Download LABOR: PRETERM/PREMATURE RUPTURE OF MEMBRANES

HOSPITAL NAME
Department:
INSTITUTIONAL POLICY AND PROCEDURE (IPP)
Manual:
Section:
TITLE/DESCRIPTION
POLICY NUMBER
LABOR: PRETERM/PREMATURE RUPTURE OF MEMBRANES:
ANTEPARTUM UNIT (PROM)
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PURPOSE
To outline the care of the woman with preterm labor (PTL) and/or premature rupture of membranes (PROM)
who requires hospitalization on the antepartum unit.
RESPONSIBILITY
Interdependent (*requires Care provider order)
CROSS REFERENCES
POLICY
SUPPORTIVE DATA:
Preterm labor (PTL) is labor which occurs before 37 weeks gestation, characterized by uterine contractions
which result in premature effacement and/or dilation of the cervix. Obstetrical management involves early
detection and suppression of uterine activity. Although the mechanisms of PTL are poorly understood, several
therapies are useful in the reduction/suppression of uterine activity including bedrest, hydration, and/or
tocolytics. Tocolytic agents are drugs that inhibit uterine contractions and include indomethacin, nifedipine,
terbutaline, and magnesium sulfate.
Premature rupture of membranes (PROM) is rupture of the fetal membranes more than 2 hours prior to onset of
labor. Preterm premature rupture of membranes (PPROM) occurs before 37 weeks gestation, with or without
accompanying labor. Risks to the mother and fetus include infection (chorioamnionitis), prolapsed cord and
fetal distress, fetal compression deformities (due to uterine compression and lack of fluid to cushion the baby),
and preterm labor/delivery. Expectant management usually consists of bedrest and assessment for infection and
fetal status. If at any time infection is suspected, management is aggressive to effect delivery.
Both PTL and PROM may necessitate long-term hospitalization. Patient/family emotional problems as well as
possible financial burdens related to prolonged hospitalization should be addressed.
ASSESSMENT:
JCI
Standards
CBAHI
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1. Assess on admission and q shift:
•color, odor, and amount of vaginal discharge and/or amniotic fluid
•presence of uterine contractions (frequency, duration, and quality)
•pain score
•abdominal tenderness
•fetal activity and fetal heart rate daily up to 24 weeks gestation, than q shift after 24 weeks gestation.
•non-compliance with activity restrictions
2. Assess twice daily:
•temperature (if membranes ruptured: q4h x 48 hours, then q shift)
•pulse
•respirations
•blood pressure
3. Assess patient/family response to hospitalization daily.
4. Assess weekly (on Wednesday):
•weight
*•urine protein
5. Assess in the event of spontaneous rupture of membranes:
•fetal heart rate
•time of rupture
•color and odor of fluid
•cord or presenting part at introitus
LABS:
6. Monitor results of:
•cervical culture
•CBC with differential
•amniocentesis
REPORTABLE
CONDITIONS/
NOTIFY Care Provider:
7. Notify physician for:
•change in color/odor of vaginal discharge
•rupture of membranes (if previously unruptured)
•any vaginal bleeding
•uterine contractions ≥4 contractions/hour
•abdominal tenderness
•decreased fetal activity or kick counts <4 movements/hour
•FHR baseline >160 bpm or <110 bpm and/or presence of decelerations (FHR
JCI
Standards
below baseline by ≥15
CBAHI
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bpm x ≥15 seconds)
•temperature >37.6°C
•pulse >120, B/P <90mmHg systolic, respirations <10/minute
•abnormal breath sounds
•weight gain >1 kilogram between successive weighings
•proteinuria >1+
•patient/family inability to cope with hospitalization
•noncompliance with activity restrictions
CARE:
*8. Perform external maternal/fetal monitoring.
9. Maintain activity restrictions, usually bedrest with bathroom privileges.
10. Position patient side lying as much as possible.
11. Provide comfort measures such as backrubs.
12. Teach patient with ruptured membranes perineal care
13. Provide measures to prevent constipation:
•increase p.o fluid intake
•high fiber foods
•prune juice/warm liquids
*•medications
14. Encourage patient to drink 8-12, 8oz glasses of fluid per day.
15. Encourage family/caregiver involvement in care.
16. Facilitate expressions of concern for baby and self.
17. Arrange a tour of NCCC for the patient by wheelchair or stretcher (if patient’s condition permits).
18. Demonstrate acceptable comfort within 1 hour of intervention as evidenced by:
•verbalization
•non-verbal behavior/posture
•decrease in pain score
EMERGENCY MEASURES
19.
PROLAPSED CORD:
•Call immediately for assistance
•Perform sterile vaginal exam; lift presenting part off cord
•Assess FHR when assistance arrives
•Administer oxygen by tight non-rebreather face mask at 8-10 liters/minute
•Remain in bed with patient, lifting presenting part off cord while others move patient in bed to Labor
and Delivery
•Notify Labor and Delivery that the patient is being transport to the Delivery Room
•Place patient in trendelenburg position
PATIENT/CAREGIVER
TEACHING:
JCI
Standards
CBAHI
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20. Explain to patient/caregiver:
•purpose of all procedures and medications
•risks/symptoms of prolapsed cord, if ruptured membranes
•rationale for maintenance of bedrest
21. Instruct patient/caregiver to notify nurse for:
•any change in vaginal discharge
•rupture of membranes or sudden increase in amniotic fluid from vagina
•any vaginal bleeding
•increase in frequency or intensity of uterine contractions
•abdominal pain or tenderness
•decreased fetal movement
•cord or presenting part felt at vagina; feeling of “something hanging” between her legs.
•More than four contractions in one hour.
22. Instruct patient/caregiver about:
•vaginal and Cesarean birth process
•possible need for neonatal intensive care
DOCUMENTATION:
23. Document on Progress Notes, Patient Care Record/flowsheet, , or Patient Education Index:
•Implementation of the Preterm Labor/Premature Rupture of Membranes: Antepartum unit protocol
•assessment findings
•interventions and patient responses/outcomes
•reported conditions
•patient/caregiver teaching and level of understanding on Patient Education Index
PROCEDURE
FORMS
EQUIPMENT
REFERENCES
th
Lowdermilk, D.L., & Perry, S.E.(2004). Maternity & Women’s Health Care (8 ed.). St. Lois: Mosby. (pp. 995996).
rd
Martin, E.J., (2002). Intrapartum Management Modules: A Perinatal Education Program (3 ed.) Philadelphia:
Lippencott. (pp. 82-88).
JCI
Standards
CBAHI
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Mandeville, L.K., & Troiano, N.H.(1999).Association of Women’s Health, Obstetrics and Neonatal Nurses:
High Risk & Critical Care Intrapartum Nursing (2nd ed). Philadelphia: Lippencott. ()pp. 114-115).
Association of Women’s Health, Obstetric and Neonatal Nurses (2002). Templates for Protocols and Procedure
for Maternity Services.
Association of Women’s Health Obstetric and Neonatal Nurses (2002). Perinatal Orientation and Education
Program.
APPROVAL:
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JCI
Standards
CBAHI
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