METRO COLLEGE O F NURSING,

GREATER NOIDA
 CASE STUDY
ON
PRE- MATURE RUTURE OF MEMBRANE

SUBMITTED TO: SUBMITTED BY:

SUBMITTED ON:

IDENTIFICATION DATA:
NAME OF THE PATIENT: Mrs. Bharti Das

NAME OF THE HUSBAND: Mr . Manoj Das

AGE: 23years

SEX: Female

MARITAL STATUS: married

HOPITAL REGISTRATION NO: 181205055

WARD/BED NO: 2(maternity Ward) / Bed No- 3

ADRESS: Uttam Nagar west Delhi south

RELIGION: Hindu

EDUCATION: Graduation

ADMISSION DATE: 28/06/23

DISCHARGE DATE: 2/07/23

DIAGNOSIS–: Pre– Labour rupture of membrane (PROM)

NAME OF THE DOCTOR: Dr. P. Sujata

OCCUPATION: Housewife

MONTHLY FAMILY INCOME: Rs- 35,000

WEIGHT: 50 kg

HIGHT: 5 feet, 1 inch

CHIEF COMPLAINS—

 Pain in lower abdomen since 6 days.

 Leaking per vagina since 1 day.
 Unable to perceive Fetal movement since 1 day

HISTORY OF PAST ILLNESS—

 There is no past medical history of TB, HTN, DM.

 she has not undergone any surgical procedure.

FAMILY HISTORY —
She belongs to a joint family having 4 numbers. Her husband & Brother-in-law are the
supporting person in her family. The monthly income of her family is nearly about Rs 35,000.
There is no history of any disease like TB, HTN, DM & hereditary disease, twin pregnancy in
her family:
a) family tree

b)Family composition

S.No Name Relationship Age Sex Education Occupation Health

to the status
patient
1. Manoj das Husband 23years Male Graduate Private job healthy
2. Bharti das Patient 35years Fema Graduate House wife sick
le
3. . Vicky das Brother in law 24years male Graduate Private job healthy

HEALTHY FACILITY NEAR HOME -

There is a CHC in her village at a distance of about 5 km. Transportation facility available
like bicycle & motorcycle.

HOUSING—
She lives in a pucca house having 8 numbers of rooms with adequate ventilation. They use
sanitary latrine for toileting. Electricity supply is available. They use municipality
water supply taps for drinking.

PERSONAL HISTORY —

 PERSONAL HYGIENE—
She is maintaining her oral hygiene by brushing daily and taking bath
once daily with soap & normal water.

 DIET—
She takes both vegetarian & non-vegetarian diet & She takes meals 4 times a day. she
don’t have any addiction of alcohol &
tobacco. She drinks about 2-3 lts of water per day. She takes rest of about 2 hrs at day time &
8 hrs during night time. She takes no drugs for sleep.

 ELIMINATION—
She has a regular bowel & bladder habit

 MOBILITY & EXERCISE—

No regular walking habits. Only moderate activity with normal house hold work

MENSTRUAL HISTORY —
She got menarche at 13 years of age with regular cycles of 28-30 days interval & 3-4 days
duration with average amount of bleeding. Her LMP is 11/3/18 and EDD- 18/12/18.

SEXUAL & MARITAL HISTORY —

She is married since 2and 1/2 years & She has satisfactory relationship with her spouse.
General health of her spouse is good.

OBSTETRICAL HITORY —

 PAST OBSTETRIC HISTORY —

Nothing significant as she is Primigravida.

 PRESENT OBSTETRIC HISTORY-She is a registered case. She had attended

antenatal clinic 4 times,
LMP :28/09/22

EDD: 05/07/23

the Gestational age (GA) is 39 weeks.

I) HEAD TO TOE EXAMINATION

General Appearance
 Nourishment : moderately nourished
 Body Built : moderate
  Hygiene and Grooming : clean and kempt
 Activity : Inactive
 Posture : normal posture
 Movement : normal movements

Mental Status Examination

 Consciousness :conscious
 Look : anxious
 Attitude : cooperative
 Affect and Mood : appropriate
 Speech : clear and relevant
 Orientation :oriented to time, place and
person
Vital Signs
 Temperature : 98.4F
 Pulse : 94/min
 Respiration : 18/min
 Blood Pressure : 100/60 mm of Hg

Weight and Height

 Height : 145 cm
 Weight : 51 kg
 BMI : 24.28 kg/m2

Head
 Shape : normal cephalic
 Scalp : presence of dandruff
 Face : no swelling
 Subjective Symptoms : no complaints

Hair : evenly distributed and thick

 Texture : dry
 Colour : brown
 Grooming : groomed
 Subjective feelings : no complaints

Eyes
 Eyebrow : normal and symmetrical
 Eyelids : normal
 Eyelashes : equally distributed
 Pupil color : black
 Size : 3 mm
 Reaction to light : PERLA
 Corneal reflex : present
 Conjunctiva : pink
 Lens : transparent
 Pupil vision : normal
 Extraocculor muscles : normal
 Subjective symptoms : no complaints


Ear
 Position : normal
 Cerumen : present
  Otorrhoea : absent
 Subjective complaints : no complaints

Hearing
 Response to normal voice tone : normal voice tone audible
 Watch tick test : watch tick heard in both ears
 Subjective symptoms : no complaints

Nose
 External : symmetrical no discharge
 Nasal septum : midline
 Patency of nasal cavity : air moves in freely as client
breaths through nares
 Frontal and Maxillary Sinuses : normal
 Olfaction : normal
 Subjective symptom : no complaints

Mouth and Larynx

 Outer lips : pink and moist
 Inner lips : pink, moist and smooth
 Teeth : all 32 teeth. Teeth are stained
with no dental caries
 Gums : brown colour and healthy
 Tongue : central position, pink in colour
 Movement : normal movement
 Palate : dark coloured
 Uvula : normal
 Tonsils : not palpable
 Odour of mouth : no foul smell
 Pharynx : gag reflex present
 Subjective data : no complaints

Neck
 Movement : range of motion normal
 Trachea : midline
 Lymph nodes : not palpable
 Jugular vein : not distended
 Carotid pulse : palpable
 Thyroid gland : not enlarged

Chest
 Transverse diameter is twice the anterior posterior diameter and Symmetrical
 Expansion of chest : symmetrical

Palpation
 Tactile fremitus : symmetrical

Auscultation
 Apical pulse : 94 / min
 Breath sounds : normal vesicular sounds
 Cough : absent
 Sputum : absent
 Heart : S1 S2 sounds are heard
 Subjective symptom : no complaint
Breast and axilla
 Symmetry : symmetrical
 Areola and nipples : color dark brown and normal
 Hair distribution : scanty
 Discharge : absent
 Lesions and masses : absent
 Axillary nodes : not palpable
 Condition of breast : secretory

Abdomen
Scar mark Of LSCS present
 Appetite : normal
 Subjective symptoms : pain present

Skin
 Color : brown
 Texture : dry
 Temperature : warm
 Lesions : absent
 Turgor : normal
 Discoloration : absent

Upper Extremities
 Symmetry : symmetrical
 range of motion : possible
 peripheral pulse : brachial and radial pulse
Palpable
 reflexes : biceps and triceps reflexes
Normal
 edema/swelling : absent
 cyanosis : absent
 joints : normal
 deformity : absent

Lower Extremities
 symmetry : symmetrical
 nails : capillary refill 2 sec
 range of motion : normal
 peripheral pulse : dorsalis pedis, posterior tibial
and popliteal pulses palpable
 reflexes : patellar and ankle jerk present
and plantar reflex absent
 edema/ swelling : absent
 cyanosis : absent
 joints : normal
 deformities : no deformities
 subjective symptom : pain in both legs after
prolonged standing

Nails
 shape : convex shaped
 texture : smooth
 nail bed color : pink
  tissue surrounding nails : intact epidermis and dark
colored
 capillary refill : 2sec

Genitals and rectum

 hemorrhoids : absent
 vaginal discharge : bleeding present
 labia majora and minora : normal

 FIRST VISIT—
She missed her menstrual period & went to nearby clinic & tested her urinefor pregnancy &
become confirm of her pregnancy. On her examination her weight was40kg,
BP=120/70mmhg , pulse =78bpm.At that time she suffered from minor
alignments like nausea & vomiting.

 SECOND VISIT-INVESTIGATION—

Hb=11gm%

FBS=83mg/dl

Urine for HCG=positive

Blood group‘B’positive

Sickling – Negative

Urine test=Albumin- Not Present=Sugar---Not Present

VDRL=Negative

HIV=Non reactive

HbsAg =Non reactive

HCV =Non reactive

USG= done on 1/11/18 showing single live intra-uterine fetus in cephalic presentation.

OBSERVATION & ASSESSMENT—

  Her general appearance is good

 Pt is conscious & anxious

 She has no foul body odour & foul breath

PHYSICAL XAMINATION—
VITAL SIGN—

 Temp–98.2 F

 BP—120/70mmhg

 Pulse–78beat/min.
 Resp–20 braeth/min.

OBSTETRICAL EXAMINATION—
INSPECTION—

 No undue enlargement of the Uterus.

 Skin condition—healthy & no discolouration.
 Linea nigra is prominent
 Striae gravidarum visible at lower abdomen
 Episiotomy wound present.

PALPATION—

 Uterus is hard, mobile & globular.

 Fundal height is 15 c.m i.e. at the level of umbilicus.

P/V EXAMINATION—
 Vulva–Normal, No oedema
 Perineal area & Anus–Clean
 Lochia rubra present in normal amount
 Episiotomy wound – Healthy

DEPENDENCY LEVEL OF PATIENT–

 Patient is partially dependent.

CLINICAL EXAMINTION NOTES :

DIAGNOSIS—Prelabour Rupture Of The Membranes ( PROM )

INTRODUCTION—

Rupture of membranes before onset of labor is considered premature. Diagnosis is clinical.

Delivery is recommended when gestational age is >/ 34 wk. and is generally indicated for
infection or Fetal compromise regardless of gestational age.

DEFINITION—
Spontaneous rupture of the membranes any time beyond 28th week of pregnancy but before
the onset of labour is called Prelabour rupture of the membranes(PROM ).

It is of 2 types: -
 Term PROM–
When rupture of the membranes occur beyond 37th
week but before the onset oflabour is called term PROM.

 Preterm PROM–
When rupture of the membranes occur before 37completed week is calledPreterm PROM.
  Prolonged rupture of membranes-When rupture of membranes occurs for more than
24 hours before delivery is called Prolonged rupture of membranes
INCIDENCE:
PROM occur in approximately 10% of all pregnancies.

ETIOLOGY—

In majority causes are not known. Possible causes are -

 Increased friability of the membranes.
 Decreased tensile strength of the membranes.
 Polyhydramnios
 Cervical incompetence
 Multiple Pregnancy
 Infection–Chorion–amnionitis, Urinary tract infections and lower genital tract
infection Cervical length < 2.5 c.m
 Prior preterm labour
 Low BMI (< 19 kg/m2)
 Idiopathic (Causes are not known)

SIGNS & SYMPTOMS—

IN BOOK IN CLIENT
Only subjective symptom- Watery discharge leak Watery discharge in
per vagina either in the form of gush or slow a gush leak
–

DIAGNOSIS:

IN BOOK IN PATIENT

1.Speculum examination Cervix Posteriorly placed, OS 1 finger

 dilated, Vagina high up, No frank
leaking, Pelvis adequate for vaginal
delivery.
2)USG
Amniotic fluid index -23 c.m., Cervical
length–3.8 c.m., single live fetus
present, Estimated Fetal weight–2428
gm

Nonreactive
3)HIV/HbsAg/HCV

4)CBC TWBC-10.65/mm3
,HB-12.4gm/dl, TPC-3,61000/
Not done
5)C-REACTIVE PROTEIN
albumin /sugar- nil

6)URINE (R/M) not done

7) VAGINAL SWAB CULTURE FHR- 140 Beat/min.
8)CTG

COMPLICATION:
IN BOOK IN PATIENT

Cord prolapsed , In my client, nothing present

, Dry labor
Placental abruption,
Fetal pulmonary hypoplasia,
Neonatal sepsis

MANAGEMENT-

PRELIMINARIES-
1) Aspectic examination with a sterile speculum is done confirm the diagnosis, to note the
state of the cervix, and to detect the cord prolapsed

2)patient is put to rest and sterile vulval pad is applied to observe any further leakage.
 Once diagnosis is confirmed, management depends on (a)gestational age of the fetus,
(b)whether the patient is in labour or not, (c) any evidenced of sepsis, (d)prospective feta
survival in that institution if delivery occurs. Maternal vital sign, FHR monitored 4 hourly
OBSTETRIC MANAGEMENT-

TERM PROM-
 Observed patient carefully If the she is not in labor and there is no evidenced of
infection or Fetal distress,
 if labor does not occur spontaneously within 24 hour, then induction of labor with
oxytocin start.

 Caesarean section is performed with obstetric condition

PRE-TERM PROM-
 If gestational age is 34 weeks or more, then wait for spontaneous labor for 24 -48
hour.

 If fails then induction with oxytocin or caesarean for non-cephalic presentation

If gestational age is less than 34 weeks
and absence of maternal and Fetal condition,

 provide bed rest, antibiotic

 pelvic rest and antibiotic help to seal leak spontaneously and reduce infection, and
pregnancy continues

USE OF ANTIBIOTICS-
 Prophylactic antibiotics are given to minimise maternal and Fetal risk of infection.

USE OF CORTICOSTEROID-
 To stimulate surfactant synthesis against RDS in preterm

IN PATIENT-
At the time of admission Obstetrical examination

ABDOMINAL VAGINALEXAMINATION ADVICE

EXAMINATION
Uterine contraction Cx– fully effected Cap
 - 2/20min at Os -3 cm dilated Erythromycin
duration 10sec Membrane absent 500mg6 hrly
Relaxation-good Station vertex -2 Inlection
Betensol 3
FHR-150 ampim start
Injection
tramadol 1ampim
start
Sterile vulval pad

OPRERATION NOTE:
Under all aspectic condition, Parts painted & draped, abdomen opened by pfannesteilincision
in layers. Uterus opened by lower segment transverse incision after pushing thebladder
downwards. A term male child delivered by using ventouse at 1.23 p.m. on 22.06.19.Baby
weight is 2.945 kg . Uterus closed in two layers Abdomen closed in layers and skinclosed by
subcuticular sutures layer
Advice for mother Advice for baby

Inj. Xone 1 gm IV BD for 5 days Exclusive Breast feeding

Iv fluids Warmth
Inj. Syntocinon 10 unit in Immunization
1st 2 pints of IV fluids

Inj. Dynaper AQ 75mg in Injection vit–k 1mg im

100 ml NS ,IV,BD

Inj. Pansec 40 mg IV OD for 5

days
Inj. Ondem 4 mg IV , SOS
Monitor Vitals Watch for
bleeding PV

DELIVERY NOTE-
Under all Aspectic condition with full term male child delivered by vaginal delivery with
right mediolateral episiotomy at 11.43 a.m. /6.12.18. Baby weight is 3.02 kg. Episiotomy
stitched with catgut
Baby-baby born by NVD, Spontaneous cry, no congenital malformation detected

Advice for mother Advice for baby

Tab MAHACEF CV BD for 5 days Exclusive Breast feeding

Tab ZERODOL SP BD for 5 days Warmth
 Tab pan 40 mg od for 5 days Immunization
T-Bact ointment L/A Injection vit–k 1mg im

Post Delivery DAY -1

MOTHER INTERVENTION

Patient conscious Tab. Monocef CV 1tab BD Bed making done

Afebrile Tab. Zerodol p 1 tabBD Mouth care given
Pallor (- ve) Tab. Pan 40 mg 1tab OD Vital sign checked
Pulse= 78bpm T-Bact ointmentL/A I/O chart maintain
BP= 122/76mmhg Bleeding P/V checked
Chest/CVS = NAD Medication given intime
P/A= contraction Perineal Care given
present
Lochia- Lochia rubra
present and of normal
amount
GENERAL ADVICE NURSING INTERVENTION
CONDITION
OF BABY
Active & Alert Exclusive breast feeding Baby is kept warm by warm
Reflex–well Immunization clothes
developed Eye care given
Pulse–134 bpm, Mouth care given
Resp-30breath/min Cord care given
Temp– 98.60f Napkin changed
Urine passed Rooming-in of mother &baby
Stool passed maintained

Post Delivery DAY -2

GENERAL ADVICE NURSINGINTERVENTION

CONDITION OF
MOTHER
Patient conscious Tab. Monocef CV 1tab BD Bed making done
Afebrile Tab. Zerodol p 1 tab BD Mouth care given
Pallor (- ve) Tab. Pan 40 mg 1tab OD Vital sign checked
Pulse= 84bpm T-Bact ointmentL/A I/O chart maintain
BP= 120/78mmhg Bleeding P/V checked
Chest/CVS = NAD Medication given intime
P/A= contraction Perineal Care given
present
Lochia- Lochia rubra
present and of normal
amount
GENERAL ADVICE NURSINGINTERVENTION
CONDITION
OFBABY
Active & Alert Passed Baby is kept warm by warm
Reflex– well Exclusive breast feeding clothes
developed Immunization Eye care given
Pulse- 130bpm,
Resp- 30breath/min Mouth care given
Temp-99F Cord care given
Urine passed Napkin changed
Stool passed Rooming-in of mother &baby
maintained

POST DELIVERY DAY 3

GENERAL ADVICE NURSINGINTERVENTION
CONDITION
OFMOTHER
Patient Tab. Monocef CV 1tab BD Bed making done
conscious Afebrile Tab. Zerodol p 1 tabBD Mouth care given Vital sign
Pallor (- ve) Tab. Pan 40 mg 1tab OD checked
Pulse= 82bpm T-Bact ointmentL/A I/O chart maintain
BP= 120/80mmhg Bleeding P/V checked
Chest/CVS = NAD Medication given intime
P/A= contraction present Perineal Care given
Lochia- Lochia. Rubra
present and of normal
amount
GENERAL ADVICE NURSINGINTERVENTION
CONDITION
OFBABY--
Active & Alert Reflex Exclusive breast feeding Baby is kept warm by
well-developed Pulse Immunization warm clothes
– Eye care given
132 bpm Mouth care given
, Resp30breath/min Cord care given
Temp–99.0f Napkin changed
 Urine passed Stool Rooming-in of mother &baby
passed maintained

PRIORITY WISE NURSING DIAGNOSIS FOR MOTHER:

1. Pain related to surgical incision as evidenced by visualization of facial expression.
2. Fluid volume deficiet related to blood loss during caesarean section.
3. Pain related to inadequate breast feeding as evidenced by engorgement of Breast.
4. Constipation related to decreased muscle tone , lack of fluid intake.
5. Activity intolerance related to pain in the incision site and weakness.
6. Knowledge deficiet regarding self care, infant care.

PRIORITY WISE NURSING DIAGNOSIS FOR BABY:

1. Ineffective thermoregulation related to exposure to environment.
2. Potential risk of infection related to newly clamped umbilical cord.
3. Risk for imbalanced nutrition less than body requirement evidenced by decreased
urine output.
4. Risk for injury related to inadequate knowledge.
Assessment Nursing diagnosis goal planning Intervention evaluation

Subjective data: Risk for infection To reduce the risk Assess for signs Signs of infection Risk for infec
Patient related to loss of for infection of infection. were checked reduced under
complaint of protective barrier as precaution.
“gush of water” evidence by positive Perform single Single digital or
and constantly ferns test digital or sterile sterile speculum
feeling wet speculum vaginal vaginal exam are
exam. performed.

Obtain history History from

from patient patient regarding
regarding complications and
complications and status of pregnancy
Objective data: status of are formed.
A fern test is pregnancy
ordered and
comes back as
positive Administer Medications and iv
medications and fluid as
iv fluid as appropriate: are
appropriate: administered.
prophylactic
antibiotic

Prepare patient for Patient for

induction of induction of labour
labour. are prepared.

Subjective data:  Asses the General condition Patient has red

patient asked Anxiety related to To reduce the general has been assessed same extent, n
about her hospitalization as anxiety condition of by the inspected patient is feelin
condition evidence by facial patient
treatment and expression Patient has been
say that I am  Ask the client ventilated with
worried about my to express her general verbalization
health feeling about
her condition

Individual
 Advise counselling has been
counselling provided to the
Objective data: by about the patient.
observing the condition
patient by facial
expression she  Provide Psychological
looks feels psychological support has been
support to the provided to the
patient patient.
NURSING EDUCATION:
 High fibre, high protein, low carbohydrate diet should take.
 Adequate fluid to drink
 To seek immediately the medical attention in case any complication arises.
 To maintain personal hygiene
 To take high calorie diet.
 Iron & calcium to be continued.
 Provide Exclusive breast feeding to baby.
 To provide warm by proper covering the baby.
 To follow the immunization schedule.
SUMMARY-
Bharti Das, a primipara having GA 39 week & with PROM, is taken to improve nursing
care. The care giver established a good IPR with the client & her trust & confidence was
gained. The client revealed all her problems; thus the care giver was able provide care to
meet the need up to an optimum. During this period she gains knowledge on different aspects
like care of herself, how to give care to her baby, how to give proper breast feeding, regular
follow up, which makes her more confident & due to this she is now able to cope to any
stressful situation .She was also given health education on nutrition
REFERENCE:
1. Textbook of obstetrics 9th edition page no. 385 – 393 D.C Duttar . jaypee
publication.
2. Textbook of obstetrics 3rd edition page no. 574- 579 neelam kumari Shivani sharma
Dr. priti shaha
3. Patient site