A CASE PRESENTATION ON PROM

STDENT NAME—Miss Itismita Biswal

HOSPITAL—IMS & SUM HOSPITAL , BBSR.

YEAR OF STUDY—2019

IDENTIFICATION DATA

NAME OF THE PATIENT—Mrs. Rojalin Biswal

NAME OF THE HUSBAND—Mr . Pramod Kumar Pradhan

AGE— 24 years

SEX— Female

MARITAL STATUS— Married

HOPITAL REGISTRATION NO— 190621078

WARD/BED NO— 4(maternity Ward) / Bed No- 13

ADRESS— At- Parulia, P.O – Baliapal, PS – Baliapal, Dist – Balasore, Odisha

RELIGION— Hindu

EDUCATION— Graduation

ADMISSION DATE— 21/06/19

DISCHARGE DATE— 25/06/19

DIAGNOSIS – Primigravida at 38 wk 3days with Pre – Labour rupture of membrane

(PROM)> 4 hrs for safe confinement

NAME OF THE DOCTOR— Dr. Padmalaya Thakur

OCCUPATION— Housewife

MONTHLY FAMILY INCOME— Rs- 35,000

WEIGHT— 65 kg

HIGHT—5 feet

CHIEF COMPLAINS—

 Pain in lower abdomen since 3 days

 Leaking per vagina since 4 hrs
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 6 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.

HEALTHY FACILITY NEAR HOME—

There is a CHC in her village at a distance of about 1 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 habits
 MOBILITY & EXERCISE— She has regular walking habits of evening everyday.

MENSTRUAL HISTORY—

She got menarche at 13 year of age with regular cycles of 28-30 days interval & 3-4 days
duration with average amount of bleeding. Her LMP is 25/9/18 and EDD- 2/7/19.

SEXUAL & MARITAL HISTORY—

She is married since 1 and 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,
Her LMP was 25/9/18 & EDD - 2/7/19 .Thus the Gestational age (GA)
is 38 weeks 3 day. She attended antenatal clinic 7 times.
 FIRST VISIT—
She missed her menstrual period & went to nearby clinic & tested her urine
for pregnancy & become confirm of her pregnancy. On her examination her weight was
54 kg, BP=120/70mmhg , pulse =78bpm.At that time she suffered from minor
ailments like nausea & vomiting.
 SECOND VISIT-
She attended OBG opd of IMS & SUM hospital for further antenatal check
st
up and 1 dose of Inj. TT 1 amp was given.
 THIRD VISIT-
She attended OBG opd of IMS & SUM hospital for further antenatal check up
nd
and 2 dose of Inj. TT 1 amp was given.
 FOURTH VISIT-
She attended OBG opd of IMS & SUM hospital for further antenatal check
up, Vitals was found normal and USG was done, showing a single live intrauterine fetus.
 FIFTH VISIT-
She attended OBG opd of IMS & SUM hospital for further antenatal check up
and Vitals was found normal.
 SIXTH VISIT-
She attended OBG opd of IMS & SUM hospital for further antenatal check up
and all the blood investigations and Vitals was found normal.
 SEVENTH VISIT-
She attended OBG opd of IMS & SUM hospital for further antenatal check up
and all the blood investigations ,Vitals & Ultrasonography was found a single live
intrauterine fetus and no congenital abnormalty was present.

INVESTIGATIONS—
 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 18/5/19 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.

HEAD TO TOE EXAMINATION—

 Her skin colour is normal

 Hair & scalp are clean & healthy. No dandruff & pediculosis is present
 In eye ,no Jaundice & Pallor is seen
 Mouth is clean
 Tongue is hydrated
 Gum is healthy
 Total no of teeth is 32
 Nose, ear, throat is clear
 In neck no abnormal enlargement of lymph node & glands.
 In breast secondary areola has formed & nipple are normal,.
 Engorged breast is present.
 Liver & spleen are not palpable
 Leg ,spine & back are normal
 pedal oedema is not present

OBSTETRICAL EXAMINATION—

INSPECTION—

 Skin condition—healthy & no discolouration.

 Linea nigra is prominent
 Striae gravidarum visible at lower abdomen
 In Lower segment of uterus, incision present.
PALPATION—

 Uterus is hard, mobile & globular.

 Fundal height is 14 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

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 of
labour is called term PROM.
 Preterm PROM –
When rupture of the membranes occur before 37 completed week is called
Preterm PROM.
 Prolonged rupture of membranes-
When rupture of membranes occur for more than 24 hours before delivery is
called Prolonged rupture of membranes.

INCIDENCE –

PROM occur in approximately 10% of all pregnancies.

ETIOLOGY —

IN BOOK IN CLIENT
In majority causes are not known. Idiopathic
Possible causes are - ( Causes are not known)
 Increased friability of the membranes
 Decreased tensile strength of the membranes
 Polyhydramnios
 Cervical incompetence
 Multiple Pregnancy
 Infection – Chorio – amnionitis, Urinary tract infections
and lower genital tract infection
 Cervical length < 2.5 c.m
 Prior preterm labour
 Low BMI ( < 19 kg/m2)

SIGNS & SYMPTOMS--

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

IN BOOK IN PATIENT

1.Speculum examination Cervix Short, Soft , Posteriorly placed, OS 1 finger

dilated, Membrane ruptured, water leaking per
vagina, Presenting part high up.

2)USG On 18.5.2019, USG shows that Amniotic fluid index

-10.4 c.m., single live fetus present, Well pulsatile
cardiac pulsation seen. Estimated fetal weight – 2428
gm

3)HIV/HbsAg/HCV Nonreactive

4)CBC TWBC-10.76/mm3 ,HB-12.8 gm/dl, TPC-

4,32000/mm3

5)C-REACTIVE PROTEIN Not done

6)URINE (R/M) albumin /sugar- nil

7)VAGINAL SWAB Not done

CULTURE
 8)CTG FHR -148 beat/min.

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 prolapse

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 fetal
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 ocurr 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,
then provide bed rest ,antibiotic
 pelvic rest and antibiotic help to seal leak sponateously 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 VAGINAL ADVICE

EXAMINATION EXAMINATION

 Uterine contraction -  Cx –fully effeced  Injection ceftriaxone 1gm

2/20min at duration 10  Os -1 cm dilated IV B.D.
sec  Membrane absent  Tab misoprostol 25µg in
 Relaxation-good  Presenting part posterior fornix at 4 hr
 FHR-150 high up apart.
 Monitor vitals & FHR.
 Watch for progress of
labor
 Apply Sterile vulval pad

DELIVERY NOTE-

Under all aspectic condition, Parts painted & draped, abdomen opened by pfannesteil
incision in layers. Uterus opened by lower segment transverse incision after pushing the
bladder 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 skin
closed 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 1st 2 pints of IV Immunization
fluids
Inj. Dynaper AQ 75mg in 100 ml NS ,IV,BD Injection vit –k 1mg im
Inj. Pansec 40 mg IV OD for 5 days
Inj. Ondem 4 mg IV , SOS
Monitor Vitals
Watch for bleeding PV
APPLICATION OF VIRGINIA HENDERSON’S NEED THEORY IN
NURSING PROCESS:-
֍ Virginia Henderson was born on 30th November, 1897, in Kansas City, Missouri
and dies on17th march 1996.
֍ She called as “the Nightingale of modern nursing”, “Modern- day mother of
nursing”, “The 20th century Florence Nightingale” & “Little Miss3*5”.
֍ She earned her Diploma in nsg. From the Army school of nursing in 1921, B.Sc. in
1932, M.A. in 1934.
֍ She worked as a teaching nursing in 1923, member of faculty&research associate.
֍ She was honored at the Annual meeting of the nursing and allied health section os
the medical library association.
֍ She created a basic nursing curriculum for nursing in 1937.
֍ She revised Harmer’s classic textbook of nursing and wrote 5th edition in 1939.
֍ She was founding member of ICIRN (Interagency council on information resources
for nursing).
֍ She developed the theory in 1950-1970.
֍ She proposed 14 components of basic nursing care:-
 Breathe normally
 Eat &drink adequately
 Eliminate body waste
 Move and maintain desirable posture
 Sleep and rest
 Select suitable clothes- dress and undress
 Maintain body temperature within normal range
 Keep body clean and well-groomed and protect from injury
 Avoid dangers in the environment and avoid injuring others.
 Communicating with others in expressing feelings.
 Worship according to one’s faith.
 Work in such a way that there is a sense of accomplishment.
 Play and participate in various forms of recreation.
 Learn, discover, or satisfy the curiosity that leads to normal development.
MANAGEMENT OF Mrs. Rojalin Biswal:-
Move and maintain
Eliminate body
Breathe normally. desirable postures.
wastes.

Sleep and rest

Eat and drink
adequately.

Select suitable
Learn, discover, or
clothes-dress and
satisfy the curiosity
undress
that leads to
normal
development

Play or participate HUMAN Maintain body

temperature within
in various forms of
normal range
recreation

Keep the body well

Work in such a
groomed and
way that there is a
protect the
sense of
integument
accomplishment

Avoid dangers in
Communicate with
Worship according the environment
others in
to one’s faith and avoid injuring
expressing
others
emotions, needs,
fears, or opinions
 PHYSICAL ASSESSMENT

Pattern Before Present Interpretation

1.Health Perception- Patient goes to the Patient is concern Patient cannot
Health Management health center once about her cesarean function normally
upon when she got section thinking that it anymore like before
pregnant. All in all, may be detrimental to because of her
she thinks she is in a her health. hospital confinement
healthy state. and condition. Her
body image changed
after the surgical
procedure done.
2. Nutritional- Prior to confinement, During Patient’s nutritional
Metabolic patient loves eating hospitalization, the and metabolic status
Management instant foods and fatty patient is on diet as has been changed due
foods like fries and tolerated. She eats to her surgical
burgers. She basically fruits like apples and incision.
loves eating whatever oranges. She eats
she likes. bread instead of rice.
She said she loss her
appetite since her
onset of labor.
3.Elimination Pattern Bowel: Bowel: Bowel:
Patient defecates 1-2 Patient defecates once There was a change in
times a day, usually a day but not on a the frequency and
morning and in the regular basis. Stool is amount.
afternoon. Stool is soft, minimal in
brown in color and amount and brown in
well-formed. color.

Bladder:
Patient voids usually Bladder: Bladder:
6-8 times a day. Urine Patient voids 3-4 There was a change in
is yellow in color. No times a day without the frequency and
pain when voiding. pain and discomfort. amount.
4.Activity, Leisure, Patient is a housewife Patient’s activities in After caesarean
and Recreation so she is always in the hospital are section, there is a
Pattern charge of the ambulation, deep limitation in her
household work. Her breathing and activities of daily living
leisure time would coughing exercise, and a disruption in
include playing Ludo taking a bath or her leisure and
and watching personal hygiene. recreation pattern.
television.
5.Sleep and Rest Patient puts herself to Due to her Patient’s sleep and
Pattern sleep by watching uncomfortable rest pattern changed
television programs. condition and pain, when she was
 She usually sleeps at patient complains of admitted. She cannot
around 11pm to 6am. difficulty of sleeping put himself to sleep
She feels rested when and short period of anymore due to
sleeping and thinks sleeps. surgical incision and
that her energy is pain plays a big factor
sufficient for her for her sleep
activities. disturbances.
6.Cognitive – Patient is a high Patient’s present No changes/
Perceptual Pattern school graduate. She condition is not a alterations.
can read and write. hindrance to her
She can speak and be cognitive- perceptual
understood by others. pattern.
7. Self-Perception / Patient is a friendly During the times of There is a slight
Self-Concept Pattern person; she loves to her confinement, she change in her self-
socialize with his doesn’t think that she perception due to
friends in their is a holistic person present condition.
neighborhoods. She anymore. However,
considers himself as she is positive that she
holistic human being will be alright after
as long as she is confinement.
healthy, complete,
and his family is
always there.
8. Role Relationship Patient can The patient’s family is Normal/ No
understand English, supportive to the alterations.
Odia and Hindi. She patient. She is happy
has satisfactory with their presence
relationship with her and support.
famil members.
9. Sexuality/ Patient has been Patient reserved her Patient reserved her
Reproductive Pattern married for 3 years. right to privacy. right to privacy.
10.Coping and Stress When patient is The recent Patient accepts
Tolerance stressed, she sings old hospitalization of the present condition with
odia songs and eats patient was stressful a positive attitude.
comfort foods like and source of anxiety.
burgers, fries. When However, she is
it comes to problems, positive that she will
she lets herself think be able to cope up
immediately for a with current
solution. condition.
11.Values- Belief Patient belongs to She follows a After Caesarean
Pattern Hindu religion. She therapeutic regimen section, patient is
has a strong faith to and her strong faith to trusting God that she
God and goes to God accounts for her will be discharge soon
temple every monday fast recovery. and will recover
with her family. without any
complications.
Post Delivery DAY -1( 23. 06. 19 )

GENERAL CONDITION ADVICE NURSING

OF INTERVENTION
MOTHER

Patient conscious Inj. Xone 1gm IV BD Bed making done

Afebrile Inj. Dynaper AQ Mouth care given
Pallor (- ve) 75mg in 100 ml NS Vital sign checked
Pulse= 82 bpm slow IV I/O chart maintained
BP= 120/70 mmhg Inj. Pansec 40 mg IV, Bleeding P/V checked
Chest/CVS = NAD OD Medication given in
P/A= Soft, contraction Inj. Tramadol 100 mg time
present IV, SOS Perineal Care given
Lochia- Lochia rubra Monitor Vitals Catheter Care given
present and of normal Watch for bleeding Positioning given
amount P/V
GENERAL CONDITION ADVICE NURSING
OF BABY-- INTERVENTION

Active & Alert Exclusive breast feeding Baby is kept warm by

Reflex – well Immunization warm 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 &
Stool passed baby maintained

Post Delivery DAY -2( 24.06.19 )

GENERAL CONDITION OF ADVICE NURSING

MOTHER INTERVENTION
 Patient conscious Inj. Xone 1gm IV Bed making done
Afebrile BD Mouth care given
Pallor (- ve) Inj. Dynaper AQ Vital sign checked
Pulse= 80 bpm 75mg in 100 ml NS I/O chart maintain
BP= 110/70 mmhg slow IV Bleeding P/V checked
Chest/CVS = NAD Inj. Pansec 40 mg Medication given in
P/A= contraction IV, OD time
present Inj. Tramadol 100 Perineal Care given
Lochia- Lochia rubra mg IV, SOS Remove catheter
present and of normal Monitor Vitals Early ambulation
amount Watch for bleeding done
P/V Liquid diet given, then
changed to Semi-solid
diet given

GENERAL CONDITION OF ADVICE NURSING

BABY-- INTERVENTION

Active & Alert Exclusive breast feeding Baby is kept warm by

Reflex – well developed Immunization warm clothes
Pulse – 130 bpm Eye care given
Resp - 30breath/min Mouth care given
Temp – 990f Cord care given
Urine passed Napkin changed
Stool passed Rooming-in of mother &
baby maintained

Post Delivery DAY -3( 25.06.19 )

GENERAL CONDITION OF ADVICE NURSING
MOTHER INTERVENTION

Patient conscious Tab. Mahacef CV 1 Bed making done

Afebrile tab BD Mouth care given
Pallor (- ve) Tab. Zerodol p 1 tab Vital sign checked
Pulse= 82bpm BD I/O chart maintain
BP= 120/80mmhg Tab. Pan 40 mg 1 Bleeding P/V checked
Chest/CVS = NAD tab OD Medication given in
P/A= contraction time
present Perineal Care given
Lochia- Lochia Rubra Solid diet given
present and of normal
amount

GENERAL CONDITION OF ADVICE NURSING

BABY-- INTERVENTION

Active & Alert Exclusive breast feeding Baby is kept warm by

Reflex – well developed Immunization warm clothes
Pulse – 132 bpm, Eye care given
Resp- 30breath/min Mouth care given
Temp – 990f Cord care given
Urine passed Napkin changed
Stool passed Rooming-in of mother &
baby maintained

ADVICE ON DISCHARGE :

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-

Bhagyabati Das, a primipara having GA 38 week 2 days & 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, personal hygiene, antenatal
exercise & regular follow up.

Bibliography:

1. Bhaskar Nima. Midwifery & Obstetrical Nursing: Assessment and management of

Pregnancy. 2nd ed. Bangalore: EMMESS Medical Publishers, 2015.P- 804-05

2. Dutta DC. Text Book of Obstetrics including Perinatology and Contraception:Preterm

Labor,PROM,postmaturity,IUD.In:Konar Hiralal editor.7th ed.London.New Central Book
Agency (P ) Ltd:2011.P.317-19

3. Jacob Annamma. A Comprehensive Text Book of Midwifery & Gynecological Nursing :

Preterm labor, Premature rupture of membrane , 3rd ed.Karnataka : JAYPEE Brothers
Medical Publishers (P) Ltd,2012.P.348-50