Running head: MANAGEMENT OF PRETERM RUPTURE OF MEMBRANES
Management of Preterm Premature Rupture of Membranes
Kimberly Johnson
Columbus State University
Evidence Based Practice RN
NURS 3195
Dr. E. Frander
November 18, 2013
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MANAGEMENT OF PRETERM RUPTURE OF MEMBRANES
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Management of Preterm Premature Rupture of Membranes
There are many organizations that identify research priorities. One of the organizations
that participate in research and quality includes the American Nurse Association (ANA). They
are responsible for ensuring that nurses are improving healthcare for all. According to ANA,
quality outcomes require the use of research for evidence-based practice ("ANA," 2011).
Medscape reports that Eighty-five percent of neonatal morbidity and mortality is a result of
prematurity (Jazayeri & Smith, 2013). Preterm Premature Rupture of Membranes (PPROM) is
likely due to many different mechanisms and processes within the body. Evidence –Based
Practice shows that management of PPROM using evidence research will likely decrease the
mortality rate in infants and allow for better patient outcomes.
When many pregnant women present with PPROM, aggressive treatment and
management is suggestive in order to ensure that a viable and stable infant is born at the
appropriate gestational age. Management of PPROM includes, tocolysis, Intravenous antibiotics,
steroids, frequent ultrasounds, monitoring of vital signs, frequent lab work, hydration, and fetal
heart monitoring. Healthcare team members must work in collaboration in order to ensure the
highest treatment is being provided for the patient. Most facilities consult with Maternal Fetal
Medicine (MFM) for appropriate management of care including adjusting medications if
necessary and ordering frequent testing if suggestive of pre-term delivery. The bottom line is that
communication between the physicians and nurses need to be addressed using the most up to
date methods to ensure continuity of care is provided.
Research Evidence
MANAGEMENT OF PRETERM RUPTURE OF MEMBRANES
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Research Article #1
Research Article (provide FULL reference):
Miyazaki K, Furuhashi M, Yoshida K, Ishikawa K. Aggressive intervention of previable
preterm premature rupture of membranes. Acta Obstet Gynecol Scand 2012; 91:923-929
Setting
Purpose
The setting is located in a tertiary referral Labor and Delivery using
records at the Japanese Red Cross Nagoya Daiichi Hospital.
To assess the neonatal and maternal outcomes of pregnancy
complicated by pre-viable preterm premature rupture of
membranes (PPROM).
Research design
Retrospective study
Sample studied
45 women having aggressive intervention with antibiotics,
amnioinfusions, cerclage, and tocolysis.
Over the study period, 72 women presented with pre-viable
PPROM occurring before 23 weeks gestation. 45 patients elected
aggressive management. 27 chose to terminate the pregnancy and
were excluded from analysis. 38 infants delivered alive and 7 were
stillborn. 27 live born survived and 1 died on the labor ward. 10
Findings/Results died prior to discharge from the hospital. Overall results showed
that patients that elected aggressive management 60% (27 of 45)
live-born infants 71.1% (27 of 38).
Limitations
Level of
Evidence and
Justification for
Level.
There are very few articles that address pre-viable PPROM.
An aggressive treatment protocol for women with pre-viable
PPROM resulted in a high neonatal survival rate. Amnioinfusions
assist with flushing any inflammation or bacteria. Cervical cerclage
can assist with arresting cervical dilation. Steroids increased the
neonatal survival rate.
MANAGEMENT OF PRETERM RUPTURE OF MEMBRANES
Are Findings
Valid?
Importance of
Findings
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Yes. 60% of neonates which was 27 of 45 women with neonates
survived meaning more than half of the neonates survived after
the mother elected aggressive management.
It shows that aggressive management should be used in preterm
patients with PPROM for a successful/favorable outcome of the
neonate.
This study allows for clinicians to educate families with accurate information
about neonatal outcomes (Miyazaki, Furuhashi, Yoshida, & Ishikawa, 2012). The
study indicated that those women that elected aggressive treatment in pre-term
labor with Rupture of Membranes (ROM) resulted in a higher survival rate.
Although there was little to no fluid in most instances, studies also showed that
amnioinfusions washed out any inflammation the patient may have occurred
(Miyazaki et al., 2012). This evidence supports the use of aggressive management
and indicates that implementation of this guideline is appropriate.
Research Article #2
Research Article (provide FULL reference):
Levy A, Wiznitzer A, Mazor M, Holcberg G, Zlotnik A, Sheiner E. Factors affecting the latency
period in patients with preterm premature rupture of membranes. Arch Gynecol Obstet
(2011) 283: 707-710
Setting
Purpose
A database in a facility was used to obtain accurate information by
conducting a Mann-Whitney U test in Chicago, Illinois, USA SPSS
To assess the factors affecting the latency period in women with
pre-term PPROM and evaluate morbidity associated with prolonged
latency.
A population-based retrospective study
Research design
Sample studied
All women at the facility seen and treated for PPROM prior to 37
MANAGEMENT OF PRETERM RUPTURE OF MEMBRANES
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weeks during the years of 1998-2008.
There were 1,399 singleton deliveries of patients with PPROM.
24.6% (345) occurred prior to 34 weeks gestation. The latency
period duration with women PPROM before 34 weeks compared to
PPROM after 34 weeks. Other factors associated included
Findings/Results
multiparty and maternal age >35.
Limitations
Level of
Evidence and
Justification for
Level.
Are Findings
Valid?
Importance of
Findings
Prediction of latency intervals with PPROM is imprecise so
consulting patients with PPROM about the length of latency is very
difficult.
The duration of the latency period is associated with gestational
age. Null parity is associated with a lower latency period.
Prolonged latency is a significant risk for chorioamnionitis.
Yes. Based upon the statistical data and the standard deviation
with the percentages and outcomes during the latency period, the
findings are valid.
The interval between ROM and the onset of labor is significant in
null parity and multiparty.
Research was performed in a population-based retrospective study to
determine the latency period after ROM occurred in determining an estimation of
when a neonate would likely deliver. The study was conducted using the MannWhitney U test due to the latency period not normally distributed. Many factors
were assessed to determine the latency period associated with PPROM and the
length of latency. While there are many factors that contribute to PPROM and there
is appropriate treatment and management for PPROM, there is no exact way to
determine how long a patient will remain in the latency period. There are some
suggestions within this article that suggest that null parity and multiparty can have
MANAGEMENT OF PRETERM RUPTURE OF MEMBRANES
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a significant factor with the interval between ROM and the onset of labor (Levy et
al., 2010).
Research Article #3
Research Article (provide FULL reference):
Margato M. F, Martins G. LP, Junior R. P, Nomura M. L. Previable preterm rupture of
membranes: gestational and neonatal outcomes. Arch Gynecol Obstet (2012) 285:15291534
Setting
A local facility database was used to determine facts from labor
and delivery using neonatal and maternal charts at the State
University of Campinas, Campinas, Brazil
Purpose
To determine neonatal outcomes relating to gestational age in
relation to pre-viable preterm rupture of membranes. The purpose
was also to evaluate neonatal morbidity and the mortality rate.
Retrospectively analyzed
Research design
One twin and 35 singleton pregnancies
Sample studied
Findings/Results
Limitations
Level of
Evidence and
Justification for
Level.
Are Findings
Perinatal mortality is high in pregnancies complicated by pre-viable
rupture of membranes; however gestational age at occurrence is a
strong predictor of the outcome.
During the study, they were not able to collect data about longterm prognosis, which is important information in the decision
making process involving termination.
Management protocol aimed to exclude infection, provide maternal
hydration, temperature monitoring, fetal heart tones, serial blood
counts, and ultrasounds, antibiotics, and steroids administration.
Yes. There were no maternal deaths. Mean gestational age 24
MANAGEMENT OF PRETERM RUPTURE OF MEMBRANES
Valid?
Importance of
Findings
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weeks ranging 16-39 weeks. Pre-term delivery 68%, 1 abruption.
C-Section 31%. Neonatal mortality 42%. Overall neonatal survival
was 35% (11 in 32 newborns)
Pre-viable ROM is a situation in which the level of evidence might
be far from ideal and individualized approach is at present the best
evidence.
In this article, neonatal outcomes studies were performed relating to
gestational age using a database retrospectively. The research confirmed that
perinatal mortality is high in pregnancies complicated by previable rupture of
membranes (Margato, Martins, Junior, & Nomura, 2012). The information was
obtained using a database at a local institution in Labor and Delivery. The design
was used retrospectively. Management in this article aimed at preventing infection,
providing maternal hydration, monitoring fetal heart tones and providing
antibiotics. This article indicates that the level of evidence may not be ideal and it is
best to assess the outcome on an individual basis.
Body of Evidence
Overall, all three articles show significant evidence that indicates the
appropriate management of patients with pre-term premature rupture of
membranes can have positive outcomes and significant factors. When caring for
patients, it is important to ensure that you are providing the highest quality of care.
Aggressive management is the key to being stable and appropriate management
should begin as earliest as possible. If this guideline is implemented using the
correct dosage of antibiotics, fetal monitoring, steroids, monitoring of labs, and
frequent monitoring of vital signs with inpatient management, the quality of care
and patient outcomes will increase significantly.
MANAGEMENT OF PRETERM RUPTURE OF MEMBRANES
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Application of the Guideline, Protocol, or Best Practice to the Clinical
Setting
This guideline should be implemented in the Women and Children services. Many
healthcare workers do not adapt to change very well and have a hard time
adjusting. Avoiding change in the healthcare field is inevitable. Technology is on
the rise and changes occur every day. As nurses and patient advocates, we must
ensure that we are caring for our patients using the latest and most up to date
recommendations. While most nurses and staff will agree that it is hard to
discontinue old habits and change the way that you have cared for patients for so
many years, we must also remember that evidence based nursing using the
appropriate research, is the recommended practice. Kurt Lewin developed a
theory to assist many with change. Lewin believed that “one’s behavior is related
both to one’s personal characteristics and to the social situation in which one finds
oneself” (Kritsonis, 2011). The concepts of the theory are based upon three things:
driving forces, restraining forces, and equilibrium. The theory consists of three
stages: unfreezing, moving to a new level or changing/movement, and refreezing.
In the unfreezing stage, people are assisted with letting go of the old and
welcoming the new in a productive manner. The status quo is challenged by the
use of aggressive management in pre-term labor patients using new and effective
methods to reduce the risk of pre-term delivery with premature rupture of
membranes. The negative factors are decreased in this stage using positive
evidence and outcomes and allowing participation in the decision making process.
When you combine the two methods together, you end up with staff that is less
reluctant to change and want to assist with changing the care to ensure the highest
quality is provided. As we move forward in the next step, it is important to remain
productive (Kritsonis, 2011). Frequent in-services should be provided to staff with
education on aggressive management, changes can be made at this time and trial
and error can be used. The last stage is refreezing. In this stage the new
guidelines for aggressive management have been established and now are ready to
be implemented. Standing Operation Procedures (SOP) is created and
management will become the “norm” when caring for patients. If someone is
unsure of the correct management, the SOP may be viewed to give guidance. Once
this stage is complete, equilibrium may now be set and quality patient care will
become the standard.
Summary
It is evident that research has shown that aggressive management of patients with
pre-term premature rupture of membranes in viable neonates will have higher
chances of survival and better outcomes. If the staff follows the correct guidelines
MANAGEMENT OF PRETERM RUPTURE OF MEMBRANES
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as written, then most neonates will be in stable condition. Administration of
antibiotics over a seven day period including alternating antibiotics, administering
procardia by mouth, ensuring frequent monitoring of vital signs are done to ensure
that the patient remains afebrile and has no signs and symptoms of
chorioamnionitis and lastly ensuring maternal fetal medicine does frequent
ultrasounds for fetal growth scans and bio physical profiles to score fetal wellbeing
will give the neonate a higher chance of survival and likely require less
management at birth.
Reflection
Nurses are patient advocates and known as “the voice” for patients when they are
unable to communicate things that they don’t know or unsure of. Because of this,
we must ensure that we remain up to date in our knowledge relating to our field of
study and ensure that evidence based research is performed on a regular basis.
While change can be difficult, we must all remember that we are not practicing care
for ourselves but ultimately for the patient. Ensuring that the staff is educated and
in-services are provided will ensure that the staff understands why they are
performing the actions that are being ordered. Knowing that you are saving lives
each day and making a difference in someone’s family should be reassuring that
you have a passion for the job that you are doing and performing it with pride.
Challenges and obstacles will always come in the mist of things, but we must
always remember, it is how we handle those challenges and obstacles that will
determine the patient’s outcome. One change in a step when providing care that
MANAGEMENT OF PRETERM RUPTURE OF MEMBRANES
was different from the way you previously cared for the patient could mean a
difference in a life time.
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References
American Nurses Association Research Agenda. (2011). Retrieved from
http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Improvi
ng-Your-Practice/Research-Toolkit/ANA-Research-Agenda/Research-Agenda-.pdf
Jazayeri, A., & Smith, C. (2013). Premature Rupture of Membranes. Retrieved November 18,
2013, from http://emedicine.medscape.com/article/261137-overview
Kritsonis, A. (2011). Change Theory. Retrieved November 19, 2013, from
http://currentnursing.com/nursing_theory/change_theory.html
Levy, A., Wiznitzer, A., Mazor, M., Holcberg, G., Zlotnik, A., & Sheiner, E. (2010, January 27).
Factors affecting the latency period in patients with preterm premature rupture of
membranes. Acta Obstet Gynecol Scand 283: 707-710 http://dx.doi.org/10.1007/s00404010-1448-7
Margato, M. F., Martins, G. L., Junior, R. P., & Nomura, M. L. (2011, December 28). Previable
preterm rupture of membranes: gestational and neonatal outcomes. Acta Obstet Gynecol
Scand, 285: 1529-1534. http://dx.doi.org/10.1007/s00404-011-2179-0
Miyazaki, K., Furuhashi, M., Yoshida, K., & Ishikawa, K. (2012, April 13). Aggressive
intervention of previable preterm premature rupture of membranes. Acta Obstet Gynecol
Scand, 91: 923-929. http://dx.doi.org/10.1111/j1600-0412.2012.01432.x