PRETERM LABOR

BY:NAWAL GALET AL-MATERY

OUTLINE DIFNATION PRETERM LABOR Other women who have many risk factors deliver at

term SIGNS AND SYMPTOMS MATERNAL RISK FACTORS FOR PRETERM LABOR PREVENTING PRETERM LABOR THERAPEUTIC MANAGEMENT Predicting preterm birth NURSING PROCESS Identifying preterm labor Frequent prenatal visits Stopping preterm labor

:DIFNATION PRETERM LABOR

Preterm labor Labor occurring between 20 and 38 weeks of pregnancy. Also called premature labor.

begins after 20th week but before the end of the 37th week of pregnancy.

The physical risk to the mother are no greter than labor at term unless complication such as infection, hemorrhage, or the need for a cesarean delivery, also exist.

Preterm labor, however, may result in the birth of an infant who is ill equipped for extra uterine life, particularly if earlier than 32 weeks gestation

Other women who have many risk factors deliver at term.

Some of the possible causes of preterm labor are the following: Maternal medical conditions, including infection of the

urinary tract, reproductive organs, or systemic organs; dental disorders (periodontal disease); preexisting or gestational diabetes; connective tissue disorders; chronic hypertension; and drug abuse

Conception enhanced by assisted reproductive technology, including conceptions resulting in a single fetal gestation rather than a multifetal gestation

Present and past obstetric condition, such as short cervical length(≤25mm), multifetal gestation, preterm membrane rupture, preeclampsia, and bleeding disorders that involve the woman, fetus, or placental implantation area

Cont… Fetal conditions such as growth retardation,

inadequate amniotic fluid volume, and chromosome abnormalities and other birth defects

Social and environmental factors such as inadequate or absent prenatal or dental care, maternal domestic violence episodes, maternal smoking, and housing deficiency such as homeliness

Demographic factors such as race and age of the parents, financial stability, and the number and birth intervals of the woman's other children

Signs and symptoms Uterine contractions that may not be painful(the woman may

not feel contractions at all) A sensation that the baby is frequently “balling up” Cramps similar to menstrual cramps Constant low backache; irregular or intermittent low back pain Sensation of pelvic pressure or feeling that the baby is

pushing down Pain, discomfort, or pressure in the vagina or thighs Change or increase in vaginal discharge ()increased, watery,

“spotting, ”bleeding) Abdominal cramps with or without diarrhea A sense of “just feeding bad” or “coming down with

something”

PREVENTING PRETERM LABOR

Community EducationIdeally, nursing strategies to prevent preterm birth begin before conception, with community education. Topics may include the following:

Role of early and regular prenatal care, including dental care, in preventing prenatal care, in preventing preterm birth

Duration of normal pregnancy Consequences of preterm birth Conditions that increase risk for preterm birth Signs and symptoms of preterm labor Consequences of preterm birth for mother, baby, and

family members

Cnot.. During pregnancy During pregnancy, measures to prevent preterm birth include the following:

Reducing barriers and improving access to early prenatal care for all women

Assessing for risk factor to permit changes, if possible Promoting adequate nutrition Promoting smoking cessation Teaching women and their partners about the subtle signs

and symptoms of Promoting labor and ways in which they differ from normal pregnancy changes

Empowering women and their partners to take an active approach in seeking care if they have signs and symptoms of preterm labor

Cont… Improve access to care: must be customized for the

community. Nurses can help coordinate various aspects of care to limit the number of different appointments a women needs to obtain complete care.

Identify risk factors: may allow reduction or elimination of these factors.

Progesterone supplementation: Progesterone (delalutine ) was used in the past to prevent spontaneous abortion.

Promote adequate nutrition : the special supplemental nutrition program for women, infants, and children (WIC) is available to supplement the diet of some low-income women. Anemia can be corrected with appropriate supplements.

Educate women and their partners about preterm

All pregnant women and their partners should be taught about symptoms of preterm labor , because half of preterm births occur in woman with no identified risk factors.

The vague signs and symptoms of early preterm labor should be reinforced regularly as part of prenatal care.

Cont… Examples of home care guidelines include:

Drink an adequate amount of water to improve hydration or reduce bladder irritation that may accompany a urinary tract infection.

Empty the bladder frequently, because a full bladder may be associated with uterine irritability and contraction.

Position yourself in a side-lying position to promote uterine blood flow. limiting physical activity may increase diuresis. Prolonged limitation of physical activity is not usually beneficial or safe for prevention of premature labor, although it may be required for serious maternal disorders, such as cardiac disease.

Palpate contractions for 1 hour or as instructed because of the duration of any prior labor.

Empower women and their partners:

Delaying birth depend critically on early identification of preterm labor.

Women should be encouraged to seek treatment promptly if they suspect preterm labor

Otherwise she may not seek care for recurrent episodes when she truly is in labor, and the opportunity to delay preterm birth may be lost.

THERAPEUTIC MANAGEMENT

Management focuses on identifying those at risk for preterm birth, identifying preterm labor early, delaying birth, and accelerating fetal lung maturity if preterm birth is likely. Onset of changes that lead to preterm labor and birth may be subtle. The woman may not perceive any changes in her pregnancy.

Predicting preterm birth Because treatment for preterm labor has been less

than satisfactory at preventing preterm birth, research has focused on predicting which women will deliver early.

The results of a major preterm prediction study looked at multiple factors and found that their relevance to preterm birth interrelated. In this study, factors most strongly associated with predicting preterm birth included: A short cervical length of ≤25 mm (≤1 inch) A previous preterm birth A Positive fetal fibronectin (fFN) result after 22 weeks

Identifying preterm labor

The reason to predict risk for preterm birth or to identify preterm labor early is to delay birth, thereby promoting further fetal maturation.

Frequent prenatal visits Women at risk for preterm labor should have more frequent

prenatal visits, at which time they are checked for evidence of preterm labor and their ability to follow preventive therapy, in addition to their regular prenatal checkup.

The should be assessed for development of new risk factors with each visit.

Gentle cervical examination, usually with sterile speculum, are done if indicated by other signs or symptoms.

A transvaginal ultrasound examination may identify the shortened, thinned cervix that often precedes onset of labor in the asymptomatic woman. Infection can be identified and treated promptly before rupture of membranes or onset of labor occurs

Stopping preterm labor Once the diagnosis of preterm labor is made,

management focuses on stopping uterine activity before the point of no return, usually after about 3-cm dilation preterm delivery may be inevitable, but steroid therapy promotes earlier fetal lung maturation.

Particularly for very gestations, such as 25 weeks, treatment may add enough time for the steroids to be effective.

Even 1 more day of fetal maturation may make a great difference in the outcome for the very premature infant.

Cont…1. Initial measures 2. Identifying and treating

infections3. Identifying other causes

for preterm contractions 4. Limiting activity 5. Hydrating the woman

Initial measures definition: The physician initially determines

whether any maternal of fetal conditions contraindicate continuing the pregnancy.

examples of these conditions include: Preeclampsia or eclampsia; persistent hypertension

from any cause; cardiac disease Significant or prolonged maternal alteration, such as

hypovolemia, hypoxemia, or acid-base imbalance Serious infection, including chorioamnionitis or

maternal infection FHR monitoring data showing inability to correct signs

that are nonreassuring for the gestation of the fetus

Identifying and treating infections

Infections, both systemic and local, has a strong association with preterm birth and premature rupture of the membranes.

Identifying other causes for preterm contractions

The woman with polyhydramnios, identified by ultrasonography, may have more contraction because her uterus is stretched more than normal

Limiting activity

Activity limits, usually by relaxing in a side-lying or semi sitting position, increase placental blood flow and reduce fetal pressure on the cervix.

Adverse effects of substantial activity restriction during pregnancy may include: Muscle weakness, including aching; muscle atrophy; and bone loss Poor nutrition as a result of appetite loss, lower food intake, and

increased indigestion; weight loss or inadequate weight gain Orthostatic hypotension caused by the change in blood pressure

regulation by baroreceptors Psychological effects, such as increased stress about separation from

her family, anxiety about the pregnancy's outcome, depression, boredom from a decreased activity level and less contact with other people, and concerns about finances if her job is essential to her family

Sleep changes as depression increases or usual activities that direct her sleep-wake cycles are not present

Cont… Although preterm birth may occur,the severity of infant

effects may be less if even a few days are gained in the duration of pregnancy. Physical therapy to help maintain muscle strength and

coordination, and to reduce muscle aching, fatigue, and bone loss

Recreation therapy to identify appropriate activities to relieve boredom

Occupational therapy to help the woman cope physical with lifestyle changes, particularly if discharge home is anticipated

Complementary therapy to reduce stressors and enhance physical care measures

social work to identify how need such as financial and child care can be met

Consultation with a psychologist to help the woman and family cope with the added stressors.

Hydrating the woman

Definition: Hydration to stop preterm contractions has not been shown to be beneficial for all women

tocolytics The advantage of tocolytic drug therapy to reduce

preterm birth is not clear. Tocolysis is most likely ordered if preterm labor occurs before the 34th week of gestation because the infants risk for respiratory and other complication of prematurity is high if the infant is born during this time.

Because tocolytic druds have significant side effects, the decision about whether to treat for preterm labor is individualized, based on risk factors, cervical dilation, and other signs and symptoms.

If the cervix is between 2 and 3 cm dilated, the physician may recheck the cervix for further dilation or effacement after 1 or 2 hours.

صورة الجدول

Four types of drugs are used for Tocolysis 1. Magnesium sulfate: is used in management of pregnancy-

associated hypertension.Common hospital criteria for continuation of magnesium sulfate therapy include the following:

Urine output of at least 30 mL per hour Presence of deep tendon reflexes At least 12 respiration per minute

2. Calcium antagonists: Nifedipine (Adalat,Procardia) is a calcium channel plocker usualy given for problems such as hypertension.

3. Prostaglandin synthesis inhibitors: Because prostaglandins Prostaglandin synthesis uterine contractions, drugs can be used to inhibit their synthesis. Indomethacin (indocin) is the drug in this class that is most often used for tocolysis.

4. Beta-adrenergic drugs

Accelerating fetal lung maturity

The physician may order corticosteroids to speed fetal lung maturation if birth before 34 weeks seems inevitable.

Current recommendation for corticosteroids for threatened preterm birth are: Betamethasone 12 mg: two doses

intramuscular (IM),24 hours apart Dexamethasone 6 mg: four doses IM, 12

hours apart

Nursing diagnoses: Nursing diagnoses that may apply to the woman with

PTLinclude the following:• Readiness for Enhanced Knowledge related to an expressed desire to understand the causes, identification, and treatmentof PTL and its implications• Fear related to early labor and birth• Ineffective Coping related to need for constant attention topregnancy• Anxiety related to the possibility of a preterm birth (PTB)

Cont.. Impaired Home Maintenance Related To

Activity Restriction And Family Demands Anticipator Grieving Related To Loss Of

Expected Term Birth Experience Anxiety Related To Unexpected

Development Of Complications.

Cont..

Other nursing diagnoses that may be used for the woman withPPROM include the following: • Risk for Infection related to premature preterm rupture

ofmembranes • Risk for Impaired Gas Exchange (Fetus) related to

compressionn of the umbilical cord secondary to prolapse of the

cord • Ineffective Coping related to unknown outcome of thepregnancy

Therapeutic management Therapeutic management begins by

determining her gestation as accurately as possible.

Several markers used to pinpoint gestation, such as ultrasound examination, fundal height measurements, dates of quickening, and first identification of fetal heart tones with a no amplified fetoscope or Doppler, may be lost if a woman begins prenatal care very late.

Also, the woman may have forgotten the date of her last me nstural period or may have irregular cycles.

Nursing considerations: Nursing care for to the woman with a

prolonged pregnancy is tied to the medical management. The nurses role may include the following: Teach the woman about procedures such as

antepartum testing or induction of labor. Support the woman's psychological and

physical fatigue. Provide nursing care related to specific

procedures such as induction of labor.

Self-Care Measures to Prevent Preterm Labor

• Rest 2 or 3 times a day, lying on your left side.• Drink 2 to 3 quarts of water or fruit juice each day. Avoid caffeine drinks. Filling a quart container and drinking from it will eliminate the need to keep track ofnumerous glasses of fluid.• Empty your bladder at least every 2 hours during waking hours.• Avoid lifting heavy objects. If small children are in the home, work out alternatives for picking them up, such as sitting on a chair and having them climb on your lap.• Pace necessary activities to avoid overexertion.• Sexual activity may need to be curtailed or eliminated.• Find pleasurable ways to help compensate for limitations of activities and boost the spirits.• Try to focus on 1 day or 1 week at a time rather than on longer periods of time.• If on bed rest, get dressed each day and rest on a couch rather than becoming isolated in the bedroom.Source: Prepared in consultation with Susan Bennett, RN, ACCE, Coordinator of the Prematurity Prevention Program.

Reference : FOUNDATION OF MWTERNAL-NEWBORN AND WOMENS

HEALTH NURSING 5th edition 2010Publishing services manager Jeff Patterson Author: Murrag, Sharon Smith Chapter27 Page 706-721 METERNAL-CHILD NURSING FORTH EDITION 2013Publishing services manager Jeff PattersonAuthor: Emily Slone McKinney,MSN,RN,CSusan Rowen James,PhD,RNSharon Smith Murray,MSN,RNKristine Ann Nelson,RNJean Weiler Ashwill,MSN,RN 03/06/1436

Reference : OLDS METERNAL-NEWBORN NURSIND &

womens health across the lifespamNinth edition 2012Author: Michele R. Davidson, PhD, CNM, CFN, RNMarcia L. London, RN, MSN, APRN, CNS, NNP-BCPatricia A. Wieland Ladewig, PhD, RN