Primary Nursing Diagnosis

Risk for infection related to loss of protective barrier

OUTCOMES. Risk control; Risk detection; Knowledge: Infection control

INTERVENTIONS. High-risk pregnancy care; Infection control; Labor induction: surveillance; Electronic fetal monitoring: Intrapartum


Treatment varies, depending on the gestational age of the fetus and the presence of infection. If infection is present, the fetus is delivered promptly, regardless of gestational age. Delivery can be vaginal (induced) or by cesarean section. Intravenous (IV) antibiotics are begun immediately. The antibiotics cross the placenta and are thought to provide some protection to the fetus.

If the patient is preterm (<37 weeks) and has no signs of infection, the patient is maintained on complete bedrest. A weekly nonstress test, contraction stress test, and biophysical profile are done to continually assess fetal well-being. If the gestational age is between 28 and 32 weeks, glucocorticoids are administered to accelerate fetal lung maturity. Use of tocolysis to stop contractions if they begin is controversial when ROM has occurred. Some patients are discharged on bedrest with bathroom privileges if the leakage of fluid ceases, no contractions are noted, and there are no signs and symptoms of infection; however, most physicians prefer to keep the patient hospitalized because of the high risk of infection.

If the patient is term and PROM has occurred, the labor can be augmented with oxytocin. It is always desirable to deliver a term infant within 24 hours of ROM because the likelihood of infection is decreased. Some patients and physicians prefer to wait 24 to 48 hours and let labor start on its own without the use of oxytocin. If this is the case, monitoring for signs and symptoms of infection and fetal well-being is critical. Follow the physician's protocol for oxytocin administration, as each may be different. When administering oxytocin, monitor: the frequency, duration, intensity and patterm of contractions; resting tone; blood pressure; intake and output; and response to pain.

Determine the patient's preference for pain relief during labor. If IV narcotics are used, assess the effects of these drugs on the respiratory status of the neonate upon birth. The neonatal nurse or nurse practitioner should be on hand to reverse respiratory depression at delivery. Many patients who receive oxytocin request an epidural because IV narcotics do not provide effective pain relief.

If the patient has an epidural, turn her from side to side hourly to ensure adequate distribution of anesthesia. Use pillows to support the back and abdomen and between the knees to maintain proper body alignment. Most patients are unable to void and require a straight catheter every 2 to 3 hours to keep the bladder empty; if a long labor is anticipated, sometimes a urinary catheter is inserted. Maintain the infusion of IV fluids to prevent hypotension, which can result from regional anesthesia.

766 Premature Rupture of Membranes

Pharmacologic Highlights

Medication or Drug Class




Ampicillin, or other antibiotics

Dosage varies with drug


Prophylaxis; treatment for infection

Oxytocin (Pitocin)

Mix 10 U in 500 mL of IV solution, begin infusion at 1 mU/min and increase 1-2 mU/min q 30 min


Stimulates labor contractions to begin

Dinoprostone (Cervidil insert or Prepadil gel)

Varies with medication


Ripens the cervix to facilitate dilation and stimulates contractions

Meperidine (Demerol)

25 mg intravenous push (IVP) q 3-4 hr

Opioid analgesic

Pain relief of labor contractions

Butorphanol tartrate (Stadol)

1-2 mg q 3-4 hr IVP


Pain relief of labor contractions


Teach every prenatal patient from the beginning to call the physician if she suspects ROM. If ROM occurs, monitor for signs and symptoms of infection and the onset of labor. Maintain the patient in the left lateral recumbent position as much as possible to provide optimal uteropla-cental perfusion. Vaginal exams should be held to an absolute minimum, and strict sterile technique should be used to avoid infection.

Assist the patient who is having natural childbirth in breathing and relaxation techniques. Often, the coach plays a significant role in helping the patient deal with the contractions. The nurse should become involved only when necessary. If a preterm delivery is expected, educate the patient and family on the expected care of the newborn in the neonatal intensive care unit (NICU). If possible, allow the patient to visit the NICU and talk to a neonatologist.

Hospital stay for a vaginal delivery is 48 hours and for a cesarean section 72 hours. Teach the patient as much as possible about self-care and newborn care while in the hospital. Arrange for a follow-up home visit by a perinatal nurse. If the baby is retained in the NICU after the patient is discharged, support and educate the family as they return to the hospital to visit their newborn.

Pregnancy And Childbirth

Pregnancy And Childbirth

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