Impact of Premature Rupture of Membranes on Maternal & Neonatal ...

<strong>Impact</strong> <strong>of</strong> <strong>Premature</strong> <strong>Rupture</strong> <strong>of</strong> <strong>Membranes</strong> on
Maternal & Neonatal Outcome at Zagazig
University Hospital
Thesis Submitted in Partial Fulfillment
<strong>of</strong> the Requirements for Master Degree
in
Maternal and Newborn Health Nursing
By
Eman Elsayed Mohamed Elsabagh
(B.Sc.N. Zagazig University)
Under the Supervision <strong>of</strong>
Pr<strong>of</strong>. Sanna Ali Nour Eldin
Pr<strong>of</strong>essor <strong>of</strong> Maternal
and Newborn Health Nursing
Faculty <strong>of</strong> Nursing
Zagazig University
Dr. Hend Salah Eldin Mohamed
Lecturer <strong>of</strong> Maternal and Newborn
Health Nursing
Faculty <strong>of</strong> Nursing
Zagazig University
Dr. Samia Abdel Hakem Aboud
Lecturer <strong>of</strong> Maternal and Newborn
Health Nursing
Faculty <strong>of</strong> Nursing
Zagazig University
Faculty <strong>of</strong> Nursing
Zagazig University
2005

INTRODUCTION
<strong>Premature</strong> rupture <strong>of</strong> membranes (PROM) is defined as rupture <strong>of</strong> the amniotic
sac surrounding the fetus before the onset <strong>of</strong> labour. While preterm premature rupture
<strong>of</strong> membranes (PPROM) is commonly used to refer to the rupture <strong>of</strong> the membranes
when it occurs before term. The period between preterm rupture <strong>of</strong> membranes and
the onset <strong>of</strong> labour is called the latency period. It is called prolonged rupture <strong>of</strong>
membranes when the latency period is extended beyond 24 hours (Gilbert &
Harmon, 2003).
The incidence <strong>of</strong> premature rupture <strong>of</strong> the membranes is 2.7% to 17%,
depending on the length <strong>of</strong> the latent period used in making diagnosis (Mercer, 2002).
Studies have shown that PROM occurs in 6% to 19% <strong>of</strong> term pregnancies (Keirse et
al., 1996). If labor is not induced, 69% <strong>of</strong> women with PROM at term will deliver
within 24 hours, and 86% will deliver until after 72 hours <strong>of</strong> rupture (Parsons &
Spellacy 2000). In their study Merenstein and Weisman, (1996) stated that, PROM
before the onset <strong>of</strong> labour was 2% to 18% <strong>of</strong> pregnancies. The time from PROM to
delivery is usually less than 48 hours in term pregnancies.
Many risk factors have been identified for PROM, however, the final unifying
mechanisms for all cases must be the weakness in the chorioamnion membranes
(relative or absolute, localized or generalized) that allows rupture (Allen, 1991). At
term weakening <strong>of</strong> the membranes may result from physiologic changes combined
with shearing forces created by uterine contractions (French & McGregor, 1996).
Intrauterine infections have been shown to play an important role in PROM
(McGregor & French, 1997). Other factors associated with an increase in PROM
include lower socio economic status, sexually transmissible infection, prior preterm
delivery (especially due to PROM), vaginal bleeding, cervical conization and cigarette
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smoking during pregnancy (French, & McGregor, 1996). In his study, Novack-
antolic et al., (1997) mentioned that the uterine distention (hydramnios, twins),
emergency cervical cerclage, prior antepartum antibiotic treatment, and preterm labor
also may be associated with PROM.
The most significant maternal risk <strong>of</strong> PROM is intrauterine infection, a risk that
increases with the duration <strong>of</strong> membrane rupture. Fetal risks associated with PROM
include umbilical cord compression and ascending infection (Hannah et al., 1996).
As reported by Robinson et al. (2000) if an intra amniotic infection develops as a
result <strong>of</strong> rupture <strong>of</strong> membranes it can quickly cause a serious maternal infection. This
can lead to septicemia and death if not treated promptly, if maternal infection occurs,
it usually develops during the postpartum period as endometritis and is more prevalent
after a cesarean delivery. Other complications resulting from premature rupture <strong>of</strong>
membranes as stated by Enkin et al., (2000) include preterm labor and delivery,
intrauterine infection and umbilical cord compression secondary to prolapse <strong>of</strong> the
umbilical cord or oligohydramnios.
The optimal management <strong>of</strong> PROM is still controversial. Some obstetricians
believe that expectant management in hospital rather than at home (or waiting for
labour to begin spontaneously ) is preferable for mothers if there is no evidence <strong>of</strong>
fetal or maternal compromise, since the risk <strong>of</strong> caesarean section may decrease
(Hannah et al., 2000).
It can be concluded that, problems encountered among women with PROM are
numerous and vast. This does not only affect mother's pregnancy, labor and
puerperium but also her fetus and the newborn. Since this problem was not studied
before in Zagazig and the effectiveness <strong>of</strong> its nursing intervention on women
condition during and after labor is mandatory, therefore, the present study was carried
out in attempt to identify maternal problems associated with PROM and their relation
to the outcome <strong>of</strong> pregnancy.
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The aim <strong>of</strong> this study was to:
AIM OF THE STUDY
(1) Estimate the incidence <strong>of</strong> premature rupture <strong>of</strong> membranes during the period from
January 2004 to December 2004.
(2) Find out the risk factors associated with PROM.
(3) Assess the impact <strong>of</strong> PROM on maternal and neonatal conditions.
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REVIEW OF LITERATURE
Definition and Incidence
<strong>Premature</strong> rupture <strong>of</strong> membranes (PROM) is defined as spontaneous rupture <strong>of</strong>
membranes before the onset <strong>of</strong> labour or regular uterine contractions regardless to the
gestational age. When it occurs after 37 weeks it is referred to as pre labour rupture <strong>of</strong>
membranes at term. It occurs in 8% <strong>of</strong> term pregnancy (Mozurkewish, 1999).
Anatomy <strong>of</strong> Fetal <strong>Membranes</strong>
Fetal membranes
The developing fetus is protected from the outside world by two fetal
membranes. The amnion composed <strong>of</strong> five distinct layers and the chorion composed
<strong>of</strong> three layers, which form a sac around the fetus. These membranes are thin but
tough; they contain no blood vessels or nerve endings. However, they are rich in
collagen, which gives them their strength and elasticity. Regulatory inhibitors control
collogenlytic enzymes such as trypsin and collagenase from breaking down the
collagen throughout pregnancy (Mercer& Lewis, 1997).
The amnion and chorion are fetal tissues, which form a sac to contain the fetus
and the amniotic fluid. These membranes are derived from formative cells <strong>of</strong> the inner
cell mass <strong>of</strong> the blastodermic vesicles <strong>of</strong> the fertilized ovum at the 7 th post conception
day (Benirschke, 2000).
Amnion
The amnion is the inner most fetal membrane and contains amniotic fluid. This
particular vascular structure occupies a role <strong>of</strong> incredible importance in human
pregnancy. It is the tissue that provides almost all <strong>of</strong> the tensile strength <strong>of</strong> the fetal
membranes. Therefore, the development <strong>of</strong> the components <strong>of</strong> the amnion that
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protects against rupture or tearing is vitally important to successful pregnancy
outcome (Casey & MacDonald, 1997).
Early in the process <strong>of</strong> implantation, a space develops between the embryogenic
cell mass and adjacent trophoblasts. Small cells that line this inner surface <strong>of</strong> the
trophoblasts have been called amniogenic cell, the precursors <strong>of</strong> the amnionic
epithelium. The human amnion is first identifiable about the seventh or eighth day <strong>of</strong>
embryo development. Initially, a minute vesicle, the amnion, develops into a small sac
that covers the dorsal surface <strong>of</strong> the embryo. As the amnion enlarges, it gradually
engulfs the growing embryo, which prolapses into its cavity. (Benirschke &
Kaufman, 2000). The normal amnion is 0.08-0.12 mm in thickness and is composed
<strong>of</strong> five layers (Bourne, 1962).
The inner surface which is bathed by the amniotic fluid is an uninterrupted,
single layer <strong>of</strong> cubiodal epithelial cells, believed to be derived from embryonic
ectoderm (Casey & McDonald, 1996). This epithelium is attached firmly to distinct
basement membrane that is connected to a cellular compact layer, which is composed
primarily <strong>of</strong> interstitial collagens I, II and V (Mc parland et al., 2000) On the other
side <strong>of</strong> the compact layer, there is a row <strong>of</strong> fibroblast-like mesenchymal cell (which
are widely dispersed at term). These cells are probably derived from mesoderm <strong>of</strong> the
embryonic disc (Craven et al., 2000).
There are also few fetal macrophages in the amnion. The outer most layer <strong>of</strong>
amnion is relatively a cellular zone spongiosa which is contiguous with the second
fetal membrane, the chorion leave. The important "missing" elements <strong>of</strong> human
amnion are smooth muscle cells, nerves, lymphatic and importantly, blood vessels
(Dizon et al., 2000).
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Amnion is fused to the chorion leave. Placental amnion covers the fetal surface
<strong>of</strong> the placenta, and thereby is in contact with the adventitial surface <strong>of</strong> the chorionic
vessels, which transverse the chorionic plate and branch into cotyledons (McLaren et
al., 1999).
Figure (1) Adopted from Pillitteri A (2003): Maternal and child health nursing, care <strong>of</strong> the
child bearing & child bearing family, (4 th ed). Philadelphia, New York 8, PP. 177-180.
Umbilical amnion covers the umbilical cord. The fused amnion are separated by
fused chorion leave, and aside from the small area <strong>of</strong> the fetal membranes
immediately over the cervical os. This is the only site at which the reflected chorion
leave is not contiguous with deciduas (Benirschke, 2000).
The amnion is clearly more than a simple vascular membrane that functions to
contain amniotic fluid. It is metabolically active, involved in solute and water
transport to maintain amniotic fluid hemostasis and produces a variety <strong>of</strong> interesting
bioactive compounds, including vasoactive peptides, growth factors, and cytokines
(Garcia-Velasco & Arici, 1999).
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Unlike the chorionic membrane, the amniotic membrane not only <strong>of</strong>fers support
to amniotic fluid but also actually produces the fluid. In addition, it produces a
phospholipid that initiates the formation <strong>of</strong> prostaglandins, which cause uterine
contractions and may be the trigger that initiates labor (Uckan & Townsend, 1999).
Chorion
The chorion is the outer most membrane, once implantation is achieved; the
trophoblastic layer <strong>of</strong> cells <strong>of</strong> the blastocyst begins to mature rapidly. As early as the
11 th or 12 th day, miniature villi, or probing "fingers" termed chorionic villi, reach out
from the single layer <strong>of</strong> cell into the uterine endometrium. At term, nearly 200 such
villi will have formed (Pilliteri, 2003).
Chorionic villi have a central core <strong>of</strong> loose connective tissue surrounded by a
double layer <strong>of</strong> trophoblast cells. The central core <strong>of</strong> connective tissue contains fetal
capillaries (Ling &Duff, 2001). The outer <strong>of</strong> the two covering layers is termed the
syncytiotrophoblast or the syncytial layer and cytotrophoblast. The layer <strong>of</strong> cells is
instrumental in the production <strong>of</strong> various placental hormones such as human placental
lactogen (HPL), estrogen and progesterone (Mc Closkey & Bulechek, 2000).
The inner layer, known as the cytotrophoblast or Langhans’ layer is present as
early as 12 days’ gestation. It appears to function early in pregnancy to protect the
growing embryo and fetus from certain infectious organisms such as the spirochete <strong>of</strong>
syphilis. However, this layer <strong>of</strong> cells disappears between 20 th and 24 th weeks, the layer
that appears to <strong>of</strong>fer little protection against viral invasion at any point (Johnson et
al., 2000).
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Figure (2) Adopted from Pillitteri A (2003): Maternal and child health nursing, care <strong>of</strong> the
child bearing & child bearing family, (4 th ed). Philadelphia, New York 8, PP. 177-180.
The chorionic villi on the medial surface <strong>of</strong> the trophoblast (those that are not
involved in implantation because they do not touch the endometrium), gradually thin
and leave the medial surface <strong>of</strong> the structure smooth (the chorion leave, or smooth
chorion). The smooth chorion eventually becomes the chorionic membrane. Once it
becomes smooth, it <strong>of</strong>fers support to the sac that contains the amniotic fluid
(Department <strong>of</strong> Heath and Human Services, 2000).
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Amniotic Fluid
The amniotic fluid is a clear fluid that collects within the amnionic cavity,
increases in quantity as pregnancy progresses until near term (Craven et al., 2000).
The amniotic sac develops in early pregnancy and has been identified in the human
embryo as 7 days. The first signs <strong>of</strong> the development <strong>of</strong> the amniotic cavity can be
seen in the inner cell mass <strong>of</strong> the blastocyst. It is formed by secretion and transudation
<strong>of</strong> fluid through the amnion and fetal skin and from the passage <strong>of</strong> fetal urine into the
amniotic sac. Circulation <strong>of</strong> amniotic fluid occurs by reabsorption <strong>of</strong> fluid through the
fetal gut, skin and amnion (Symond & Symond, 2004).
By 8 weeks gestation, 5-10 ml <strong>of</strong> amniotic fluid has accumulated. Therefore,
the volume increases rapidly in parallel to fetal growth and gestational age up to a
maximum volume <strong>of</strong> 1000 ml at 38 weeks. Subsequently, the volume diminishes by
42 weeks. It may fall below 300 ml. The estimation <strong>of</strong> amniotic fluid volume forms a
standard part <strong>of</strong> the ultrasound assessment <strong>of</strong> fetal well being (Magann et al., 2000).
Amniotic fluid is an important protective mechanism for the fetus, it shields
against pressure or a blow to the mother’s abdomen (Seifer et al., 2001). Amniotic
fluid protects the fetus from changes in temperature, because liquid changes
temperature more slowly than air (Symond & Symond, 2004). It probably aids in
muscular development because it allows the fetus freedom to move, it protects the
umbilical cord from pressure, protecting fetal oxygenation (Seifer et al., 2001).
Normal amniotic fluid contains an antibacterial substance, which gradually
increases with gestational age until term and then decreases. A diet deficient in protein
and zinc may decrease the antibacterial and antiviral activity <strong>of</strong> the amniotic fluid
(Sikorski et al., 1990).
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As the pregnancy approaches, goes near term, a normal decrease in regulatory
inhibitors and an increase in collagenolytic enzyme activity occur. Among these are
relaxin and cytokines. At the same time, phospholipase enzymes are activated, which
convert phospholipids to a rachidonic acid, the precursor <strong>of</strong> prostaglandins. These
prostaglandins initiate labour. The decrease in phospholipids creates rubbing forces
between the chorion and amnion. During labor this increase in collagenolytic enzymes
and the decrease in phospholipids are what normally causing the membranes to
rupture (Garite, 1999).
Mechanism <strong>of</strong> <strong>Premature</strong> <strong>Rupture</strong> <strong>of</strong> <strong>Membranes</strong>:
<strong>Premature</strong> rupture <strong>of</strong> the fetal membranes occurs when there is focal weakening
as the result <strong>of</strong> extensive changes in collagen metabolism or when the intra amniotic
pressure is increased (Perry & Strauss, 1998 and Woods et al., 2000).
The enzymes plus the inflammatory response <strong>of</strong> neutrophils act together to
decrease the collagen content <strong>of</strong> the membranes, thus, focally weakening the strength
and elasticity <strong>of</strong> the membranes. Bacterial proteases also activate the prostaglandin
cascade (Arias et al., 1999).
After prolonged rupture <strong>of</strong> membranes, an intraamniotic infection <strong>of</strong>ten
develops as the result <strong>of</strong> ascending vaginal organisms such as ureaplasma,
urealyticum, mycoplasma hominis, bacteroides bivius, group B streptococci, and
gardnerella vaginalis, neisseria gonorrhea, herpes simplex virus, cytomegalovirus, and
candida albicans have been implicated as well (Gabbes et al., 1996).
There are two possible mechanisms that cause an intra amniotic infection. Some
patients have normal inhibitory activity <strong>of</strong> the amniotic fluid, but when large volumes
<strong>of</strong> bacteria enter the amniotic cavity, they are unable to overpower the inhibitors. In
other patients inhibitory activity in the amniotic fluid may be lacking. These patients
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are susceptible to an intraamniotic infection, if any bacteria enter the amniotic fluid
(Weitz, 2001).
It is also hypothesized that tissue damaging molecules called reactive oxygen
species (ROS) damage, the integrity <strong>of</strong> the collagen, causing membrane weaking
(Woods et al., 2001). Overproduction <strong>of</strong> relaxin increased collagenase activity has
been linked with preterm PROM. It is also possible that placental vascular thrombotic
lesions may cause decidual activation and cause preterm PROM (Arias et al., 1999).
Risk Factors <strong>of</strong> <strong>Premature</strong> <strong>Rupture</strong> <strong>of</strong> <strong>Membranes</strong>:
The exact cause <strong>of</strong> premature rupture <strong>of</strong> membranes is unknown, but
predisposing factors that include genetic abnormalities, fetal malpresentation, multiple
gestation, polyhydramnios, trauma, previous PROM, cervitis, amniocentesis and
substance abuse (Gilbert & Harmon, 2003 and Green & Wilkinson, 2004). The
premature rupture <strong>of</strong> membranes may also occur after cervical cerclage or
amniocentesis (Greenberg & Hankins, 1991; Gaute & Spellacy, 1994; King, 1994).
Another risk factor for premature rupture <strong>of</strong> membranes is a positive history in
a prior pregnancy (Garite, 1999). The risk <strong>of</strong> PROM is increased in socio-
economically disadvantaged patients, sexually promiscuous teenagers, patient who
have inadequate nutrition especially in zinc, vitamins C, E and copper (Perry &
Strauss, 1998 and Woods et al., 2001), patients who smoke , as well as patients with
decreased immunity (Woods et al., 2001).
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1. Malpresentation:
Ante-partum rupture <strong>of</strong> membranes is common when the presenting part <strong>of</strong> the
fetus does not fit down into the lower uterine segment, as in cases <strong>of</strong> complete breech,
shoulder presentation and lack <strong>of</strong> engagement in contracted pelvis (Percival et al.,
1980).
2. Increased intrauterine tension:
The intrauterine tension is considerably increased during the last weeks <strong>of</strong>
pregnancy. In multiple pregnancies and hydramnios, the incidence <strong>of</strong> PROM also is
increased (Woods et al., 2001). Polyhydramnios is a rare condition that tends to rise
in the second trimester or the early part <strong>of</strong> the third trimester and commonly results in
the premature onset <strong>of</strong> labour. The condition is painful for the mother and may cause
dysapnea and vomiting. The uterus becomes acutely distended and it may be
necessary to relieve the pressure by amniocentesis (Symond & Symond, 2004).
3. Local membrane defects tensile strength:
Benirschke and Kaufman, (2000) reported that, during tests <strong>of</strong> tensile
strength- resistance to tearing and rupture, the deciduas and then chorion leave gate
way long before the amnion ruptured. Indeed the membranes are quite elastic and can
expand to twice normal size during pregnancy.
However, Mercer and Lewis (1997) found no association between premature
rupture <strong>of</strong> membranes and a possible reduction in the tensile strength <strong>of</strong> the
membranes, thus a higher stress tolerance was found in preterm membrane as
compared with term. Furthermore, they have shown that stress tolerance <strong>of</strong> the
membrane decreases with advancing <strong>of</strong> the gestational age, thus forming suitable
condition for rupture at term.
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4. Infection:
Several observations support the hypothesis that maternal genital tract infection
may frequently play an etiologic role in premature rupture <strong>of</strong> membranes. This
association between PROM and infection has been attributed to a preexisting bacterial
invasion or to the presence <strong>of</strong> pathogens in the vagina that ascend into the amniotic
cavity after disruption <strong>of</strong> the amniotic membrane (Yoon et al., 1999). It has been also
proposed that amniotic fluid possesses certain bacteriostatic properties that protect
against potential infectious processes and that a decreased in amniotic fluid volume
may impair the gravid woman's ability to combat such infection (Vermillion et al.,
2000).
Intrauterine infection is a clinical or sub clinical infection associated with varied
symptoms and signs and with significant perinatal morbidity and mortality. The
diagnosis <strong>of</strong> intra-amniotic infections can be based on clinical criteria. However,
clinical symptoms and signs are frequently subtle or inconsistent, and many affected
women are virtually symptom free. Direct examination <strong>of</strong> amniotic fluid obtained
through amniocentesis is frequently necessary (Hsu et al., 1998).
Microbiology <strong>of</strong> premature rupture <strong>of</strong> membranes
Group B-streptococcus
Group B-streptococcal is a cervical infection associated with prematurity more
than 25 years ago (Hillier et al., 1993 ). On the same context, Greig et al., (1993)
found that 13% <strong>of</strong> cases with PROM were positive for group B-streptococci.
Colonization with group B-streptococci by itself does not appear to affect the latency
time from premature <strong>of</strong> membranes to delivery (McKenzie et al., 1994 and Simpson
et al., 1994). It is one <strong>of</strong> the most frequent causes <strong>of</strong> life threatening infection in the
neonate (American College <strong>of</strong> Obstetricians and Gynecologists, 1996).
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Among infants born to patients with premature rupture <strong>of</strong> membranes at term,
clinical chorioamnionitis and maternal colonization with group B-streptococci are the
most important predictors <strong>of</strong> subsequent neonatal infection (Seaward et al., 1998). In
the newborn, early-onset disease with group B-streptococcus (GBS) is leading cause
<strong>of</strong> neonatal morbidity and mortality including sepsis, meningitis, and pneumonia.
Early-onset disease is defined as within the first week <strong>of</strong> life. The newborn can
become infected in utero or during passage through the birth canal. Vertical
transmissions from mother to baby primary occur after the onset <strong>of</strong> labor or after the
membranes rupture (Center for Disease Control and Prevention, 2002).
Chlamydia trachomatis (CT):
Chlamydia trachomatis is an obligator intracellular bacterium that have serotypes,
including that causes lymph granuloma venerum. Genital infection with chlamydia
trachomatis is the most common sexually transmitted bacterial disease in woman
cultures, from the cervix, are positive in up to one fourth <strong>of</strong> pregnant woman
(Webster et al., 1993). Women with a diagnosis <strong>of</strong> chlamydia in early pregnancy
have an increased risk <strong>of</strong> testing positive in late pregnancy (Allaire et al., 1998). The
American Academy <strong>of</strong> Pediatrics and American College <strong>of</strong> Obstetricians and
Gynecologists, (1997) found that untreated cervical chlamydial infection increases the
risk for preterm delivery, PROM and prenatal mortality.
Neisseria gonorrhea:
Gonococcal infection may have deleterious effect on pregnancy outcome in any
trimester. There is an association between untreated gonococcal cervicitis and preterm
delivery, prematurely ruptured membranes, chorioamnionitis and post partum
endometritis (Center for Disease Control and Prevention, 1998a). Earlier Elliot et
al., (1990) found that, the attributable risk for preterm birth was 14 percent with
gonococcus infection.
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Candida albicans:
No association between premature rupture <strong>of</strong> membranes and candida albicans
is evidenced (Center for Disease Control and Prevention, 1996).
Trichomonas vaginalis:
Trichomonas vaginalis is a sexually transmitted anaerobic parasite, and may
cause amnionitis, PROM, prematurity, and postpartum endometritis (American
College <strong>of</strong> Obstetricians and Gynecologists, 1997). Trichomonas vaginalias is
associated with increased risk <strong>of</strong> preterm and low birth weight infants either
independent or associated with gonorrhea, chlamydia infection, and bacterial
vaginoses (Hillier et al., 1995 and Mastroiacovo et al., 1996).In a similar study
Gibbs et al., (1992) reported a significant association between trichomoniasis and
preterm prematurely ruptured membranes, preterm delivery and low birth weight
infants.
Bacterial vaginosis:
Bacterial vaginosis is a condition in which the normal lactobacillus
predominant vaginal flora is replaced with anaerobic bacteria, gardnerella vaginalis,
bacteroids species, mycoplasma hominis (Hillier et al., 1995).
Bacterial vaginosis has been associated with preterm delivery, low birth weight
infants, prelabor membranes rupture, late miscarriages, chorioamnionitis at delivery,
and postpartum endometritis (McGregor et al., 1995; Meis et al., 1995; Subtil et al.,
2002).
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Herpes simplex:
Brown et al., (1999) found that, late pregnancy primary infection by herpes
simplex results in an increased incidence <strong>of</strong> preterm labour.
5. Coitus and premature rupture <strong>of</strong> membranes:
Frequent coitus by itself is not associated with an increased risk <strong>of</strong> preterm
labor, however, women who colonized with specific microorganisms and who
engaged in frequent coitus are at increased risk <strong>of</strong> preterm labor (Read & Kleban<strong>of</strong>f,
1993).
Harmanli et al., (1998) studied the effect <strong>of</strong> human ejaculate on the
biochemical properties <strong>of</strong> the human chorioamniotic membranes. They concluded that
in vitro exposure to human ejaculate for one hour. Significantly, weakness the human
chorioamniotic membranes.
6. Cervical incompetence and premature rupture <strong>of</strong> membranes:
The term incompetent cervix is applied to a discrete obstetric entity. It is
characterized by painless dilatation <strong>of</strong> the cervix in the second trimester or perhaps
early in the third trimester. The presumptive diagnosis usually can be made if a
woman has experienced cervical dilatation and spontaneous rupture <strong>of</strong> membranes
without the usual discomforts <strong>of</strong> labor (Iams, 1996).
The dilated cervix exposes the fetal membranes to the vaginal flora and
secretions predisposing to infection and so PROM. The treatment is surgical through
cerclage procedure (Groom et al., 2002).
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7. Smoking and drug abuse:
Vitorato et al., (1997) studied that the role <strong>of</strong> maternal smoking during
pregnancy in the occurrence <strong>of</strong> premature ruptures <strong>of</strong> membranes and preterm labor.
There was no apparent effect <strong>of</strong> smoking on length <strong>of</strong> gestation. However, results
showed that smoking had a marked effect on preterm labor <strong>of</strong> less than 32 weeks; it
was also found a statistically significant correlation between PROM in premature
deliveries and smoking during pregnancy.
However, Mercer et al., (2000), in their preterm prediction study found that,
there is no significant association between smoking and preterm PROM. Also, Myles
et al., (1998), in a study <strong>of</strong> the effects <strong>of</strong> smoking, alcohol and drugs abuse on the
outcome <strong>of</strong> expectantly managed cases <strong>of</strong> preterm PROM found that, the use <strong>of</strong>
tobacco during pregnancy appears to shorten the latency period in pregnancies
complicated by premature rupture <strong>of</strong> membranes.
8. Previous history <strong>of</strong> premature rupture <strong>of</strong> membranes:
Martha and Thomas, (1996) reported that, premature rupture <strong>of</strong> membranes
has a recurrence rate <strong>of</strong> 21% in the following pregnancy. When PROM occurs in the
first pregnancy this means that premature rupture <strong>of</strong> membranes had strong tendency
to repeat in the next pregnancy.
Diagnosis <strong>of</strong> <strong>Premature</strong> <strong>Rupture</strong> <strong>of</strong> <strong>Membranes</strong>:
Diagnosis <strong>of</strong> PROM is one <strong>of</strong> the challenges met with regarding this setting. An
incorrect diagnosis can subject the patient to iatrogenic risks <strong>of</strong> inappropriate
intervention. Conversely, failure to diagnosis PROM can hinder the implementation <strong>of</strong>
a ppropriate obstetric measure. Diagnosis <strong>of</strong> PROM in practice depends usually on a
combination <strong>of</strong> the patient's history, identification <strong>of</strong> amniotic fluid (AF) pooling and
ferning or nitrazine test (Mercer & Lewis, 1997).
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A firm diagnosis <strong>of</strong> rupture <strong>of</strong> the membranes isn't always easy to make unless
amniotic fluid is seen or felt escaping from the cervical os by the examiner. Although
several diagnostic tests for the detection <strong>of</strong> ruptured membranes have been
recommended, none is completely reliable (Cunningham et al., 1997b).
A. History:
Martha and Thomas, (1996) found that, a typical history includes a gush <strong>of</strong>
fluid from the vagina with subsequent contained leakage. A constituent history
correctly identifies the diagnosis more than 90% <strong>of</strong> the time.
It is important for the midwife to make an accurate diagnosis without increasing
the risk <strong>of</strong> infection. Leakage <strong>of</strong> amniotic fluid has to be differentiated from urinary
incontinence, vaginal or cervical discharge, semen or (rarely) rupture <strong>of</strong> the chorion.
The following data are used to make a diagnosis:
a. Amount <strong>of</strong> fluid loss: <strong>Rupture</strong> <strong>of</strong> the membranes may initially cause a large gush
<strong>of</strong> fluid followed by a continuous discharge. In some instance <strong>of</strong> rupture membranes,
however, the only symptoms the woman notices may be a small, continuous discharge
(clear, cloudy, yellow, or green) and a feeling <strong>of</strong> moistness on her panties.
b. Inability to control leakage with Kegel exercise: Differentiates PROM from
urinary incontinence.
c. Time <strong>of</strong> rupture.
d. Color <strong>of</strong> fluid: Amniotic fluid can be clear or cloudy; if meconium stained the
fluid it will be yellow or green.
e. Odor <strong>of</strong> fluid: Amniotic fluid has a distinct musty odor, which differentiates it
from urine.
f. Last sexual intercourse: Semen expelled from the vagina can sometimes be
mistaken from amniotic fluid (Ghidini & Romero, 1993 and Garite, 1999). In a
18

study carried out by O' Herlihy and Turner (1991) they highlight that since leakage
is generally greater at first, confirmation <strong>of</strong> rupture <strong>of</strong> membranes is expected if the
woman attempts initially to collect some <strong>of</strong> the fluid. They found that the diagnosis
was facilitated by obtaining a specimen <strong>of</strong> amniotic fluid where the presence <strong>of</strong> free
floating vernix after 32-43 week gestation or even meconium, would differentiate it
from urine or vaginal discharge.
B. Physical examination:
A pool <strong>of</strong> fluid is visible in the posterior fornix, and a sterile speculum
examination is used to obtain vaginal fluids for testing and to diagnose PROM. Fluid
for laboratory tests should be collected over the lower blade <strong>of</strong> the speculum before it
comes into contact with the vaginal wall. If no fluid is present, slight pressure on the
uterus and gentle moving <strong>of</strong> the fetus may provoke leaking (American College <strong>of</strong>
Obstetricians and Gynecologists, 1998).
When premature rupture <strong>of</strong> membranes is suspected, a sterile speculum
examination is done. If amniotic fluid is observed, leaking from the cervix and
collecting in the posterior fornix <strong>of</strong> the vagina, an accurate diagnosis <strong>of</strong> PROM can be
made. A digital vaginal examination should never be done if any attempt is to be made
in delaying the labour, vaginal bacteria could be transported into the cervical canal
from the vaginal examination thereby increasing the risk <strong>of</strong> an intraamniotic infection
and thus precipitates early delivery (Gilbert & Harmon, 2003).
19

C. Investigations:
1. Nitrazine test:
If there is no visual sign <strong>of</strong> loss <strong>of</strong> amniotic fluid from the cervix, the secretions
<strong>of</strong> the posterior fornix <strong>of</strong> the vagina should be tested with nitrazine paper for pH
determination. Because amniotic fluid is alkaline and vaginal secretions are acidic, the
nitrazine paper turns blue in the presence <strong>of</strong> amniotic fluid. Blood, cervical mucus and
povidone (Betadine) should not be allowed to contaminate the specimen; they are also
alkaline (Gilbert & Harmon, 2003).
2. Fern test:
A smear <strong>of</strong> fluid from the vaginal fornix creates atypical fern pattern. To
perform this test, a sample <strong>of</strong> fluid is placed on a glass side and allowed to dry. The
slide is observed under the microscope, looking for a crystallization pattern that
resembles a fern, the accuracy <strong>of</strong> the test is affected by blood or meconium. The test
may produce false positive results if the sample is obtained from the cervix because
dry cervical mucus forms an arborization pattern that may be confused with PROM
(Bennett et al., 1991).
The fern test is more reliable than nitrazine paper test. This is because a number
<strong>of</strong> materials besides amniotic fluid have a more alkaline pH, including cervical mucus,
vaginal discharge caused by bacterial vaginosis or trichomonal infection, blood, urine,
semen, and glove powder. Thus, a specimen taken directly from the cervical os and
then smeared on nitrazine paper may produce a false-positive color change (Ghidini
& Romero, 1993).
20

3. The Evaporization test:
It is based on heating the endocervical material on a glass slide to evaporate
water, thus, if a white residue is left, amniotic fluid is present. If the residue is brown,
the membranes are intact (Arias, 1993a).
4. Amniocentesis:
Amniotic fluid is obtained by the procedure <strong>of</strong> amniocentesis. This procedure
involves inserting a fine-gauge needle under aseptic conditions through the anterior
abdominal wall <strong>of</strong> the mother under local anesthesia. The procedure must be
performed under ultrasound control to identify the best and most accessible pool <strong>of</strong>
amniotic fluid, the placenta, and fetus. Up to 10 ml <strong>of</strong> fluid is withdrawn and the
presence <strong>of</strong> a fetal heart beat is checked both before and after the procedure (Reece,
1997). Amniocentesis can be used to measure functional lung maturity in the fetus
after 28 weeks gestation and prior to premature delivery (Symond & Symond 2004).
Ultrasound examination:
Ultrasound technology has been accepted as a reliable means <strong>of</strong> documenting
fetal viability, gestational age, fetal growth pattern, amniotic fluid volume and
selected anomalies (Crane, 1994). The development <strong>of</strong> ultrasound imaging has
provided an indirect means <strong>of</strong> measuring fluid level, the ability to correctly identify
fetuses with abnormal low volume <strong>of</strong> fluid is important in planning management for a
potentially compromised fetus (Chauhan et al., 1997; Magann 1999a; Magann
1999b).
Ultrasound should not be used as the primary means <strong>of</strong> diagnosis <strong>of</strong> PROM.
False positive findings occur in patients with oligohydramnios resulting from causes
other than PROM. False negative results may occur in patients with discrete amniotic
fluid losses. However, it should be assumed that PROM has occurred if ultrasound
21

examination shows little or no fluid in the uterus. In contrast, the presence <strong>of</strong> a normal
amount <strong>of</strong> fluid makes the diagnosis <strong>of</strong> PROM is unlikely (Sarno et al., 1990 and
Arias, 1993a).
Procedures for estimating amniotic fluid volume:
Amniotic fluid index
The woman is positioned in a semi-Fowler or recumbent position with a lateral
tilt. The uterus is divided into four quadrants, with the umbilicus as the landmark for
dividing the left and right segments and the Lineanigra for dividing the left and right
segment. The maximum vertical diameter <strong>of</strong> a pocket <strong>of</strong> fluid without loops <strong>of</strong> cord or
extremities is determined in centimeters. The maximum vertical diameter for the
largest pocket in each quadrant is added to obtain the amniotic fluid index (AFI). A
sum <strong>of</strong> 0 to 5 is considered oligohydramnios; 5.1 to 8 cm indicated low normal
(border line); 8.1 to 18 cm indicated normal volume; and greater than 18 cm indicated
high volume (Lagrew et al., 1997).
[
Maternal Hazards <strong>of</strong> <strong>Premature</strong> <strong>Rupture</strong> <strong>of</strong> <strong>Membranes</strong>:
A. Infection:
<strong>Premature</strong> rupture <strong>of</strong> membranes is associated with an increased risk <strong>of</strong>
acquiring perinatal infections which include chorioamnionitis, endometritis, and
neonatal sepsis (Yoon et al., 1999). Chorioamnionitis is acute inflammation <strong>of</strong> the
membranes. It is clinically diagnosed in 1 % to 2% <strong>of</strong> all pregnancies, but has been
identified histological in as many as 10% to 20%. When a woman experiences
prolonged rupture <strong>of</strong> membranes, the risk <strong>of</strong> clinical infection increases from 3% to
15% (Walsh, 2001).
Chorioamnionitis occurs in approximately 0.5 – 1% <strong>of</strong> pregnancies (Mark et
al., 2000), while it is 26-28% in women with a latency period (time between PROM
22

and onset <strong>of</strong> labour) <strong>of</strong> 24 hours or more. In their study, Nelson et al., (1994) found
that the incidence <strong>of</strong> chorioamnionitis following PROM ranges from 10% to 40%.
Signs <strong>of</strong> chorioamnionitis include maternal fever (37.8˚C), maternal and fetal
tachycardia, foul-smelling vaginal discharge, uterine tenderness, and leukocytosis.
Moreover, chorioamnionitis is associated with endometritis and postpartum fever, and
may lead to septic shock, acute renal failure, and disseminated intravascular
coagulation (Casey and Cox, 1997).
Yancey et al., (1996) and Seaward et al., (1998) mentioned that, the neonatal
infection occurs in 3% <strong>of</strong> cases in which chorioamnionitis has been identified. Infants
who become infected have an increased risk <strong>of</strong> respiratory distress and
intraventricular hemorrhage. The infection is usually introduced into the fetal
oropharynx, leading to pulmonary and gastrointestinal effects. Occasionally, the
infection is introduced transplacentally in which case the liver, brain, meninges and
heart may be affected.
The precise pathogenesis <strong>of</strong> chorioamnionitis is not known, especially when it
occurs in the presence <strong>of</strong> intact fetal membranes. In the presence <strong>of</strong> ruptured
membranes ascending infection is the most likely mechanism <strong>of</strong> infection. The
majority <strong>of</strong> women with ruptured membrance is in labour and has frequent cervical
examinations, which allows for in occultation and colonization <strong>of</strong> the cervix, lower
uterine segment, and amniotic cavity with bacteria that are part <strong>of</strong> indigenous vaginal
flora (Gilstrap & Cox, 1989).
Chorioamnionitis is caused by group B-streptococcus (GBS) or Escherichia
coil. The mode <strong>of</strong> transmission is ascension from the vagina into the uterus. Other
common pathogens include streptococcus faecalis, proteus, klebsiella and
pseudomonas (Regan et al., 1996 and Casey & cox 1997).
23

Risk factors for chorioamnionitis include premature rupture <strong>of</strong> membranes,
abnormal vaginal flora (urea plansmaurealyticum colonization), bacterial vaginosis
(sexually transmitted disease), and obstetric manipulations (vaginal examination or
internal fetal heart monitoring) and diminished host immune response (Casey & Cox,
1997 and Abele-Horn et al., 1997).
Management <strong>of</strong> chorioamnionitis begins with development <strong>of</strong> a plan for
delivery. Induction or augmentation <strong>of</strong> labor is preferred, since cesarean section
increases the risk <strong>of</strong> systemic infection. When delivery seems remote, cesarean
delivery is considered to decrease the fetus' exposure to infection. Antibiotic therapy
is initiated before delivery, and the combination <strong>of</strong> ampicillin and gentamycin is
commonly used to provide broad coverage (Rouse, 1994).
Chorioamnionitis requires obstetric consultation. In cases in which the woman
is stable, the fetal status is reassuring, and vaginal delivery is anticipated, co-
management <strong>of</strong> the case is appropriate. In case in which the maternal or fetal status is
not reassuring, referral to the obstetric specialist is expected. The neonatal or pediatric
team should be notified <strong>of</strong> the diagnosis, and aseptic workup <strong>of</strong> the neonatal is usually
expected (Rouse et al., 1999).
B. Abruptio placenta:
Abruptio placenta also occurs more frequently in the women with preterm
PROM. The phenomenon <strong>of</strong> abruption, which in turn leads to lowered amniontic fluid
volume, is thought to be the result <strong>of</strong> thrombotic lesions activating the deciduas and
leading to preterm PROM. This condition is known as chronic abruption
oligohydramnios (Robinson et al., 2000).
24

Fetal and Neonatal Effects:
Prematurity:
Weitz, (2001) found that, the preterm premature rupture <strong>of</strong> membranes causes
one third <strong>of</strong> all preterm births before 36 weeks <strong>of</strong> gestation. Respiratory distress
syndrome is the main cause <strong>of</strong> morbidity and mortality <strong>of</strong> the neonate resulting from a
preterm PROM.
Fetal and Neonatal Infection:
The incidence <strong>of</strong> fetal neonatal sepsis is small, 2% to 4%, with the rate
correlating directly with length <strong>of</strong> time the membranes are ruptured. However, if an
intra amniotic infection develops, the fetus has a 15% to 20% risk <strong>of</strong> developing
septicemia, pneumonia or a urinary tract infection (Garite, 1999; Robinson et al.,
2000). The incidence <strong>of</strong> neonatal infection after membrane rupture <strong>of</strong> more than 24
hours is approximately 1% and when clinical chorioamnioitis is presents the risk
increases to between 3% and 5% (American College <strong>of</strong> Nursing Midwives, 1997).
A tenfold increase in neonatal infection has been noted in uncomplicated cases
<strong>of</strong> premature rupture <strong>of</strong> the membranes compared with neonates in general. The early
diagnosis <strong>of</strong> neonatal bacterial sepsis remains difficult, so that the effective
management <strong>of</strong> labour can minimize subsequent neonatal infection and allows a
reduction in appropriate use <strong>of</strong> antibiotics in the neonatal period (Flenady & King,
2002).
Fetal Compromise:
<strong>Premature</strong> rupture <strong>of</strong> membranes can cause fetal compromise as the result <strong>of</strong>
prolapsed cord or oligohydramnios. The cord can prolapse if the presenting part is not
well engaged. If the amniotic fluid volume is affected to a large degree, pressure can
25

e applied on the cord as the fetus moves, thereby causing fetal compromise. Seventy-
five percent <strong>of</strong> patients with PROM will experience variable decelerations related to
cord compression. If fetal compromise is allowed to persist for any length <strong>of</strong> time,
fetal hypoxia can result, causing the anal sphincter to relax and release meconium into
amniotic fluid. Deep, gasping respiratory movements are triggered, which moves the
meconium-stained amniotic fluid deep into alveoli. Then, the neonate is at risk <strong>of</strong>
developing aspiration pneumonia (Garite, 1999).
Developmental Anomalies:
If the membranes rupture before 26 to 28 weeks <strong>of</strong> gestation and marked
oligohydramnios results, the fetus is at an increased risk (12%-40%) for skeletal
compression deformities, amniotic band syndrome, and pulmonary hypoplasia
(Garite, 1999). Pulmonary hypoplasia is more common with PROM because lung
development depends more on extrinsic factors such as amniotic fluid than other fetal
organs. Amniotic band syndrome occurs when the fetal membranes adhere to and
constrict fetal parts causing deformities. The other developmental abnormalities
associated with an early rupture are intestinal obstruction, diaphragmatic hernia,
clubfoot, scoliosis and hip dislocation (Mercer & Lewis, 1997 and Weitz, 2001).
26

Role <strong>of</strong> the Nurse in the Management <strong>of</strong> <strong>Premature</strong> <strong>Rupture</strong> <strong>of</strong>
<strong>Membranes</strong>:
Treatment <strong>of</strong> premature rupture <strong>of</strong> membranes depends on the stage <strong>of</strong> the
patient’s pregnancy. If PROM is occurring at term, the mother and baby will be
watched closely for the first 24 hours to see if labour will begin naturally, if no labour
begins after 24 hours, most doctors will use medications to start labour. This is called
inducing labour, labour is induced to avoid a prolonged gap between PROM and
delivery because <strong>of</strong> the increased risk <strong>of</strong> infection (Joseph, 2004).
The gestational age and the presence or absence <strong>of</strong> an intra amniotic infection
(chorioamnionitis) determine the initial management <strong>of</strong> patients with PROM, if a
patient has evidence <strong>of</strong> intra amniotic infection by clinical examination (e.g. maternal
temperature >38º C, fetal tachycardia, fundal tenderness, foul or purulent vaginal
discharge, maternal tachycardia, elevated c-reactive protein level) or by amniocentesis
(positive stain finding, glucose

Because infections and lower amniotic fluid immunity play a significant role in
PROM. The ultimate goal <strong>of</strong> the nurse should be educating the patient. Prenatal
education should cover the need for adequate fluid and nutrition, appropriate hygiene,
and the significance <strong>of</strong> reporting any signs <strong>of</strong> an infection immediately. This decreases
the risk <strong>of</strong> PROM. Once the membranes rupture, the goal <strong>of</strong> treatment is to maintain
the pregnancy to allow for fetal maturity as long as the uterine environment is healthy.
If the uterine environment becomes infected or causes fetal compromise, the fetal
outcome may be improved by premature delivery (American College Of
Obstetricians and Gynecologist, 1998).
Prevention:
Because the actual cause <strong>of</strong> PROM is unknown, prevention is difficult,
however, it may be helpful to look at the risk factors and guard against their presence
during pregnancy. Statistics indicate that, socio-economically disadvantaged patients
and teenagers have an increased risk <strong>of</strong> PROM. The reason for this is unknown, but
nutrition probably plays an important role. Therefore, these patients should be
instructed early in pregnancy regarding a healthy diet for pregnancy and should be
provided with reasons to follow this diet. They may also need referral to financial
assistance and food supplement programs, as well as instructed on how to prepare
nutritious foods.
Cleanliness by daily bathing and wiping the perineum from front to back are
important prenatal instructions. Multiple sexual relationships also increase the vaginal
bacterial count and should be avoided. So cleanliness can decrease the risk <strong>of</strong>
premature rupture <strong>of</strong> membranes.
28

Any attempt to facilitate increased immunity against infection is beneficial.
Therefore, the nurse should explain that to the PROM patients and instructs them
about drinking 6 to 8 ounces <strong>of</strong> fluid per waking hours, exercising daily and resting
adequately to avoid fatigue, eating an adequate diet that is high in protein and zinc,
and maintaining cleanliness are all beneficial in guarding against PROM.
A relationship between smoking and PROM has been demonstrated in
numerous studies. Therefore, patients who smoke while pregnant should be instructed
by the nurse regarding its effect on pregnancy and should be supported in their
attempts to stop smoking.
All pregnant women should be instructed by the nurse regarding the danger
signs in pregnancy, and PROM should be pointed out as one <strong>of</strong> these signs. The signs
<strong>of</strong> membrane rupture and the necessity <strong>of</strong> prompt notification if these signs occur
should be explained early in prenatal care (Symond & Symond, 2004).
Nursing Intervention to decrease the Risk <strong>of</strong> Infection after PROM:
The nurse has the responsibility to:
Assess and prove membrane rupture with a sterile speculum
examination for two out <strong>of</strong> three tests proving positive, positive
pooling, positive ferning on collected slide specimen when viewed
under a microscope or nitrazine positive test (turns from yellow to
blue).
Assess temperature every 4 hours or as indicated (A fever is the
most reliable indicator, but it is a late indicator <strong>of</strong> an intra amniotic
infection).
Assess maternal pulse and blood pressure as indicated (Tachycardia
is one <strong>of</strong> the earlier signs <strong>of</strong> an intra amniotic infection).
29

Assess FHR as indicated (fetal tachycardia is one <strong>of</strong> the earlier
signs <strong>of</strong> an intra amniotic infection).
Assess vaginal discharge for odor or colour change.
Assess for excessive discharge <strong>of</strong> clear fluid from the vagina to
detect possible rupture <strong>of</strong> membranes, amniotic fluid is clear and
can be confused with fluid from urinary incontinence.
Assess for vaginal pooling <strong>of</strong> fluid, amniotic fluid appears similar
to urine but pools in the vagina after membranes have ruptured.
Test fluid discharge with nitrazine paper to differentiate between
urinary incontinence from uterine pressure on the urinary bladder
and PROM.
Monitor white blood cell counts daily, a white blood cell greater
than 18,000/mm 3 suggests the presence <strong>of</strong> infection.
Observe for abdominal pain or tenderness. These are signs <strong>of</strong> intra
amniotic infection.
Assess for signs <strong>of</strong> urinary tract infection.
Assess risk factors associated with PROM to facilitate early
recognition and intervention, so that complications that may
compromise the mother or fetus can be avoided.
Refer to diagnostic data as C-reactive protein; a normal C-reactive
protein level is a valuable predictor <strong>of</strong> no intra amniotic infection.
Assess in obtaining vaginal and urethral cultures for group B-
streptococci, chlamydia, and gonococcus. If any <strong>of</strong> these organisms
is present be prepared to start antibiotic therapy to decrease
neonatal infection risk (group B-streptococcus is the most common
cause <strong>of</strong> neonatal sepsis).
Assist with an amniocentesis to measure for gram-positive bacteria.
30

Instruct and provide good perineal hygiene. Cleaning and wiping
from front to back help prevent transfer <strong>of</strong> organism from anus and
perineal area to the vagina, where they can a scend to the uterus.
Avoid vaginal examinations until the patient is in active labour.
Determine duration <strong>of</strong> the rupture <strong>of</strong> membranes. There is a high
incidence (10%) <strong>of</strong> intraamniotic infection associated with rupture
<strong>of</strong> membranes. The risk for infection may be directly related to the
time involved.
If signs <strong>of</strong> intra amniotic infection are manifested, be prepared to
begin broad spectrum antibiotic therapy such as penicillin G and
gentamicin, ampicilin and gentamicin or cephalosporin, if the
patient has a cesarean delivery, clindamycin may be administrated
in addition (Green & Wilkinson, 2004).
Nursing Interventions to Decrease Impaired Fetal Gas Exchange:
Continuously monitor fetal heart rate (FHR) initially for about 48 to
72 hours after membrane rupture, to rule out fetal stressors.
Assess maternal temperature, palpable abdominal tenderness
unassociated with contractions, purulent vaginal discharged, or
both.
During expectant management, periodically monitor FHR for
variable decelerations and fetal activity.
Observe amount <strong>of</strong> amniotic fluid that is being lost.
Instruct patient to report any decrease in fetal activity studies.
31

Prepare the patient for ordered fetal wellbeing and maturity studies,
biophysical pr<strong>of</strong>ile test (BBp), ultrasound, non stress test (NST) and
amniocentesis are usually ordered on frequent basis in attempt to
determine the optimal time for delivery.
Notify physician if a baseline or periodic (FHR) change is noted, an
NST is non reactive, or a BBp <strong>of</strong> 6 or less (Gilbert& Harmon,
2003).
Nursing Interventions to Decrease Fear:
Assess family’s anxiety over maternal, fetal, and neonatal well
being.
Assess family’s coping strategies and resources.
Encourage expectant parents to communicate openly about their
feelings and concerns.
Clarify any misconceptions.
Provide information to the patient and her family regarding the
pregnancy complications, treatment plan, and implications for mother
and fetus in understandable terms.
Arrange an orientation tour to the intensive care nursery in the
event <strong>of</strong> a possible preterm delivery.
Refer to the social worker if inadequate coping is noted (Perry &
Strauss, 1998).
32

Intrapartum Nursing Interventions:
Use continuous fetal monitoring for early detection <strong>of</strong> non
reassuring FHR changes.
Notify the physician at the first signs <strong>of</strong> non reassuring FHR
change.
Assess amniotic fluid for meconium.
Reposition patient, administer oxygen by mask at 8 to 10 L and
increase the intravenous fluid rate if variable decelerations occur.
Ask the women when contractions begins (if u/s present) to help
determine if she is in labour.
Once delivery is imminent, notify the intensive care nursery <strong>of</strong> a
possible high-risk infant.
Prepare for complications <strong>of</strong> the newborn, such as complications <strong>of</strong>
oligohydramnios include IUGR and limb deformities.
Assess for vaginal bleeding, abdominal pain and strong uterine
contraction, that doesn't let up. These signs <strong>of</strong> placenta abruption.
Assess for uterine activity and change in the cervix, signs that labor
is occurring for 60% to 80% <strong>of</strong> women, labor occurs within 24
hours <strong>of</strong> PROM.
Keep client on modified bed rest (in event <strong>of</strong> cord prolapsed),
placing client in slight Trendelenburgs' position, to prevent more
cord from coming into the vagina and prevent the weight <strong>of</strong> the
fetus from compressing the cord against pelvis.
Inserting a sterile-glove hand into the mother's vagina and applying
gentle pressure to the fetal presenting part, to prevent the weight
<strong>of</strong> the fetus from compressing the cord against pelvic (Arias et al.,
1999).
33

Major aim:
SUBJECTS AND METHODS
To assess the impact <strong>of</strong> premature rupture <strong>of</strong> membranes on maternal and
neonatal conditions.
Subobjectives:
1- To estimate the incidence <strong>of</strong> premature rupture <strong>of</strong> membranes.
2- To find out the risk factors associated with PROM.
3- To assess the impact <strong>of</strong> PROM on maternal and neonatal conditions.
34

Research design:
A descriptive case-control design was selected for this study. Such design fits
the nature <strong>of</strong> the study under investigation, in which the researcher tried to investigate
the impact <strong>of</strong> premature rupture <strong>of</strong> membranes on maternal and neonatal outcomes at
Zagazig University Hospital. The comparison was done between two groups, one was
the intervention or case group and the other was the control group.
Setting:
The study was carried out at the Delivery Room in Zagazig University Hospital
in Zagazig City during the period from the first <strong>of</strong> May 2004 to the end <strong>of</strong> January
2005. This provides free services to public clients, and provides care for women
during pregnancy, labor, postpartum, and also for miscarriage. Additionally, it
provides family planning services, as well as care for women with gynecological
problems. Flow rate <strong>of</strong> normal labor was 7000-7500 cases in 2004.
Sample:
The total sample consisted <strong>of</strong> 300 parturient women in labor selected
purposively from the Labor Unit in Zagazig University Hospital. The sample was
divided into two groups, the case and the control groups consisting <strong>of</strong> 150 parturient
women each entering in the first stage <strong>of</strong> labor with gestational age from 37weeks to
42 weeks. The first group was diagnosed by the attendant physician together with the
researcher as having premature rupture <strong>of</strong> membranes. While, the second group was
also diagnosed by the attendant physician together with researcher as having intact
membranes.
35

Data Collection Tools
The researcher used four tools to collect the data, 1) namely an interviewing
questionnaire, 2) an assessment sheet, 3) Apgar scoring at first and five minutes, and
4) Ballard’s Scale. The interviewing questionnaire and assessment sheets for the
mothers were designed by investigator based on review <strong>of</strong> pertinent literature; the
remaining two tools were adapted from references.
1-Tools I: Interview questionnaire (Appendix I)
Data collection was obtained by using the following:
- Socio-demographic data which consists <strong>of</strong> questions about personal characteristics
such as age, education, occupation and family income.
- Past and family history including questions about medical and genetic disorders that
may affect the women such as diabetes mellitus, hypertension and cardiac diseases.
- Obstetric history dealing with history <strong>of</strong> para, gravida, abortion and still birth.
- Menstrual history that consists <strong>of</strong> questions about last menstrual period (LMP),
expected date <strong>of</strong> delivery (EDD), previous menstrual cycles (regular, irregular).
- Data about the present pregnancy such as for present complaint and patient's life
style which include drugs, activity, diet, smoking, infections, and previous leakage
during pregnancy, and duration <strong>of</strong> membranes rupture, amount, color and odor <strong>of</strong>
amniotic fluid.
36

Tools II: Mother assessment sheet (Appendix 2)
- Assessment <strong>of</strong> the general condition <strong>of</strong> the mother on admission.
-Vitals signs (temperature, Pulse, respiration and blood pressure).
- Obstetrical examination; fundal level (grips), fetal presentation and auscultation <strong>of</strong>
fetal heart sound.
- Assessment <strong>of</strong> progress <strong>of</strong> labor by using partograph and the mode <strong>of</strong> delivery, total
duration <strong>of</strong> labor, complications during 2 nd and 3 rd stages, delivery <strong>of</strong> placenta,
amount <strong>of</strong> blood loss during fourth stage <strong>of</strong> labor by using summary <strong>of</strong> labor sheet
Tool III: Neonatal assessment sheet (Appendix 3)
Apgar score permits a rapid assessment <strong>of</strong> the need for resuscitation based on five
signs that indicate the physiologic state <strong>of</strong> the neonate heart rate, respiration, muscle
tone, reflexes and color. Each item is scored as 0, 1, or2. Evaluation is made at 1 and 5
minutes after birth. Scores <strong>of</strong> 0 to 3 indicate severe distress, scores <strong>of</strong> 4 to 6 indicate
moderate difficulty, and scores <strong>of</strong> 7 to 10 indicate that the infant should have no
difficulty adjusting to extra uterine life (Letko, 1996).
Neonatal reflexes assessment sheet
The reflexes tested included moro reflex, suckling reflex, Babinsky reflex,
grasping reflex and coughing reflex. Each baby took about l0 minutes for assessment
<strong>of</strong> the neonatal reflexes.
Ballard's Scale (neurological assessment)
The Ballard scale was used to measure gestational ages <strong>of</strong> infants. It assesses
six external physical and six neuro muscular signs. Each sign has a score, and the
cumulative score correlates with a maturity rating <strong>of</strong> 37 to 42 weeks <strong>of</strong> gestation. The
37

score is accurate to plus or minus 2 weeks and is accurate for infants <strong>of</strong> all races
(Stevens Simon et al., 1989). If a newborn score was 35, this indicates that he/she had
38 weeks, if the newborns score was 40, it corresponds to 40 weeks gestational, and so
on.
Pilot study
A pilot study was conducted on 40 women, 20 women having PROM (case)
and 20 women haven't PROM (control). The result <strong>of</strong> the pilot study was used in
determining the feasibility and practicability <strong>of</strong> the data collection tools. The pilot
study also helped to estimate the time needed to fill in the tools. Based on its results,
modifications needed were performed. Those who shared in the pilot study were
included in the study sample.
Operation Design
Field Work:
The study was conducted in the period ranging from the first <strong>of</strong> May 2004 to the end
<strong>of</strong> January 2005.
Interviewing: Interviews were carried out with parturient women <strong>of</strong> the two groups
on admission to the labor unit. The investigator introduced herself to the women and
explained the aim <strong>of</strong> the study, the interview questionnaire was written in a simple
way. The investigator asked questions in Arabic language for all women, recorded the
answer in the sheet. It filling the interviewing sheet consumed about 15 minutes for
each women.
Maternal assessment
After a complete history was taken, the investigator performed general
examination on admission by taking the vital signs <strong>of</strong> the two groups, performing
vaginal, abdominal examination, and identifying the date and time <strong>of</strong> membranes
38

upture. The investigator followed up the women during the labor by using a
partograph and a summary <strong>of</strong> the labor sheet. She observed the women all time to
detect any signs <strong>of</strong> infection caused by premature rupture <strong>of</strong> membranes.
Apgar score was performed in the first and fifth minutes for all babies in the two
groups. All signs <strong>of</strong> Apgar score were assessed and recorded for each newborn in the
Apgar scoring sheet. The total score was calculated to indicate the baby's condition.
Each baby took about 10 minutes for measuring Apgar score.
* Neonatal reflexes assessment
Assessment <strong>of</strong> the presence <strong>of</strong> reflexes is important to determine the state <strong>of</strong> the
newborn's central nervous system. The reflexes tested included: more reflex, grasping
reflex, Babinski reflex, suckling reflex and coughing reflex.
Ballard Scale
Ballard scale was used to measure gestational age <strong>of</strong> infants, which consists <strong>of</strong>
six physical signs (skin, lanugo, breast, planter, eye-ears and genitalia) and six neuro
muscular signs (posture, square window, arm recoil, popliteal angle, heel to ear and
scarf sign). Each item scored 0 to 5 and the total score was calculated. Assessment <strong>of</strong>
each infant took 20 minutes.
Administration design:
An approval from the Chairman <strong>of</strong> the Obstetric and Gynecological Department
was obtained in order to conduct this study . A proposal <strong>of</strong> thesis was attached to the
letter.
39

Statistical analysis:
All data were coded, entered, and analyzed using Epi info–Version 6 s<strong>of</strong>tware
package.
The test used
Chi-square X 2 oE =
o = observed
E = expected
E=
E
Colum total X Raw total
Grand total
(Dean et al., 1994).
40

RESULTS
The results <strong>of</strong> this study are presented as the following sequence:
Section I:
Socio-demographic characteristics, family history, obstetric and medical
history <strong>of</strong> the study groups (Tables 1-4).
Section II:
Last coitus, risk factors, mode <strong>of</strong> delivery, complications <strong>of</strong> labor during and after
labor (Tables 5-13 & Figs 1-4 ).
Section III:
Neonatal outcomes (Tables 14-19 & Fig s5-7).
Section V:
. Relationship between duration <strong>of</strong> PROM and complications <strong>of</strong> labor among
mothers in case group (Table 20).
. Relationship between duration <strong>of</strong> PROM and C-Reactive protein among mothers
in case group (Table 21).
41

Section I:
Table (1): Socio-demographic characteristics <strong>of</strong> parturient women in the
Age (in years)
> 20
21-25
26-30
Items
More than 30
(*) Statistically significant
PROM and control groups.
Cases
(n=150)
Control
(n=150)
N % N %
13
87
25
25
Table (1) shows the socio-demographic characteristics <strong>of</strong> parturient women in the
PROM and control groups. It can be noticed that, women age ranged between 18-40
with a mean <strong>of</strong> 25.4±5.9 among cases <strong>of</strong> PROM, while it was 24.3±4.8 among the
control group. Differences observed were statistically significant (P

Parturient women who had PROM were more likely to be the youngest (8.7%)
and oldest (16.7%) age groups than the control group (6.7% and 10.7% respectively).
However, differences observed were not statistically significant (P>0.05).
The same table shows that, the highest percentage <strong>of</strong> women in the two groups
had no education (illiterate) 76.7% in PROM group and 83.3% in the control group.
Differences observed were not statistically significant (P>0.05).
The majority <strong>of</strong> women in the two groups were housewives. However, working
women (16.7%) were more likely to have PROM compared to 12.7% among the
control group.
Furthermore, those who had PROM were more apt (28.7%) to have low
income compared to 24.0% in the control group. However, differences observed were
not statistically significant (P>0.05).
]
43

Table (2): Family history <strong>of</strong> parturient women in PROM and control
Family history
Types
Absent
Present
FE = Fisher exact
groups.
Items
Hypertension
Diabetes
Cardiovascular diseases
Cases
(n=150)
Control
(n=150)
N % N %
Concerning the family history <strong>of</strong> parturient women in the two groups, table (2)
demonstrates that nearly one fifth (20.7%) <strong>of</strong> the PROM cases had history <strong>of</strong> family
diseases compared to 16.7% <strong>of</strong> these in the control group. However, a difference
observed was not statistically significant (P>0.05).The diseases encountered were
mostly hypertension, diabetes mellitus and cardiovascular disease.
119
31
18
8
5
79.3
20.7
58.1
25.8
16.1
125
25
16
6
3
83.3
16.7
64.0
24.0
12.0
X²
0.79
0.13
0.30
FE
pvalue
0.37
0.71
0.58
0.72
44

Table (3): Obstetric history <strong>of</strong> parturient women in PROM and control groups.
Gravidity
Items
Primigravida
Multi gravida
Parity
Nullipara
Multipara
Fetal loss
No
Yes
(*) Statistically significant
Obstetric history <strong>of</strong> parturient women in the PROM and control groups is
described in table (3). It can be seen that two fifths <strong>of</strong> cases (40.0%) were
primigravida compared to only 28.7% among the control group. As regards parity,
nearly half women (45.3%) who have PROM were nullipara compared to control
group (33.3%). Differences observed were statistically significant (P

No; 88%
Yes; 12%
Figure (1)
Incidence <strong>of</strong> premature rupture <strong>of</strong> membranes
Fig (1): Illustrates that the researcher took all cases <strong>of</strong> PROM from the Labor
Unit at Zagazig University Hospital, during for one year, all cases who
entered the same unit and the same year after that calculated the
frequency <strong>of</strong> premature rupture <strong>of</strong> membranes
46

Table (4): Medical history <strong>of</strong> parturient women in PROM and control groups.
Items
Medical history
Absent
Present
Types
Hypertension
Diabetes
Cardiovascular
Others
(*) statistically significant
Cases
(n=150)
Control
(n=150)
N % N %
Table (4): shows that the higher percentage <strong>of</strong> women with medical diseases was
present among 38.6% <strong>of</strong> PROM cases compared to 27.3% in the control group.
However, the difference observed was statistically significant (p

Section II:
Table (5):Comparison <strong>of</strong> last coitus before hospital admission in the PROM and
control groups.
Last Coitus
Not remember
One day before
Two days before
No coitus done
Case
group
(n= 150)
Control
group
(n=150)
N % N %
55
42
25
28
36.6
28
16.7
18.7
60
35
24
31
X² p-value
Table (5) & Fig (2) show comparison <strong>of</strong> last coitus before hospital admission in the
PROM and control groups. More than one quarter <strong>of</strong> the women (28.0%) have last
coitus one day before hospital admission in PROM group compared to 23.4% in the
control group.
40.0
23.4
16.0
20.6
0.35
0.86
0.02
0.19
0.55
0.35
0.87
0.66
48

Two days before
16.7%
Two days before
16.00%
No citus done
18.7%
No citus done
20.60%
Case group (n = 150)
One day before
28.0%
Control group (n = 150)
One day before
23.40%
Figure (2)
Not remember
36.6%
Not remember
40.00%
Last coitus before hospital admission in the PROM and control group
49

Table (6): Risk factors <strong>of</strong> parturient women in PROM and control groups.
Items
Previous PROM
No
Yes
Infection
Anemia
No
Yes
No
Yes
(*) statistically significant
Table (6): shows the risk factors <strong>of</strong> parturient women in PROM and control groups. It
can be noticed that one tenth (10.6%) <strong>of</strong> the women having previous PROM in PROM
group compared to 6.6% in the control group. However, the difference observed was
not statistically significant (P> 0.05).
Cases
(n=150)
The same table shows that about one quarter <strong>of</strong> the women (23.3%) have
anemia in PROM group compared to 15.3% in the control group. The differences
observed was statistically significant (P

Table(7): Percentage distribution <strong>of</strong> women according to duration <strong>of</strong> PROM in
case group.
Duration <strong>of</strong> PROM No %
< 6 hrs
6-

Table (8): Percentage distribution <strong>of</strong> women according to condition <strong>of</strong> PROM
in the case group.
Condition <strong>of</strong> rupture No %
Amount <strong>of</strong> amniotic fluid
according to u/s
Average
Decreased
Meconium stained
No
yes
92
58
61.3
38.7
Table (8): Precentage distribution <strong>of</strong> women according to condition <strong>of</strong> PROM in the
case group. Nearly two fifths <strong>of</strong> the women (38.7%) have decreased amount <strong>of</strong>
amniotic fluid according to ultrasonography in the case group. The table also shows
141
9
94.0
6.0
that only 9 <strong>of</strong> the women (6.0%) had meconium stained in the case group.
52

Table (9): Percentage distribution <strong>of</strong> women according to c-reactive protein in
the case group.
C-reactive protein
C-reactive protein
No
yes
No %
Percentage distribution <strong>of</strong> women according to c-reactive protein in the case group is
described in table (9). It can be seen that only 5 <strong>of</strong> the women (3.3%) have positive C
- reactive protein.
145
5
96.6
3.3
53

Table (10): Comparison <strong>of</strong> vital signs on time <strong>of</strong> admission <strong>of</strong> parturient women
Temperature
in PROM and control groups.
Items
Up to 37.4°C
37.5°C more
Pulse (b/M)
Less than 90
More than 90
Systolic Bp (mm Hg)
Up to 110
111-139
140 or more
Diastolic Bp (mm Hg)
Less than 80
80 < 100
100 or more
Case
(n=150)
Control
(n=150)
N % N %
113
37
138
12
78
59
13
73
66
11
75.3
24.7
92.0
8.0
52.0
39.3
8.7
138
12
141
9
67
76
7
92.0
8.0
94.0
6.0
44.7
50.7
4.7
X²
15.27
0.46
1.62
0.34
1.93
pvalue
0.000**
0.497
Table (10): shows the comparison <strong>of</strong> vital signs on time <strong>of</strong> admission <strong>of</strong> parturient
women in case and control groups. More than one quarter <strong>of</strong> the women (24.7%) have
elevated temperature more than 37.5˚C in PROM group compared to 8.0% in control
48.7
44.0
7.3
59
84
7
39.4
56.0
group. The difference observed was statistically significant (p0.05).
4.6
2.65
1.33
0.95
0.20
0.56
0.16
0.10
0.24
0.33
54

Table (11): Comparison <strong>of</strong> diagnostic condition at time <strong>of</strong> admission <strong>of</strong>
parturient women in PROM and control groups.
Items
Weeks <strong>of</strong> gestation
37
38
39
≥40
Cases Control
No % No %
38
39
42
31
25.3
26.0
28.0
20.6
19
25
63
43
12.7
16.7
42.0
28.6
X²
7.82
3.89
6.46
2.58
Mean ± SD 38.4 ±1.3 38.9±1.1 0.12
Position & present
ROA
LOA
ROP
LOP
Breech
(*) statistically significant
47
80
9
4
10
31.3
53.3
6.0
2.7
6.7
78
29
17
12
14
52.0
19.3
11.3
8.0
9.3
13.1
37.4
2.7
4.23
0.72
Pvalue
0.005
0.04
0.01
0.11
0.000**
0.000**
0.1
0.03
0.39
Table (11): represented a comparison <strong>of</strong> diagnostic condition at time <strong>of</strong> admission <strong>of</strong>
parturient women in PROM and control groups. Weeks <strong>of</strong> gestation between 37 to 42
wks with a mean <strong>of</strong> 38.4±1.3 among case group and 38.9±1.1 among the control
group. The difference observed was not statistically significant.
Furthermore, those who were more apt to have malpresentation in the cases
group (6.7%) compared to the control group 9.3%. And the difference observed was
not statistically significant.
Table (12): Mode <strong>of</strong> delivery among women in the case group.
55

Mode <strong>of</strong> delivery
Items No %
Normal delivery
Caesarean section
Instrumental
Causes <strong>of</strong> CS:
Fetal distress
Failure <strong>of</strong> progress
Previous CS
Maternal distress
Breech presentation
Contracted pelvic
Table (12) & Figure (3): show the mode <strong>of</strong> delivery among women in the case group.
More than one third (38.0%) <strong>of</strong> women, who have PROM, were delivered by C.S. It
can be observed that, the most common causes <strong>of</strong> C.S were fetal distress (43.3%),
failure <strong>of</strong> progress (29.8%), previous C.S (12.3%), maternal distress (8.7%), breech
presentation (2.6%) and contracted pelvic (1.7%), were all encountered.
92
57
1
25
17
7
5
2
1
61.3
38.0
0.7
43.3
29.8
12.3
8.7
2.6
1.7
56

Previous C.S
12.3%
Failure <strong>of</strong> progress
29.8 %
Maternal distress
8.7%
Contracted pelvic
0.6%
Figure (3)
Indication <strong>of</strong> doing caesarean section
Fetal distress
43.3%
57

Table (13): Comparison <strong>of</strong> maternal complications <strong>of</strong> labor between parturient
women in PROM and control groups.
Fetal distress
No
Yes
Items
Maternal distress
No
Yes
Meconium
Inertia
No
Yes
No
Yes
(*) Statistically significant
Cases
(n=150)
Control
(n=150)
N % N %
119
31
145
5
141
9
145
5
79.3
20.7
96.7
3.3
94.0
6.0
96.6
3.3
137
13
147
3
134
16
142
8
91.3
8.7
98.0
2.0
89.3
10.7
94.7
5.3
X²
8.62
0.51
2.13
4.92
Pvalue
0.003*
0.473
0.144
0.02*
As shown in table 13 & fig (4) comparison <strong>of</strong> maternal complications <strong>of</strong> labor between
parturient women in PROM and control groups. One fifth (20.7%) <strong>of</strong> parturient
women in PROM have fetal distress compared to 8.7% in the control group. The
differences observed was statistically significant (p

Percentage (%)
100
90
80
70
60
50
40
30
20
10
0
Case Control
Fetla disress Maternal
distress
Meconium
Items
Ijnteria
Figure (4)
Comparison <strong>of</strong> maternal complications <strong>of</strong> labor between parturient women in
PROM and control groups
59

Section III:
Table (14): Comparison <strong>of</strong> neonates Apgar score between parturient women in
PROM and control groups.
Items
Apgar score (1 min)
0-4
5-7
8-10
Case
(n=150)
Control
(n=150)
N % N %
21
114
15
14.5
76.0
10.0
17
88
45
11.3
58.7
30.0
X²
0.48
10.24
18.75
pvalue
0.48
0.001*
0.001*
Mean SD 6.21.5 6.71.8 2.75 0.006*
Apgar score (5 min)
0-4
5-7
8-10
Mean SD
(*) Statistically significant
8
14
128
6.7
5.3
9.3
85.3
1.31
3
22
125
7.26
2.0
14.7
83.3
1.38
2.36
2.02
0.23
3.03
0.12
0.15
0.63
0.003*
Table 14 & Fig (5) show the comparison <strong>of</strong> neonates Apgar score between parturient
women in PROM and control groups. The newborn had Apgar score 0-4 at 1 min
(14.5%) in the case group compared to 11.3% in the control group. The mean Apgar
score at 1 min was 6.21.5 among case group and 6.71.8 among control group. The
difference observed was statistically significant (p< 0.05).
The same table shows that the mean <strong>of</strong> Apgar score at 5 min were 6.71.31 and
7.21.38 respectively. The differences observed were statistically significant (p

7.4
7.2
7
6.8
6.6
6.4
6.2
6
5.8
5.6
Case Control
Apgar score (1 min) Apgar score (5 min)
Items
Figure (5)
Comparison <strong>of</strong> neonates mean Apgar score between parturient women in PROM
and control group
61

Table (15): Comparison <strong>of</strong> neonatal temperature and weight measurements <strong>of</strong>
parturient women in PROM and control groups.
Items
Neonatal temperature
Up to 37.4°C
37.5°C +
Neonatal Weight
MeanSD
(*)Statistically significant
Cases
(n=150)
N %
137
13
3.34.02
91.4
8.6
Control
(n=150)
N %
141
9
3.4 4.7
94.0
6.0
X²
2.64
1.66
p-value
0.07*
0.09*
Table (15): shows comparison <strong>of</strong> neonatal temperature and weight measurements
between parturient women in PROM and the control group. It can be noticed that, less
than one tenth (8.6%) <strong>of</strong> newborn had fever in PROM group compared to 6.0% in the
control group. The difference observed was statistically significant (p

Table (16): comparison <strong>of</strong> neonatal reflexes between parturient women in
More reflex
Absent
PROM and control groups.
Items
Present
Babinski reflex
Absent
Present
Grasping reflex
Absent
Present
Cough reflex
Absent
Present
Case
(n=150)
Control
(n=150)
N % N %
8
142
7
143
13
137
7
143
5.3
94.7
4.7
95.3
8.7
91.3
3
147
2
148
8
142
2.0
98.0
1.3
98.7
5.3
94.7
X²
2.36
1.87
0.72
pvalue
Table 16 & Fig (6) reveal the comparison <strong>of</strong> neonatal reflexes between parturient
women in PROM and control groups. Only 8 (5.3%) newborns had not moro reflex in
PROM compared to 3 (2%) newborn in the control group. The difference observed
was not statistically significant (p>0.05). The same table also shows that 7 (4.7%)
newborn were absent <strong>of</strong> cough reflex in PROM group compared to 4 (2.6%) newborn
in the control group. There was no statistically significant difference (p>0.05).
4.7
95.3
4
146
2.6
97.3
0.85
0.12
0.17
0.39
0.35
63

Percentage (%)
100
90
80
70
60
50
40
30
20
10
0
Case Control
More reflex babin ski reflex Grasping reflex
Items
Cough reflex
Figure (6)
Comparison <strong>of</strong> neonatal reflexes <strong>of</strong> parturient women in PROM and control
groups
64

Table (17): Comparison <strong>of</strong> neonatal physical maturity score <strong>of</strong> parturient
Skin
Lanugo
Physical
Maturity
Planter surface
Beast
Eye/ear
women in PROM and control groups.
Case
(n=150)
control
(n=150)
MeanSD MeanSD
3.20.4
2.60.4
2.80.6
2.70.5
3.30.4
Genitalia
3.30.6
(**) Highly statistically significant
4.10.3
3.20.4
3.20.6
3.20.5
3.50.5
3.40.4
X²
21.1
10.88
4.7
7.4
2.5
1.7
P-value
0.000**
0.000**
0.000**
0.000**
0.01*
0.07*
Table (17) shows that there were a highly statistically significant differences <strong>of</strong>
physical maturity between the two studied groups. The control group had higher score
(4.1) than the case group (3.2). As regards lanugo, the control group had the higher
score (3.2) than the case group (2.6). Infants in the case group had lower score <strong>of</strong>
breast (2.7), whereas those in the control group had the higher score (3.2).
65

Table (18): Comparison <strong>of</strong> neonatal neurological maturity score <strong>of</strong> parturient
Neurological
maturity
Posture
Square window
Arm recoil
Scarf sign
Popliteal angle
Heal to ear
women in PROM and control groups.
Case
(n=150)
Control
(n=150)
MeanSD MeanSD
1.70.5
1.90.6
2.90.7
2.90.7
2.30.4
2.20.9
3.00.6
2.80.7
3.40.6
3.50.4
3.30.4
3.00.8
X²
18.45
11.54
6.73
8.92
17.42
8.39
pvalue
0.000**
0.03*
0.000**
0.01*
0.000**
0.000**
As table (18) indicates mean scores for all items <strong>of</strong> physical maturity were
lower among the case group compared to the control groups. For posture, Square
windows and heal to ear the means were for the case group 1.7 0.5; 1.9 0.6 & 2.2
0.9 respectively while, for the control group they were 3.0 0.6; 2.8 0.7 & 3.0
0.8 respectively. The differences were statistically significant.
As the same table shows infants in the case group had lower scores <strong>of</strong> posture
(1.70.5) than the control group (3.00.6). Square window score <strong>of</strong> infants in the case
group (1.9) compared to the control group (2.8). Infant <strong>of</strong> the case group had lower
score (2.2), whereas those in the control group had the lower score (2.2) in relation to
heal to ear score.
66

Table (19): Comparison <strong>of</strong> the Ballard score (total neurological & physical
Items
Neurological score
Physcial score
Total Ballard score
score) <strong>of</strong> parturient women in PROM and control groups.
Cases
(n=150)
Control
(n=150)
MeanSD MeanSD
14.11.6
18.21.04
32.31.7
19.31.6
20.61.34
39.92.3
X²
27.37
17.46
31.54
pvalue
0.000**
0.001*
0.000**
Table (19) indicates the presence <strong>of</strong> statistically significant difference between the
two studied groups. Concerning total neurological scores, control group was higher
(19.3 1.6) compared to the case group (14.1 1.6). The same trend was observed in
the relation to Ballard score, which was higher in the control group (39.9 2.3) than
in the case group (32.3 1.7).
67

No; 86.80%
No; 90.00%
Case group
Control group
Yes; 13.40%
Yes; 10.00%
Figure (7)
Newborns admitted to neonatal intensive care unit (NICU) <strong>of</strong>
parturient women in PROM and control groups.
Figure (7) The above figure illustrates the newborns admitted to neonatal intensive
care unit (NICU) between parturient women in PROM and the control
groups. It can be noticed that, more than one tenth <strong>of</strong> newborns
(13.4%) were admitted to NICU in PROM group compared to 10.0%
<strong>of</strong> newborns in the control group.
68

Section V:
Table (20) Relationship between duration <strong>of</strong> PROM and complication <strong>of</strong> labor
among mothers in case group.
Complication No %
Fetal distress
No
Yes
Meconium
No
Yes
Maternal distress
No
Yes
Inertia
No
Yes
119
31
141
9
145
5
142
8
79.3
20.7
94.0
6.0
96.7
3.3
94.6
5.3
Mean duration
<strong>of</strong> PROM (hrs)
32.74
21.79
37.44
20.12
42.40
22.05
16.25
23.09
Sig
0.000**
0.001*
0.001*
0.136
Relationship between duration <strong>of</strong> PROM and complication <strong>of</strong> labor among
mothers in case group is described in table (20). The results demonstrated that there
were statistically significant associations between duration <strong>of</strong> PROM and fetal
distress, meconium and maternal distress, only inertia had not reached a statistically
significant association (p>0.005).
69

Table (21) Relationship between duration <strong>of</strong> PROM and C-reactive protein
among mothers in case group.
C-reactive
protein
Negative
Positive
No %
145
5
96.6
3.3
Mean <strong>of</strong> duration <strong>of</strong>
PROM (hrs)
22.20
38.20
Sig
.000**
Relationship between duration <strong>of</strong> PROM and C-reactive protein among
mothers in case group is described in table (21). The results show that a highly
significant association between duration <strong>of</strong> PROM and mother's C-reactive protein.
70

DISCUSSION
<strong>Premature</strong> rupture <strong>of</strong> membranes (PROM) is a major obstetric problem facing
obstetricians, with variable incidence regarding the gestational age. <strong>Premature</strong> rupture
<strong>of</strong> membranes is the rupture <strong>of</strong> fetal membranes prior to the onset <strong>of</strong> labor in up to
8% <strong>of</strong> pregnancies at term and it are a major contributor to perinatal and neonatal
morbidity and mortality (Brian, 2000).
This study was designed to estimate incidence <strong>of</strong> premature rupture <strong>of</strong>
membranes, to find out the risk factors associated with PROM, and to assess the
impact <strong>of</strong> PROM on maternal and neonatal conditions.
This study was carried out on 300 parturient women, 150 women having PROM
and 150 having intact membranes, selected purposively from the Labor Unit at
Zagazig University Hospital.
The incidence <strong>of</strong> PROM among parturient women in the present study was
12%. These findings are in agreement with Mercer (2002) who found that, the
incidence <strong>of</strong> PROM is 2.7 to 17%. In a similar study, Merenstein and Weisman,
(1996), reported that PROM before the onset <strong>of</strong> labour occasion 2% to 18% <strong>of</strong>
pregnancies. The time from PROM to delivery is usually less than 78 hours in term
pregnancies. Mercer, (2003) showed that PROM affects over 120.000 pregnancies
annually in the United States and is associated with significant maternal fetal and
neonatal risks. Ladfors, (1998) found that the prevalence <strong>of</strong> PROM in an urban
Swedish population was 12.9% that is similar to present study findings.
Results <strong>of</strong> the present study indicated that the age <strong>of</strong> women ranged between
18-40 years, the minority <strong>of</strong> parturient women who had PROM were more likely to be
younger (table 1) among both the cases and the control groups. With lesser percentage
71

for the later group. However, the difference observed was statistically significant.
These findings are in agreement with what was reported by Abdel-kader., (1997),
who stated that PROM was more commonly encountered in the age group from 18 to
26 years (63.8%), which can be explained by its being a high fertility age, which is
more reproductive with higher performance, so accompanied by more obstetric
complications including PROM. On the same line, Hediger et al., (1997) found that,
young adolescent less than 16 years and especially those <strong>of</strong> low gynecologic age are at
increased risk for preterm delivery and PROM.
As regards educational level, results <strong>of</strong> the present study indicated that, the
highest percentages <strong>of</strong> women in the two groups were illiterate (table 1). The
investigator observed that both the highly educated and the non educated mothers
lacked knowledge and awareness regarding PROM. Bibby and Stewart (2004) found
that there were statistically significant relation between less education, lower social
class and occurrence <strong>of</strong> PROM, which are in accordance with the current study
findings.
Occupation may be a factor which aggravates the occurrence <strong>of</strong> PROM. The
results <strong>of</strong> present study showed that although the majority <strong>of</strong> women were
housewives, however, working women were more likely to have PROM when
compared to the control group (table 1). These data are in agreement with Newman et
al., (2001) who found that each source <strong>of</strong> occupational fatigue was independently
associated with a significantly increased risk <strong>of</strong> premature rupture <strong>of</strong> membranes.
Income as well, was a factor which might have contributed to the incidence <strong>of</strong>
PROM. Results <strong>of</strong> the study indicated that those who have PROM were more
prevalent among the low income women compared to less than quarter in the control
group (table 1). These findings are in agreement with Gilbert and Harman (1993),
who also reported that defects in the membranes is accompanied with low socio-
economic status.
72

Investigating gravidity as related to PROM, two fifths <strong>of</strong> cases were primigravida
compared to more than quarter among control group. Less than half <strong>of</strong> women, who
have PROM, were nullipara compared to one third in the control group. Differences
observed were statistically significant (P

The present study revealed that about one quarter <strong>of</strong> the women have anemia in
PROM group compared to less than one fifth in the control group. Difference
observed was statistically significant (table 6). Conversely, Perry and Strauss,
(1998) reported that a relationship between lack <strong>of</strong> zinc and protein and occurrence <strong>of</strong>
PROM was detected. On the same context Borna et al., (2005) reported a statistically
significant relation between anemia and occurrence <strong>of</strong> PROM.
The results <strong>of</strong> the current study showed that one tenth <strong>of</strong> the women have
previous PROM in the study group compared to only 6.6% in the control group (table
6). However, the difference observed was not statistically significant. In a similar
study, Mercer et al., (2000) found that multiparous with a history <strong>of</strong> previous PROM,
have a recurrence rate <strong>of</strong> 2.2% <strong>of</strong> preterm birth and PROM.
The results <strong>of</strong> present study revealed that, weeks <strong>of</strong> gestation were between 37-
42 weeks with a mean <strong>of</strong> cases (38.41.3) weeks, and among the control (38.91.1).
There was no statistically significant difference between the two groups (table 11). As
well, Atallah., (1995) showed that the group <strong>of</strong> premature rupture <strong>of</strong> membranes
(mean 38.6 weeks)was not statistically significant as compared to the control group
(mean 39.1weeks).
As regards malpresentation, there were no significant relationship between
occurrence <strong>of</strong> PROM and fetal presentation between the two studied groups (table 11).
This result was similar to that <strong>of</strong> Zaghloul, (1996), who found that malpresentation
was commonly seen with PROM.
As regards to mode <strong>of</strong> delivery, more than one third (38.0%) <strong>of</strong> women who
have PROM were delivered by C.S. It can be observed that the most common causes
<strong>of</strong> C.S, were fetal distress (43.3%), failure <strong>of</strong> progress (29.8%), previous C.S (12.3%),
maternal distress (8.7%), breech presentation (2.6%) and contracted pelvic (1.7%),
were all encountered. No significant relation was found between duration <strong>of</strong> PROM
74

and mode <strong>of</strong> delivery (table 12). These findings were similar to those <strong>of</strong> Karwan and
Okninska (2004), who found that no significant difference between mode <strong>of</strong> delivery
and duration <strong>of</strong> PROM between study and control group. In accordance with the study
findings, Wingfield et al., (1993) reported that patients with PROM had a greater rate
<strong>of</strong> C.S. delivery because <strong>of</strong> suspected fetal distress. There were major indicators for
doing CS and forceps delivery in their study as obstructed labor (29.8%), fetal distress
(43.8%), previous C.S. (12.2%), maternal distress (8.7%), breach presentation (3.5%)
and contracted pelvic (1.7%). These data were similar to those reported by Kong et
al., (1992) and Hjertberg et al., (1996), as the major indicators for operative delivery
were fetal distress, failure <strong>of</strong> progress, infection and occipito posterior position.
In the present study, the most common complications during labor were fetal
distress (20.7%), meconium stained amnion (6.0%) maternal distress and inertia
(3.3%). Results <strong>of</strong> the study indicated significant relationship between duration <strong>of</strong>
PROM and fetal distress (table 13). This result is in agreement with Pajntar and
Verdenik, (1997), who found statistically significantly relation between duration <strong>of</strong>
PROM and fetal distress. This finding disagrees with Mazor et al., (1995), who found
no significant association between fetal distress and PROM.
The results <strong>of</strong> this study indicated a significant association between PROM and
meconium stained amnion (table 13). This finding was supported by Rao et al.,
(2001) which showed a significant association between PROM and intra-amniotic
infection and meconium stained amnion.
As well, the current study results showed a significant association between
duration <strong>of</strong> PROM and maternal distress (table 13). This result was supported by
Zaghloul (1996), who found a strong association between prolonged duration <strong>of</strong>
PROM and maternal distress.
75

The present study revealed that a highly statistically significant relation
between duration <strong>of</strong> PROM and mother's C-reactive protein (table 9).This finding is
in agreement with Abou Seeda and Abdel Hady (1990), who found a positive
correlation between CRP level in the serum <strong>of</strong> patients with premature rupture <strong>of</strong>
membranes and duration <strong>of</strong> rupture.
The results <strong>of</strong> this study indicated a highly significant correlation between
duration <strong>of</strong> PROM and maternal temperature in case group (table10). This may be due
to the administration <strong>of</strong> massive dosage <strong>of</strong> antibiotics during hospitalization.
The present study revealed that, more than one quarter <strong>of</strong> the women (24.7%)
have elevated temperature equal to 37.5°C or more in PROM group compared to 8.0%
in control group. Difference observed was statistically significant (p

chorioamnionitis is an accelerated maternal pulse rate and if it is followed by fetal
tachycardia; it is an evidence <strong>of</strong> fetal distress, and concerning the results <strong>of</strong> his study
he found that, a highly statistically significant relationship between duration <strong>of</strong> PROM
and mother’s C-reactive protein. This finding agrees also with Yoon et al., (1996),
who found that women with positive amniotic fluid culture and clinical
chorioamnionitis had significantly higher median creative protein with prolonged
duration <strong>of</strong> PROM.
According to the immediate assessment <strong>of</strong> the neonate. Results <strong>of</strong> this study
showed that the mean Apgar score at 1 min was 6.21.5 among the case group and
6.7 among control group. Differences observed were statistically significant
(table14). The mentioned data were in agreement with Averbuch et al., (1995) which
showed that Apgar scores at 1min were significantly different with duration <strong>of</strong>
PROM. In this respect, Sperling et al., (1993) found no statistically significant
difference in the number <strong>of</strong> neonates with Apgar scores less than 7 at 5 min in the
study group. In agreement with the current study findings, Atallah., (1995) found that
the Apgar score at 1 min was statistically decreased with PROM group compared to
the control group and this indicates that there is an indirect relation between the Apgar
at 1 min and the duration <strong>of</strong> rupture <strong>of</strong> membranes.
Concerning the neonate's temperature, results <strong>of</strong> the present study revealed a
significant correlation between the two studied groups and neonate's body temperature
(table15). In this context, Blanchot et al., (1993) suggested that when high
temperature develops in labor, it is important to deliver the infant as quickly as
possible because there is high incidence <strong>of</strong> neonatal’s infection which is manifested by
acceleration <strong>of</strong> FHR, increase in body temperature and stained liquor. Pajntar and
Verdenik, (1997) reported that, a significant increase time elapsed since PROM to
delivery.
77

As regards the neonatal birth weight, the current study showed that their weight
ranged between 3 - 4.5 with a mean <strong>of</strong> 3.34.02 among cases <strong>of</strong> PROM and 3.4 4.7
among the control group. Difference observed was statistically significant (p

CONCLUSION
The aim <strong>of</strong> this study was to estimate the incidence <strong>of</strong> premature rupture <strong>of</strong>
membranes, find out the risk factors associated with PROM, and assess the impact <strong>of</strong>
PROM on maternal and neonatal condition.
Generally, the study concluded that premature rupture <strong>of</strong> membranes (PROM)
is one <strong>of</strong> the most problems facing pregnant women and physicians. The exact
etiology is unknown, although many prides posing factors were suggested such
as infection, low social class and malnutrition.
Infection associated with PROM was indicated by maternal vital signs,
abdominal tenderness, C - reactive protein and cervical culture.
The effect <strong>of</strong> PROM on maternal outcome was demonstrated through duration
<strong>of</strong> PROM, progress <strong>of</strong> labor and mode <strong>of</strong> delivery. The main complications
during 1 st stage <strong>of</strong> labor were obstructed labor, maternal distress and
chorioamnionitis during 2 nd stage, the main complication was fetal distress,
meconium stained maternal distress and inertia.
Follow up assessment <strong>of</strong> the neonates after delivery through Apgar score,
reflexes and neurological assessment are indicated that PROM is closely
associated with low Apgar and there is no association between PROM and
neurological assessment <strong>of</strong> neonates (by using Ballard's scale).
79

RECOMMENDATIONS
Based up on the findings <strong>of</strong> the current study, the following
recommendations can be deduced:
The nurse should be an educator and counselor for mothers during ante-natal
period to increase their awarness regarding PROM.
Women who have signs and symptoms <strong>of</strong> PROM should consult their physicians
immediately.
Monitoring the most important simple clinical signs <strong>of</strong> infection as: uterine
tenderness, fever, fetal tachycardia and foul odor <strong>of</strong> vaginal discharge as they are
early signs <strong>of</strong> chorioamnionitis.
Nurses should identify the risk group <strong>of</strong> women who have PROM and how to deal
with them.
Evaluation <strong>of</strong> the clinical and laboratory findings increases awarness <strong>of</strong> premature
rupture <strong>of</strong> membranes to choose the best time for intervention for delivery.
Follow up <strong>of</strong> the neonatal after PROM should be emphasized.
Further research studies need to be undertaken to determine the maternal problems
associated with PROM.
80

SUMMARY
<strong>Premature</strong> rupture <strong>of</strong> membranes (PROM) is one <strong>of</strong> the most common problems
that caused maternal and neonatal morbidity and mortality.
The aim <strong>of</strong> this study was to estimate the incidence <strong>of</strong> premature rupture <strong>of</strong>
membranes, find out the risk factors associated with PROM and assess the impact <strong>of</strong>
PROM on maternal and neonatal conditions.
A questionnaire and assessment sheets were developed by the researcher and
used on 300 parturient women, (150) having PROM, (150) having intact membranes,
selected purposively from Labor Unit at Zagazig University Hospital.
A pilot study was carried out on 40 parturient women to evaluate the content <strong>of</strong>
the questionnaire and assessment sheets as well as to estimate the time needed for data
collection.
The study results can be summarized as follows:
Demographic and obstetric characteristics demonstrated that, parturient women
who had PROM were more likely to be younger (8.7%) and older age (16.7%) than
control group (6.7% and 10.7% respectively).Women who have PROM were
housewives (83.3%) compared to control group (87.3%).Women who had PROM
were apt to be illiterate (76.7%) compared to control group (83.3%), and parturient
women having low income were 28.7% in case group compared to control group who
represented 24.0%.
81

Regarding obstetric characteristics, nearly half <strong>of</strong> women (40%) in case group
and 28.7% in control group were primigravida.
Predisposing factors to PROM as revealed by this study were: anemia (23.3%),
previous history <strong>of</strong> PROM (10.6%) in case group. Frequency <strong>of</strong> last coitus before
PROM was also examined as predisposing factor, indicating that only 28.0% in case
group and 23.4% in control group had coitus one day before hospital admission, no
coitus done before occurrence <strong>of</strong> PROM in 18.7% & 20.6% respectively in the case
and control groups. Also, no relationship between coitus and PROM was found.
Infection association with PROM was indicated by maternal temperature,
abdominal tenderness and mothers C-reactive protein.
According to maternal temperature, it was found that temperature ranged from
36.6-38ºC in the case group and 36.8-38.5ºC. in the control group. Pulse rate ranged
from 60-100 b/min in the case group and 70-110 b/min in control group.
Concerning C-reactive protein, it was positive, and there was a statistically
significant association between PROM and mother's c-reactive protein.
As regards the effect <strong>of</strong> PROM on maternal outcome findings demonstrated that
it was through duration and progress <strong>of</strong> labor in each stage. Duration <strong>of</strong> first stage
managed between 5-22 hours; while 2 nd stage ranged between 20-50 minutes and 3 rd
stage ranged from 10-20 minutes.
Concerning, the mode <strong>of</strong> delivery, 61.3% <strong>of</strong> mothers had normal vaginal
delivery with or without episiotomy and 38% delivered by cesarean section and
(0.7%) delivered by forceps. The main complications, were fetal distress (20.7%),
Meconium stained (6.0%), maternal distress and inertia (3.3%).
82

Regarding fetal and neonatal outcomes near to revealed that mean Apgar score
ranged between 5-7 during 1 st minuet and 8-10 during 5 th minute
Concerning Ballard scale, the mean neurological score was 19.3% in the case group
and 14.1% in the control group, in the same way, mean total Ballard score was 39.9%
in the case group and 32.3% in the control group.
83

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يبرعلا صخلملا
ىثيدح لفطلاو ملأا هجاوت يتلا لكاشملا رثكأ نم ركبملا هايملا بيج راجفنا ربتعي
. هافولا ىلا انايحأ مھضرعت دقو تافعاضملا نم
لماوعلا ديدحتو . ركبملا هايملا بيج راجفنا
ريثكلا مھل ببستو
هدلاولا
ثحبلا نم فدھلا
ةبسن ةفرعم هلواحمل هساردلا هذھ تيرجأ
ملأا ىلع هريثأت ىدمو هل ةبحاصملا لكاشملا ديدحتو ،ركبملا
هايملا بيج راجفنإب ةبوحصملا
150 اھددعو ىلولأا ةعومجملا ،نيتعومجم
. هدلاولا يثيدح لفطلاو
ىلإ مھميسقت متو ةديس 300 ىلع تلمتشأ
نھل ثدحي ملو
150 اھددعو ةيناثلا ةعومجملاو ،هايملا
بيجل ركبم ضاضفنأ
ثحبلا ةنيع
نھل ثدح دقو
. قيزاقزلا ىفشتسمب ديلوتلاو ءاسنلا مسق نم ايضرغ نھرايتخإ
متو هايملا بيجل ركبم ضاضفنأ
تانايبلا عمج تنمضتو هدلاولا ءانثأ ملأا هظحلامو نايبتسإ تارامتسإ تمدختسأ
ملأا
ىلع هريثأتو
ثحبلا تاودأ
ركبملا هايملا بيج ضاضفنا تارشؤمو ةيلئاعلاو ةيصخشلاو ةيفارجوميدلا
. هدلاولا يثيدحو
-:
ىتلأا نع ثحبلا جئاتن ترفسأو
ركبملا هايملا بيج ضاضفنأ نم نيناعي
ىتلاا تاديسلا نم ًانس رغصلأا تناك
و % 6.7 نك ةيناثلا ةعومجملل ةبسنلاب امأ،
% 16.7 نلثمي ًانس ربكلأا
امنيب % 8.7
. يلاوتلا
هايملا بيج ضاضفنأ نم نيناعي ىتلاا تلاماع ريغلا تاديسلا
ةبسن تناك
.% 87.3
،ىعماجلاو
ىوناثلا ميلعتلاو
ةيناثلا ةعومجملاو % 76.7
لثمت تناك دقف ةيناثلا ةعومجملل ةبسنلاب امأ،
% 83.3
ىلع
: رمعلا
نلثمي
% 10.7
: ةفيظولا
لثمت ركبملا
ةيملأا نيب جردتي تاھملأا ميلعت ىوتسم ناك : ميلعتلا ةجرد
نلثمي ىلولأا ةعومجملا ىف تايملأا تاديسلا تناكو
،ىلولأا
ةعومجملا ىف % 28.7 نھتبسن ضفخنم لخد تاوذ تاديسلا تناكو
.
ةيناثلا ةعومجملا ىف
% 83.3
% 24و
-
-
-

ةعومجملا نم % 28.7 و ىلولأا ةعومجملا تاديس نم % 40
اھنأ
ةساردلا تحضوأ دقف
تحضوأو
% 10.6
،هايملا
بيجل
ناك : ةيلئاعلا ةلاحلا
. ةدحاو ةرمل
نلمح ةيناثلا
ركبملا ضاضفنلأل ةدھمملا لماوعلل ةبسنلاب
ةقباسلا لمحلا تارم يف هايملا بيج ضاضفناو
% 23.3
: يتلأاك
ايمينلأا
دحاو مويب ىفشتسملا لوخد لبق ىسنجلا طاشنلا نسرام ىتلآا
تاھملأا نأ اضيأ ةساردلا
تاھملأل ةبسنلاب
،ةيناثلا
ةعومجملا نم
ةعومجملا نم
% 23.4 و ىلولأا
ةعومجملا نم
% 28
نلثمي
% 18.7 نلثمي ،هايملا
بيج ضاضفنأ لبق عامجلا نسرامي مل ىتلآا
نيب ةقلاع دوجو مدع ةساردلا تحضوأ دقلو . ةيناثلا
. ركبملا هايملا بيج ضاضفنا
نع تناكف هايملا بيجل ركبملا ضاضفنلأل
ةبحاصم
ةعومجملا نم
% 20.6
و ىلولأا
ثودح نيبو ىسنجلا طاشنلا
ىودع ثودح تارشؤمل ةبسنلاب امأ
تارابتخإ قيرط نعو نطبلا ملآا
ةظحلامو ،ملأل
ةيويحلا تاملاعلا هظحلام قيرط
. نيتوربلل ج لماع لثم
ملأا مدب ةصاخ
˚38.5
و ةيوئم ˚36.8
نيب تحوارت
تاھملأا ةرارح ةجرد نأ جئاتنلا تحضوأ
دقلو
ضبن نأ دجو امك ةيوئم ˚ 38 ىلا ةيوئم ˚ 36.6 ةيناثلا ةعومجملا ىفو ،ةيوئم
نم ةيناثلا ةعومجملاو ةقيقدلا/
ةضبن
100 ىلا 60 نم حوارتي ناك ىلولأا ةعومجملا
. ةقيقدلا/
ةضبن 110 ىلا70
لماعلا اذھ دوجو نيب ةيوقلا ةقلاعلا ةساردلا تحضوأ دقف ،نيتوربلا
ج لماعل ةبسنلاب امأ
. هايملا بيجل ركبملا ضاضفنلأا دوجوو
روطتو ةدم قيرط نع ميق دقف ،ملأا
ىلع ركبملا هايملا بيج ضاضفنأ ريثأتل ةبسنلاب امأ
ةلحرملا امنيب ،ةعاس
22 ىلا 5 نيب ام حوارتت ىلولأا ةلحرملا نأ دجو دقف ،ةلحرم
لك
20 ىلا 10 نيبام حوارتت تناك ةثلاثلا ةلحرملل ةبسنلاب امأ ةقيقد 50 ىلا20
اعضو نعضو تاھملأا نم
نعضو
نم ةيناثلا
. ةقيقد
% 61.3 نأ ةساردلا ترفسأ دقف ،هدلاولا
عونل ةبسنلاب
امأ
% 0.7 امنيب ، % 38 ةبسنب ةيرصيق نعضوو ،لا
مأ ناجعلا
قشب ءاوس
ايعيبط
. تفجلا قيرط نع
ىودع ثودح يھ هدلاولل ىلولأا ةلحرملا ءانثأ ملأل تثدح ىتلا تافعاضملا مھأ ناكو
داھجإ ىھ تافعاضملا مھأ تناكف ةيناثلا ةلحرملل ةبسنلاب
امأ
% 7.5
ةبسنب ةيرتكب
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-
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رسعتو ملأا
داھجإو ،%
6 قيقعلاب ىسوينملأا لئاسلا جازتمأو ،%
20.7 ةبسنب ةنجلأا
.% 3.3
ةنسنب هدلاولا
دقف ،هدلاولا
ىثيدح لفطلاو نينجلا ىلع ركبملا هايملا بيج ضاضفنأ ريثأتل ةبسنلاب امأ
ةقيقدلا ىف ناك امنيب
، 7-5
نيب ام حوارتي ىلةلأا
ةقيقدلا ىف
،ىلولأا
ةعومجلا نم
تافعاضمو
راطخأ ىلأ
راجبأ لدعم نأ دجو
. 10-8
ةسماخلا
% 39.9 نيبام ةطسوتم دجو دقف ،درلااب
سايقمل ةبسنلاب امأ
-:
. ةيناثلا ةعومجلا نم (% 32.3)
ثحبلا اذھ تايصوت مھأ نإف جئاتنلا هذھ ءوض ىلعو
لمحلا ةعباتم ءانثأ تاديسلا ةيعوتب متھت نأ ةضرمملا ىلع بجي
. هايملا بيجل ركبملا ضاضفنلأا
بيبطلا ةراشتسأ ركبملا هايملا بيج ضاضفنأ نم ىناعت ىتلا لماحلا ةديسلا ىلع بجي
ةجرد عافترأو ،نطبلا
ملآا
ةظحلام قيرط نع
دعت تاملاعلا هذھ لك)
. هثودح روف
ىودعلا ثودح تارشؤم سايق بجي
ةھيرك ةحئار تاذ تازارفأ دوجوو نينجلا ضبن ةدايزو ةرارحلا
.( ىودع دوجو
ىلا رشؤم
نع ركبملا هايملا بيج ضاضفنأ نم نينعي ىتلاا تاھملأل ىودعلا ىلع ةرطيسلا بجي
. ةليوط ةرتفل ثدح راجفنلأا اذھ نوكي امدنع ةصاخ ةيويحلا تاداضملا مادختسأ قيرط
،ركبملا
هايملا بيج راجفنلأ ةبحاصملا
تلااحلل ىلمعملاو ىكينيلكلإا مييقتلا ةعباتم بجي
.
ركبملا هايملا بيج راجفنأ دعب ةصاخ هدلاولا ىثيدح لافطلأا
. هدلاولل بسانملا تقولا رايتخإو
ةعباتم ىلع ديكأتلا بجي
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