Angeles University Foundation

College of Nursing

Premature Rupture Of Membranes,

Umbilical prolapsed, Preterm

Labor, Intrauterine Fetal Death

(CASE REPORT- DELIVERY ROOM)

Submitted by:

Antonio, Alneil T.

Group 44

BSN IV-11

Submitted to:

Ivy Delos Santos R.N, M.N

January 12, 2011

PREMATURE RUPTURE OF MEMBRANES (PROM)

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.

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.

Causes

The causes of PROM have not been clearly identified. Some risk factors include

smoking, multiple pregnancies 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.

Clinical Manifestation

fluid leaking from the vagina-It may be a sudden, large gush of fluid, or it may be a slow,

constant trickle of fluid.

Complications

premature labor and delivery of the fetus

infections of the mother and/or the fetus

o amnionitis

o endometritis

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. 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.

Diagnostic Test

Amniotic fluid has a very characteristic musty smell.

Pelvic exam using a sterile medical instrument (speculum) - reveal a trickle of amniotic fluid

leaving the cervix, or a pool of amniotic fluid collected behind the cervix.

Sonogram

Culture of Neisseria Gonorrhoeae, Streptococcus B and Chlamydia

WBC Count and C-Reactive Protein

One of two easy tests can be performed to confirm that the liquid is amniotic fluid.

1. 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.

2. 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.

Medical Management

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 toprevent 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.

Medications

CORTICOSTEROIDS

Corticosteroids decrease perinatal morbidity and mortality after preterm PROM. The

most widely used and recommended regimens include intramuscular betamethasone

(Celestone) 12 mg every 24 hours for two days, or intramuscular dexamethasone (Decadron) 6

mg every 12 hours for two days. The National Institutes of Health recommends administration of

corticosteroids before 30 to 32 weeks’ gestation, assuming fetal viability and no evidence of

intra-amniotic infection. Use of corticosteroids between 32 and 34 weeks is controversial.

Administration of corticosteroids after 34 weeks’ gestation is not recommended unless there is

evidence of fetal lung immaturity by amniocentesis. Multiple courses are not recommended

because studies have shown that two or more courses can result in decreased infant birth

weight, head circumference, and body length.

ANTIBIOTICS

Giving antibiotics to patients with preterm PROM can reduce neonatal infections and

prolong the latent period.

TOCOLYTIC THERAPY

Tocolytic therapy may prolong the latent period for a short time but do not appear to

improve neonatal outcomes.

Nursing management

Instruct the patient to take her temperature twice a day and report a fever(temp of

greater than 100.4F or 38C.

Report presence of uterine tenderness, or odorous vaginal discharge

Instruct the mother to ref Rain from tub bathing, douching, and coitus because of the

danger of introducing infection

The white cell count shall be assessed frequently, perhaps as oftn asdaily, (a count

more than 18,000-20,000/mm3 suggest infection)

PRETERM LABOR

Preterm labor occurs before the end of week 37 of gestation. It occurs approximately 9

to 11% of all pregnancies. It is responsible for almost two thirds of all infant deaths in the

neonatal period. Any woman having persistent uterine contractions (for every 20 minutes)

should be considered to be in labor.

Preterm labor is a very serious complication of pregnancy. Early detection can help prevent

premature birth and possibly enable you to carry your pregnancy to term or to give your baby a

better chance of survival.

Preterm birth can cause health problems or even be fatal for the baby if it happens too early.

The more mature a child is at birth, the more likely it is that he will survive and be healthy.

Premature babies born between 34 and 37 weeks generally do very wel

Causes

Although the cause is often unknown, a variety of factors play a role in preterm birth:

Certain genital tract infections, such as chlamydia, bacterial vaginosis (BV),

and trichomoniasis, are associated with preterm delivery.

Substances produced by bacteria that weaken the membranes around the amniotic sac and

cause it to rupture early.

Even when the membranes remain intact, bacteria can cause preterm labor if they get into

the amniotic fluid or sac.

Chlamydia and gonorrhea .

Signs of Premature Labor

Contractions or cramps, more than 5 in one hour

Bright red blood from your vagina

Pain during urination, possible urinary tract, bladder or kidney infection

Sudden gush of clear, watery fluid from your vagina

Low, dull backache

Intense pelvic pressure

Prevention of Preterm Labor

While not all cases of preterm labor can be prevented there are a lot of women who will

have contractions that can be prevented by simple measures.

One of the first things that your practitioner will tell you to do if you are having

contractions is staying very well hydrated. We definitely see the preterm labor rates go up in the

summer months. What happens with dehydration is that the blood volume decreases, therefore

increasing the concentration of oxytocin (hormone that causes uterine contractions) to rise.

Hydrating yourself will increase the blood volume.

Others things that you can do would be to pay attention to signs and symptoms of

infections (bladder, yeast, etc.) because they can also cause infections. Keeping all of your

appointments with your practitioner and calling whenever you have questions or symptoms. A

lot of women are afraid of "crying wolf," but it is much better to be incorrect than to be in preterm

labor and not being treated.

Management of Preterm Labor

There are a lot of variables to managing preterm labor, both in medical options and in terms of

what is going on with you and/or your baby. Here are some of the things that you may deal with

when in preterm labor.

Hydration (Oral or IV)

Bedrest (Home or Hospital), usually left side lying

Medications to stop labor (Magnesium sulfate, brethine, terbutaline, etc.)

Medication to help prevent infection (More likely if your membranes have ruptured or if the

contractions are caused by infection)

Evaluation of your baby (Biophysical profile, non-stress or stress tests, amniotic fluid volume

index (AFI), ultrasound.

Medications to help your baby's lung develop more quickly (Usually if preterm birth in

inevitable)

Nursing Management

Remain on bed rest except to use bathroom

Drink eight to ten glasses of fluid per day

Instruct to take the prescribed tocolytic medication

Monitor Fetal heart rate and uterine contractions daily

Instruct to avoid activities that could stimulate labor, such as nipple stimulation

Instruct to consult the health care provider as to whether sexual relations should be restricted

Immediately report signs of ruptured membranes, vaginal bleeding

Instruct to report signs of UTI or vaginal infection (burning or frequency of urination, vaginal

itching or pain)

If Uterine Contraction Occur:

Instruct to empty the bladder to relieve pressure

Instruct the mother to lie down on left or right side to encourage blood return to the uterus

Drink 2-3 glasses of fluid to increase hydration.

INTRAUTERINE FETAL DEATH

Intrauterine Fetal Death Demise (IUFD) is the death of a fetus that occurs for no

apparent reason in a normal, uncomplicated pregnancy. It happens in about 1 percent of

pregnancies and is usually (depending on the resource) considered a fetal death when it occurs

after the 20th week of pregnancy and/or weight equal to or more than 500 grams. The American

College of Obstetrics and Gynecologists also recommends including deaths occurring at 22

weeks of gestation or greater (other groups use 20 weeks of gestation). 

Causes 

Only rarely is the exact cause of the death obvious. Unexplained causes account for 25-60% of

all fetal demise; the incidence increases with increasing gestational age. In cases where a

cause is clearly identified, the cause of fetal death can be attributable to fetal, maternal, or

placental pathology.

In some cases, examination of the stillborn fetus shows an abnormality in the umbilical cord, a

problem with the placenta or the fetus. These problems include infections plus a variety of birth

defects and genetic disorders. 

POSSIBLE MATERNAL CAUSES

Prolonged pregnancy (greater than 42 weeks).

Diabetes (poorly controlled).

Systemic lupus erythematosus

Infection.

Hypertension.

Preeclampsia.

Eclampsia.

Hemoglobinopathy.

Advanced maternal age.

Rh disease.

Uterine rupture.

Antiphospholipid syndrome.

Acute, severe maternal hypotension.

Maternal death.

POSSIBLE FETAL CAUSES

Multiple gestations.

Intrauterine growth restriction.

Congenital abnormality.

Genetic abnormality.

Infection ( parvovirus B-19, CMV, listeria).

POSSIBLE PLACENTAL CAUSES

Cord accident.

Abruption.

Premature rupture of membranes.

Vasa previa

Manifestations

Signs and symptoms of pregnancy may subside.

No symptoms may occur in the early stages of pregnancy. The diagnosis is based on

the absence of fetal heart tones, the lack of uterine growth or ultrasound studies during

prenatal examinations.

In later stages of pregnancy, a woman may be aware of changes in the fetal movement

(kicks) or that the movement has stopped.

Complications 

Disseminated intravascular coagulation (DIC), a disruption of blood clotting mechanisms

that can result in hemorrhage or internal bleeding, which may rarely develop relatively

late after fetal death.

Infection.

Medical Management 

Most women on learning that their fetus is dead prefer early evacuation of the uterus. Induction

may be accomplished with preinduction cervical ripening followed by intravenous oxytocin.

Patients with a history of a prior cesarean delivery should be treated cautiously because of the

risk of uterine rupture, just as in any birth following cesarean delivery (VBAC - Vaginal Birth

After Cesarean Delivery). 

In the first trimester, this is usually done with suction curettage. Early fetal demise may be

managed with laminaria insertion followed by dilatation and extraction. In the second trimester, it

is more frequently accomplished withprostaglandin E (Prostin) suppositories, or suction

curettage in combination with laminaria (a sterilized seaweed product that absorbs moisture and

expands to gradually stretch the cervix). In the third trimester, it may be accomplished with the

suction curettage in combination with laminaria or with intravenous oxytocin plus prostaglandin

E. 

PROSTAGLANDIN E1 

In women with fetal death before 28 weeks' gestation, induction may be accomplished using

prostaglandin E2 vaginal suppositories (10-20 mg every 4-6 h), misoprostol (ie, prostaglandin

E1) vaginally or orally (400 mcg every 4-6 h), and/or oxytocin (preferred in women with prior

uterine surgery). In women with fetal death after 28 weeks' gestation, lower doses should be

used. 

The American College of obstetricians and gynecologists guidelines for induction of labor states

that prostaglandin E2 and misoprostol should not be used in women with a history of a prior

uterine incision because of the risk of uterine rupture. In 2003, Dickinson and Evans reported on

the efficacy of oral, vaginal, and combined administration of misoprostol for second-trimester

induction and found that the superior regimen was misoprostol at 400 mcg vaginally every 6

hours. Pretreatment with antidiarrheal and antiemetic agents may reduce adverse effects.

These effects are generally less common with misoprostol than with prostaglandin E2. 

WAITING FOR SPONTANEOUS LABOR OPTION 

An additional treatment option is to wait for spontaneous labor which usually occurs within 2

weeks, but may be longer. This is termed expectant therapy. Occasionally a woman will not

expel the fetus, but instead, reabsorb it into her system (missed abortion). 

When a dead fetus has been in utero for 3-4 weeks, fibrinogen levels may drop, leading to a

coagulopathy. This is rarely a problem with singleton pregnancies because of earlier recognition

and induction, another reason for patients to be encouraged to begin induction soon after the

diagnosis. In some cases of twin pregnancies, depending on the type of placentation, induction

after the death of a twin may be delayed to allow the viable twin to mature. In these cases,

some perinatologists recommend checking a set of baseline coagulation labs at the time of fetal

demise and only rechecking them if the clinical situation warrants. Other perinatologists do not

recommend checking coagulation labs at all. Overall, the risk of developing disseminated

intravascular coagulopathy is rare. 

PAIN MANAGEMENT 

Pain management in patients undergoing induction of labor for fetal demise is usually easier to

manage than in patients with live fetuses. Higher doses of narcotics are available to the patient

and often a morphine or Dilaudid PCA is sufficient for successful pain control. Should a patient

desire superior pain control to intravenous narcotics, epidural anesthesia should be offered. 

AFTERWARD 

Examination of the stillborn fetus is usually performed to help determine any problems

that might prove helpful in consideration and planning of subsequent pregnancies.

Other issues to be explored by the parents with the help of the health care provider

team; whether or not to see, touch or photograph the infant; whether to name the infant;

deposition of the remains (burial or cremation); and holding religious services.

Parental feelings of loss, guilt, loneliness, anxiety and hostility should be acknowledged

and faced. Family and friends can help with sympathetic listening and close physical

comforting. If severe grief lasts longer than several months, professional counseling is

recommended. Both the parents are urged to join a grief support group (available in

most communities). 

MEDICAL MANAGEMENT OF FETAL DEATH IN UTERO 

The loss of a fetus at any stage is a fetal demise. According to the 2003 revision of the

Procedures for Coding Cause of Fetal Death Under ICD-10, the National Center for Health

Statistics defines fetal death as "death prior to the complete expulsion or extraction from its

mother of a product of human conception, irrespective of the duration of pregnancy and which is

not an induced termination of pregnancy. The death is indicated by the fact that after such ex

pulsion or extraction, the fetus does not breathe or show any other evidence of life, such as

beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles.

Heartbeats are to be distinguished from transient cardiac contractions; respirations are to be

distinguished from fleeting respiratory efforts or gasps." It is further classified as early (before 20

weeks' gestation), intermediate (20-27 weeks' gestation), or late (after 28 weeks' gestation). 

Management of fetal death in utero has changed dramatically from earlier

recommendations that regarded the event as a medically innocuous condition to be managed

conservatively except under life-threatening circumstances, with 75% of women delivered within

2 weeks after fetal demise. After coagulopathy was observed in pregnancies complicated by

fetal death in utero and with newer agents to effect cervical ripening and uterine contractions,

the management of stillbirth has become more proactive. Investigations have evaluated the

significance of a previous stillbirth, maternal serum biochemical markers, genetic causes,

maternal complications of pregnancy, infective agents, intrapartum events, usefulness of

autopsy examinations, and placental findings in the cause of fetal death. The one material

complication frequently evaluated after the diagnosis of a fetal demise is the development of

disseminated intravascular coagulopathy (DIC). Numerous publications have evaluated the

causes of fetal death in utero, but except for the rarely encountered case of DIC, other maternal

complications associated with the management and delivery of a stillbirth have not been

assessed in a large investigation. 

Nursing Management

Carefully observe all woman who deliver a dead fetus for excess bleeding because it the fetus

has been dead in utero for any length of time, the risk for the development of DIC increases.

Encourage a support person to remain with the woman during labor, but remember the support

person is grieving too.

Explain the hospital Procedure such as when the body will be released or what additional

permission for autopsy needed,

Prepare the couple for the possibility they may feel sad on the day the infant would have been

born if the pregnancy have been carried to term

UMBILICAL CORD PROLAPSE (UCP)

Umbilical cord prolapse (UCP) is a rare, obstetrical emergency that occurs when the umbilical

cord descends alongside or beyond the fetal presenting part. It is life threatening to the fetus

since blood flow through the umbilical vessels is usually compromised from compression of the

cord between the fetus and the uterus, cervix, or pelvic inlet. There are two types of UCP:

Overt prolapse, which is the most common, refers to protrusion of the cord in advance of

the fetal presenting part, often through the cervical os and into or beyond the vagina.

The fetal membranes are invariably ruptured in these cases and the cord is visible or

palpable on examination.

Occult prolapse occurs when the cord descends alongside, but not past, the presenting

part. It can occur with intact or ruptured membranes. The diagnosis should be

considered in the setting of a sudden, prolonged fetal heart rate deceleration. An occult

prolapse often cannot be diagnosed with certainty, but is suggested by clinical features

(eg, fetal bradycardia) and findings at cesarean delivery.

Causes

The most common cause of an umbilical cord prolapse is a premature rupture of the

membranes that contain the amniotic fluid. Other causes include:

Premature delivery of the baby

Delivering more than one baby per pregnancy (twins, triplets, etc.)

Excessive amniotic fluid

Breech delivery (the baby comes through the birth canal feet first)

An umbilical cord that is longer than usual

Complication

An umbilical cord prolapse presents a great danger to the fetus. During the delivery, the fetus

can put stress on the cord. This can result in a loss of oxygen to the fetus, and may even result

in a stillbirth.

Manifestations

The symptoms of umbilical cord prolapse include seeing or feeling the umbilical cord in the

vagina prior to the baby's delivery. Low heart rate of less than 120 beats per minute is also a

symptom that the baby is in distress from umbilical cord prolapse.

Management

Treatment options include:

Having a C-section—If the baby cannot be quickly delivered without risk of insufficient

oxygen, then the baby will be delivered by C-section.

Removing pressure from the cord—In some cases, the doctor may be able to move the

baby away from the cord so as not to disrupt oxygen supply to the baby. The mother

may also be asked to move into a position that removes pressure from the cord and

protects the baby.

Rapid delivery—If the mother is ready to deliver, the doctor may try to deliver the baby

very quickly using forceps or a vacuum extractor.

Cesarean Delivery