fluids and medication as appropriate for the patient. And you want to prepare the patient for delivery if it’s not spontaneously done within 12 to 24 hours. And as always, educate the patient on every treatment plan that you initiate. 

You guys did a wonderful job. We love you guys. Be sure you go out and be your best self today. And, as always, happy nursing.

 

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