Artificial Rupture of Membranes (Maternal-Newborn) - CE

ALERT

Consult the state’s nurse practice act and the organization’s practice to determine which level of clinician may perform an artificial rupture of membranes (AROM).

Ensure that a practitioner is immediately available in the event an emergency related to the procedure occurs.

OVERVIEW

An AROM, or amniotomy, may be performed by a physician or an advanced practice registered nurse (APRN) for the purpose of shortening labor by stimulating the uterine contraction pattern. An AROM may be performed using a sterile, disposable plastic membrane perforator (Figure 1).^{undefined#ref4">4}

An AROM should be performed only after the practitioner determines that the cervix is favorable for labor induction and when the fetal vertex is at a station that minimizes the opportunity for umbilical cord prolapse.⁴ Once the amniotic sac is ruptured, the amniotic fluid is allowed to drain slowly. If the fetal presenting part is well applied to the cervix, a small amount of fluid should be seen upon membrane release. An AROM may be performed alone or in combination with the administration of pharmacologic agents.

The nurse may provide the practitioner with sterile supplies, monitor the maternal and fetal responses to the AROM, and document the procedure and characteristics of the amniotic fluid. Abnormal characteristics of amniotic fluid include blood, meconium staining or meconium particulates, and signs of infection (chorioamnionitis) (e.g., foul odor, purulence). Amniotic fluid is normally clear with a mild musty odor. Small pieces of vernix may be observed; larger amounts of vernix in the fluid may suggest fetal prematurity. Green or muddy yellow meconium-stained fluid may indicate interruption of oxygenation to the fetus. Meconium-stained amniotic fluid may indicate the need for resuscitative measures for the newborn after delivery, such as positive pressure ventilation. Routine intubation for tracheal suction of newborns delivered through meconium-stained fluid is not recommended.⁵ Meconium may also be present if the fetus is in a breech position and the fetal abdomen is compressed.

Once the amniotic membranes rupture, a risk of intrauterine infection exists, and the risk increases with the duration of the membrane rupture.¹ Antibiotics should be administered to a patient with intrapartum risk factors, such as when a rupture occurred more than 18 hours ago and Group Beta Streptococcus (GBS) culture results are unknown or indications of infection such as chorioamnionitis or pyelonephritis are noted.² Contraindications to an AROM include active vaginal infections (e.g., genital herpes)³ because the recommended route of birth in a patient with that condition is cesarean delivery.

Risks resulting from an AROM include umbilical cord prolapse, umbilical cord compression, bleeding from an undiagnosed vasa previa, intra-amniotic infection, and placental abruption.⁴

PATIENT AND SUPPORT PERSON EDUCATION

• Support the practitioner’s explanation of the purpose of the procedure and the methods used to accomplish it; notify the practitioner if the patient and support person request additional information for clarification.
• Advise the patient to expect sensations similar to those felt during a sterile vaginal examination.
• Advise the patient that she may feel fluid draining from her vagina.
• Instruct the patient to notify the practitioner of any signs or symptoms of infection:
• Fever
• Chills
• Uterine tenderness
• Foul-smelling vaginal discharge
• Instruct the patient regarding relaxation techniques during the procedure.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Assess the patient’s vital signs.
5. Review the prenatal history thoroughly and assess the patient for contraindications to AROM. Report any contraindications to the practitioner.
6. Assess the uterine contraction pattern.
7. Assess the fetal heart rate (FHR) pattern.

Preparation

1. Gather the necessary supplies.

PROCEDURE

1. Perform hand hygiene and don gloves.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient and ensure that she agrees to treatment.
4. Support the patient as necessary throughout the procedure.
5. Place several disposable pads or towels under the patient’s buttocks.

   Rationale: The fluid that drains after an AROM may soak the patient’s linens if adequate preparation is not made to absorb it.

6. Position the patient in the supine position with her knees bent. Place a padded bedpan or rolled towel under her hips.
7. Assist the practitioner with donning sterile gloves and add a small amount of lubricant to an established sterile field, if requested.
8. Using sterile technique, open the package containing the membrane perforator (Figure 2) and allow the practitioner access to it.

   Maintain aseptic technique throughout the procedure to avoid introducing pathogens into the uterus.

9. Provide an ongoing assessment of FHR throughout and immediately after the procedure. Notify the practitioner immediately of any adverse reactions.

   Rationale: FHR changes may indicate umbilical cord prolapse or cord compression. ⁴

   Normal accelerations in FHR may occur during and after an AROM because of fetal scalp stimulation.

10. Assess the color, clarity, odor, consistency, and gross amount of amniotic fluid and record the time of the AROM.

    Rationale: Monitoring the amniotic fluid for signs of infection, blood, or meconium is critical when preparing for appropriate interventions at delivery.

11. Perform perineal care and replace wet underpads with clean, dry ones.
12. Discard supplies, remove gloves, and perform hand hygiene.
13. Assist the patient into a comfortable side-lying or tilted position.
14. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Immediately after the procedure, monitor the color, clarity, odor, consistency, and amount of amniotic fluid.
2. Immediately after the procedure, monitor the fetus and mother for serious complications, including umbilical cord prolapse, fetal heart tracing characteristics of umbilical cord compression (FHR decelerations), infection, rupture of undiagnosed vasa previa, and placental abruption.
3. Assess the patient’s temperature every 2 hours until the birth of the newborn.³ Notify the practitioner of temperatures above 38°C (100.4°F).³
4. Assess the patient periodically for signs of infection.
   1. Fever or chills
   2. Elevated maternal heart and respiratory rates
   3. Uterine tenderness upon palpation
   4. Strong- or foul-smelling vaginal discharge
   5. Fetal tachycardia
5. Perform perineal care and change underpads as needed to maintain patient comfort and to prevent skin breakdown.
6. Assess the uterine response to the AROM.
7. Assess, treat, and reassess pain.

EXPECTED OUTCOMES

• Ruptured amniotic sac
• Clear amniotic fluid
• Uterine contraction pattern adequate for progression of labor
• Vaginal birth without injury to patient or newborn

UNEXPECTED OUTCOMES

• Intact amniotic sac
• Meconium-stained amniotic fluid
• Strong- or foul-smelling purulent vaginal discharge
• Umbilical cord prolapse
• Rupture of undiagnosed vasa previa
• Placental abruption
• Maternal or fetal infection
• Labor dystocia
• Cesarean delivery

DOCUMENTATION

• Time of AROM
• Color, clarity, odor, consistency, and amount of amniotic fluid
• Patient’s vital signs
• FHR pattern including baseline changes, variability, accelerations, and decelerations
• Contraction pattern
• Sterile vaginal examination findings as reported by the practitioner:
  • Cervical position
  • Dilation and effacement
  • Fetal presenting part and station
• Patient’s response to procedure
• Patient and support person education
• Communication with practitioner
• Unexpected outcomes and related nursing interventions

REFERENCES

1. American Academy of Pediatrics (AAP) Committee on Fetus and Newborn, American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice. (2017). Chapter 7: Intrapartum care of the mother. In Guidelines for perinatal care (8th ed., pp. 227-278). Elk Grove Village, IL: AAP. (Level VII)
2. American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice. (2011, reaffirmed 2016). ACOG Committee opinion no. 485: Prevention of early-onset group B streptococcal disease in newborns. Obstetrics & Gynecology, 117(4), 1019-1027. doi:10.1097/AOG.0b013e318219229b Retrieved May 22, 2019, from https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co485.pdf?dmc=1&ts=20190522T1658412441 (Level VII) (Erratum published 2018, Obstetrics & Gynecology.)
3. Bambini, D.R. (2016). Chapter 32: Labor and birth complications. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (11th ed., pp. 759-801). St. Louis: Elsevier.
4. Scheffer, K.L., DeButy, K. (2019). Chapter 15: Nursing care during labor and birth. In S.S. Murray and others (Eds.), Foundations of maternal-newborn and women’s health nursing (7th ed., pp. 373-425). St. Louis: Elsevier.
5. Wyckoff, M.H. and others. (2015). Part 13: Neonatal resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 132(18 Suppl. 2), S543-S560. doi:10.1161/CIR.0000000000000267 Retrieved May 14, 2019, from http://circ.ahajournals.org/content/132/18_suppl_2/S543.full (Level VII)

ADDITIONAL READINGS

Jozwiak, M. and others. (2012). Mechanical methods for induction of labour. Cochrane Database of Systematic Reviews, 3, Art. No.: CD001233. doi:10.1002/14651858.CD001233.pub2 (classic reference)*

Simpson, K.R. (2013). Cervical ripening and labor induction and augmentation: Practice monograph (4th ed.). Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nurses.

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports