Premature or preterm labor is defined as labor beginning before 37 weeks of pregnancy. It is a significant cause of perinatal morbidity and mortality. The causes of preterm labor are often unknown, but can include infections, medical complications in the mother or fetus, multiple pregnancies, or a history of preterm labor. Management involves delaying delivery through bed rest and tocolytic drugs to allow for corticosteroid administration to improve fetal lung maturity. The goal is to prolong pregnancy as long as possible while monitoring for signs of fetal distress. After delivery, immediate newborn care focuses on preventing respiratory issues and infection.

1. Presented by :
Ms. Suparna
PREMATURE LABOUR

2. Preterm Labor or Premature Labor
 Preterm labor (PTL) is defined as one where the labor starts
before the 37th completed week (< 259 days), counting from the
first day of the last menstrual period. In developing countries,
the lower limit is 28 weeks. Preterm birth is the significant cause
of perinatal morbidity and mortality
 INCIDENCE:The prevalence widely varies and ranges between
5–10% worldwide.The premature labor effect almost 23%
pregnancies in India.

3. ETIOLOGY
 50%, the cause of preterm labor is not known.
History
Complications in present pregnancy
Iatrogenic
Idiopathic

4. a) History:
Previous history of
induced or
spontaneous abortion
or preterm delivery;
Pregnancy following
assisted reproductive
techniques (ART);
Asymptomatic
bacteriuria or
recurrent urinary
tract infection
Smoking habits Maternal stress.
Low socioeconomic
and nutritional status;

5. b) Complications in present pregnancy
Maternal Fetal Placental

6. Maternal
• Preeclampsia,
antepartum
hemorrhage,
premature
rupture of the
membranes,
polyhydramnios
Pregnancy
complications
• Cervical
incompetence,
malformation
of uterus;
Uterine
anomalies
• Acute fever,
acute
pyelonephriti
s, diarrhea,
acute
appendicitis,
toxoplasmosis
Medical and
surgical
illness
• Bacterial
vaginosis, beta-
hemolytic
streptococcus,
bacteroides,
chlamydia,
mycoplasma.
Genital tract
infection

7. Fetal
 Multiple pregnancy,
 congenital malformations,
 intrauterine death.

8. Placental
 Infarction,
 thrombosis,
 placenta previa or
 abruption.

9. Cont…
 (C) Iatrogenic: Indicated preterm delivery due to medical
or obstetric complications.
 (D) Idiopathic: (Majority)—Premature effacement of the
cervix with irritable uterus and early engagement of the head
are often associated. In the absence of any complicating
factors, it is presumed that there is premature activation of
the same systems involved in initiating labor at term.
Etiopathogenesis of preterm labor.

11. SIGN AND SYMPTOMS
Backache Contractions
every 10
minutes
Cramping in
lower abdomen
Fluid leaking
from vagina
nausea, vomiting,
Diarrhea
Menstrual like
cramps
Increased vaginal
bleeding
Regular uterine
activity

12. DIAGNOSIS:
Regular uterine contractions with or without pain (at least one
in every 10 minute);
Dilatation (> 2 cm) and effacement (80%) of the cervix;
Length of the cervix (measured byTVS) < 2.5 cm and funneling
of the internal os
Pelvic pressure, backache and or vaginal discharge or bleeding.
It is better to overdiagnose preterm labor than to ignore the
possibility of its presence.

13. INVESTIGATIONS:
Full blood
count;
Serum
electrolyte
s and
glucose
levels
(during
tocolytic
used )
Ultrasono
graphy for
fetal well
being,
Urine for
routine
analysis,
culture
and
sensitivity
Cervicova
ginal swab
for culture
and
fibronecti
n;

14. Predictors Of Preterm Labor:
A. Clinical
predictors:
B. Biophysical
predictors:
C. Biochemical predictors:
(i) Multiple pregnancy;
(ii) History of preterm
birth;
(iii) Presence of genital
tract infection;
(iv) Symptoms of PTL.
(i) Uterine
contractions (UC) >
4/hr;
(ii) Bishop score > 4;
(iii) Cervical length
(TVS) < 25 mm.
(i) Fetal fibronectin (fFN) in cervico vaginal
discharge (see below)
(ii) Others IL-6, IL-8,TNF-a. Fibronectin is a
glycoprotein that binds the fetal membranes to the
decidua. Normally it is found in before 22 weeks
and again after 37 weeks of pregnancy.
Presence of fibronectin in the cervicovaginal
discharge between 24 and 34 weeks is a predictor
of preterm labor.

15. PREVENTION OF PTL
Primary care
(e.g. infection)
Secondary care
(e.g. tocolytics)
Tertiary care
(e.g. use of
corticosteroids).

16. Management Of Preterm Labor
To prevent preterm onset of labor, if possible;
To arrest preterm labor, if not contraindicated;
Appropriate management of labor;
Effective neonatal care.

17. Principles Of Management Of Women
With Preterm Labor
Glucocortic
oids to the
mother to
reduce
neonatal
RDS, IVH
and NEC.
Antenatal
transfer of
the mother
with fetus
in utero to a
center
equipped
with NICU
Tocolytic
drugs to the
mother for
a short
period
unless
contraindic
ated.
Antibiotics
to prevent
neonatal
infection
with Group
B
Streptococc
us (GBS)
(5) Careful
intrapartum
monitoring,
minimal
trauma and
presence of
a
neonatologi
st during
delivery
(6)Vaginal
delivery is
preferred,
unless
otherwise
indicated
for cesarean
birth

18. Measures To Arrest Preterm Labor
 — Bed rest
 —The patient is to lie preferably in left lateral position though the benefits
are doubtful.
 — Adequate hydration is maintained. Prophylactic antibiotic is not
routinely given. It is recommended when infection is evident or culture
report suggests.
 — Prophylactic cervical circlage for women with prior preterm birth and
short cervix in the present pregnancy may be beneficial.
 —Tocolytic agents:Various drugs including progesterone (micronized)
have been used to inhibit uterine contractions.The tocolytic agents can be
used as short term (1–3 days) or long-term therapy.

19. Cont…
 Short-term therapy: It is commonly employed with success.The objectives are:
 (1)To delay delivery for at least 48 hours for glucocorticoid therapy to the
mother to enhance fetal lung maturation;
 (2) In utero transfer of the patient to a unit with an advanced neonatal
intensive care unit (NICU).
Contraindications
A. Maternal: Uncontrolled diabetes, thyrotoxicosis, severe hypertension, cardiac
disease, hemorrhage in pregnancy, e.g. placenta previa or abruption.
B. Fetal: Fetal distress, fetal death, congenital malformation, pregnancy beyond 34
weeks.
C. Others: Rupture of membranes, chorioamnionitis, cervical dilatation more than 4
cm.

20. Glucocorticoid therapy:
 Maternal administration of glucocorticoids is advocated where the
pregnancy is less than 34 weeks.This helps in fetal lung maturation
so that the incidence of RDS, IVH and NEC are minimized.This is
beneficial when the delivery is delayed beyond 48 hours of the first
dose. Benefit persists as long as 18 days. Either betamethasone
(Betnesol) 12 mg IM 24 hours apart for two doses or
dexamethasone 6 mg IM every 12 hours for 4 doses is given.
Betamethasone is the steroid of choice.

21. Risks of antenatal corticosteroid use:
(a) Premature
rupture of the
membranes
specially with
evidence of
infection as the
infection may
flare-up;
(b) Insulin
dependent
diabetes mellitus
where patients
need insulin
dose
readjustment;
(c)Transient
reduction of
fetal breathing
and body
movements.

22. Management Of Preterm Labor
The principles in management of preterm labor are:
 (1)To prevent birth asphyxia and development of RDS;
 (2)To prevent birth trauma.
 Duration of labor is usually short.

23. First stage Second stage
 The patient is put to bed to prevent
early rupture of the membranes
 To ensure adequate fetal oxygenation
by giving oxygen to the mother by
mask
 Epidural analgesia is of choice
 Labor should be carefully monitored
prefer-ably with continuous EFM
 Cesarean delivery is done for obstetric
reasons only
 NICU is a sin-quanon for good
outcome
 The birth should be gentle and slow to avoid rapid
compression and decompression of the head
 Episiotomy may be done to minimize head
compression if there is perineal resistance
 Tendency to delay is curtailed by low forceps.As
such, routine forceps is not indicated
 The cord is to be clamped immediately at birth to
prevent hypervolemia and hyperbilirubinemia
 To shift the baby to neonatal intensive care unit
under the care of a neonatologist.

24. Immediate management
of the preterm baby following birth—
 The cord is to be clamped quickly
 The cord length is kept long in case exchange transfusion is required
 The air passage should be cleared of mucus
 Adequate oxygenation
 Aqueous solution of vit.k 1mg given I/M to prevent hemorrhagic
manifestations
 The baby should be wrapped including head in a sterile warm towel

25. PROGNOSIS:
 Preterm labor and delivery of a low birth weight baby
results in high perinatal mortality and morbidity.
However, with neonatal intensive care unit, the survival
rate of the baby weighing between 1000–1500 g is more
than 90%.With the use of surfactant , survival rate of
infants born at 26 weeks is about 80 percent.

26. NURSING MANAGEMENT
 1.Assess the mother’s condition to evaluate signs of labour.
 Obtain a through obstetrics history
 Determine the frequency , duration,& intensity of uterine
contraction.
 Determine the cervical dilatation and effacement.
 Assess the status of membranes, and bloody show
 2. Evaluate the factors for distress, size and maturity.
(sonography & lecithin-sphingomyelin ratio)

27.  3. Perform measures to manage or stop pre term labour.
 Place the client on bed rest in the side lying position.
 Prepare for possible ultrasongraphy, amniocentesis, tocolytic drug
therapy or steroid therapy.
 Administer tocoltyic agent as prescribed.
 Assess for side effects of tocolytic therapy
 Decreased maternal Blood pressure
 Dyspnea
 Chest pain
 FHS >180beats/min

28. Cont…
 4- Provide physical and emotional support
 5- Provide adequate hydration
 6- Provide client and family education