AMNIOTIC MEMBRANE COMPLICATIONS

Prelabor rupture of membranes (PROM) (previously known as premature rupture of membranes) refers to the rupture of membranes one hour or more before the onset of labor. Labor may be medically induced to reduce the risk of chorioamnionitis (infection of the chorion and amnion of the placenta), which can be life-threatening for the patient and fetus.

Preterm prelabor rupture of membranes (PPROM) (previously known as preterm premature rupture of membranes) refers to the rupture of membranes at approximately 23–37 weeks’ gestation. PPROM is often associated with preterm labor and birth. The most common identifiable risk factor for PPROM is genital tract infection.

PPROM can cause a variety of problems, especially for the fetus. Without the protective barrier of the amniotic membrane, the fetus is at a greater risk for the development of infection and preterm delivery. The fetus is also at risk for becoming septic after delivery. Additionally, without the cushioning of the amniotic fluid, there is a higher probability of umbilical cord compression as well as cord prolapse.

Medical Treatment

The first step in determining the appropriate course of action for patients with possible PROM or PPROM involves distinguishing amniotic fluid from urine or other vaginal discharge. Often, patients complain of a “sudden gush” and/or a continuous or intermittent trickle of fluid from the vagina once the membranes have actually ruptured.

The healthcare practitioner performs a sterile speculum examination to look for pooling of amniotic fluid near the cervix. Fluid may be observed as pooling on a sterile speculum exam. It may also be tested using nitrazine paper as well as via microscopic examination for the presence of ferning (the appearance of a fernlike pattern in a dried specimen of cervical mucus or vaginal fluid, which would indicate the presence of amniotic fluid). Commercial tests, such as AmniSure, may also be used to test for ruptured membranes. Ultrasound examination may be performed to determine the amount of available amniotic fluid after the rupture of membranes.

Medical treatment for patients with PROM or PPROM depends on a variety of factors. Gestational age, fetal lung maturity, available amniotic fluid, and etiology must be considered before deciding on treatment. Patients near term whose labor does not begin spontaneously following the rupture of membranes may be induced if the cervix is ripe. For preterm patients, providers and patients may desire to prolong the pregnancy to promote fetal lung maturity; such patients may be prescribed corticosteroids to promote fetal lung maturity until delivery occurs or until there is a need to induce labor.

Nursing Care

As with medical treatment, nursing care greatly depends on whether the medical diagnosis is PPROM or PROM. However, nursing care typically involves assisting the healthcare practitioner to confirm the rupture of membranes, monitoring the patient for infection and the presence of uterine contractions, and monitoring the status of the fetus. It is imperative that the nurse change patient underpads frequently and avoid unnecessary vaginal examinations to help prevent infection (and with PPROM to avoid decreasing the time until delivery) (Duff, 2022).

When caring for a patient with PPROM and PROM, the nurse should be prepared to address cord prolapse and compression, which can occur as the umbilical cord slips down in the pelvis. This is a life-threatening situation for the fetus; therefore, the fetus must be monitored closely. In the event of cord prolapse and compression, the nurse attempts to relieve pressure on the umbilical cord and instructs the patient to quickly move into the knee-chest or Trendelenburg positions. Oxygen is administered, and the healthcare practitioner notified immediately. Emergency cesarean section is likely.

Patient Teaching

It is important for patients with PPROM to understand the signs and symptoms that suggest infection as well as preterm labor, which often follows PPROM. The patient is watched for any of the following signs and symptoms:

• Fever >100.4 °F (>38 °C)
• Foul-smelling vaginal discharge or other signs of infection
• Uterine contractions or cramping (including tightening of the abdomen)
• Decreased fetal movement

In addition, patients are encouraged to avoid activities or objects that might induce labor or cause infection by exposing the cervix to bacteria. These include sexual activity, orgasm, nipple stimulation, tampons, and douches. Some patients may be placed on bed rest and should be encouraged to follow this directive to prevent preterm labor.