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Premature Labor Signs, Causes and Management
- 3. INTRODUCTION ➢Premature labour is generally a labour that occurs after 20 wks & before 37 completed wks of gestation
- 4. DEFINITION Preterm labour (PTL) is defined as one where the labour starts before the 37th completed week (<259 days), counting from the 1stday of the last menstrual period
- 5. DEFINITION ●Pre term labour is defined by WHO as onset of labour prior to the completion of 37 weeks of gestation in a pregnancy beyond 20 weeks of gestation.
- 6. INCIDENCE Approx. 10% of deliveries in public hospital occur before the 37t h week A much smaller %age is involved in the 24-32 weeks period. The prevalence widely varies and ranges between 5-10%
- 7. ETIOLOGY In about 50%, the cause of preterm labour is not known But some of the high risk factors are: HISTORY COMPLICATIONS In Present Pregnancies IATROGENIC IDIOPATHIC
- 8. Conti.. HISTORY- -previous history of abortion or preterm delivery -recurrent UTI -smoking habits -low socio-economic & nutritional status
- 9. Malpresentations Previous abortion history
- 10. Conti.. COMPLICATIONS IN PRESENT PREGNANCY- It may be due to 3 causes:-MATERNAL -FETAL -PLACENTAL A) MATERNAL : Pregnancy Uterine anomalies Genital tract infection Medical & surgical illness
- 12. Incompetent cervix malformation of uterus
- 14. Conti.. FETAL : - Multiple pregnancy - Congenital malformations - IUD PLACENTAL :- Infarction -Thrombosis - Placenta praevia or abruption
- 16. Conti.. IATROGENIC: -Elective induction with wrong estimation of gestational period. - IDIOPATHIC: -Premature effacement of cervix with hyper-irritable uterus -Early engagement of head
- 17. ETIOPATHOGENESIS ACTIVATION OF FETAL HPA AXIS CRH, Cortisol PGE2, F2α TXA2, Leukotrienes ↓PG Dehydrogenase proteases choriodecidual bacterial Colonisation TNF, IL-1,6,8 myometrial PATHOLOGIC UTERINE ENLARGEMENT contraction (Polyhydramnios , multiple pregnancy) cervical Mechanical stretch, IL8 ripening Gap junction, PG Synthesis preterm labour and delievery Chorion, amnion & decidua
- 18. Risk factors ❖Low BMI ❖Short maternal height ❖History of spontaneous pre term birth ❖Bacterial vaginitis. ❖Asymptomatic bacteriuria ❖Low socio economic status ❖Short cervical length
- 19. Factors influencing during pregnancy ❑Multiple pregnancy ❑Use of fertility medication ❑High blood pressure ❑Pre –eclampsia ❑Maternal diabetes mellitus ❑Asthma ❑Thyroid disease
- 20. Cont.. ❑Heart diseases ❑Uterine malformations ❑Placenta praevia ❑Abruptio placenta ❑Poly hyrdaminos ❑Oligohydramnios ❑Anxiety & depression ❑Use of tobacco, cocaine
- 21. ❑Excessive alcohol during pregnancy ❑ babies with birth defects
- 22. SIGN AND SYMPTOMS ❖Backache ❖Contractions every 10 minutes are more often ❖Cramping in lower abdomen ❖Menstrual like cramps( feel like gas pain , not a/w diarrhea) ❖Fluid leaking from vagina ❖Flu like symptoms- nausea, vomiting, diarrhea
- 23. Cont.. ●Increased pressure in pelvis ●Increased vaginal bleeding ●Regular uterine activity ●Vaginal spotting ●Pelvic pressure
- 24. DIAGNOSIS ❖ Regular uterine contractions with or without pain (at least one in every 10 mins.) ❖ Dilatation(≥2cm) & Effacement (80%) of the cervix Length of cervix ≤2.5cm Funnelling of internal OS ❖ ❖ ❖ Pelvic pressure, backache or vaginal discharge or bleding.
- 25. INVESTIGATIONS ●Full blood count ●Routine urine-analysis,culture & senstivity ●Cervicovaginal Swab- culture,FIBRONECTIN ●Serum electrolytes & glucose levels when tocolytic agents are to be used
- 26. ● USG-fetal well being, cervical length & placental localization
- 27. FIBRONECTIN ➢A PROTEIN that binds the FETAL MEMBRANES to DECIDUA ➢Normally found in CERVICOVAGINAL discharge before 22wks & again after 37wks of pregnancy PRESENCE OF FIBRONECTIN IN CVD B/W 24Wks & 34 Wks PREDICTS PRE-TERM LABOUR
- 29. MANAGEMENT ●It includes Arrest of preterm Labour, if not contraindicated Appropriate management Prevention,if possible Neonatal care
- 30. Prevention of Preterm Labour Primary Care – to reduce the incidence of preterm labour by reducing the high risk factors (e.g. infection etc.) Secondary Care includes screening tests for early detection & prophylactic treatment (e.g. tocolytics) Tertiary care- to reduce the perinatal morbidity & mortality after the diagnosis (e.g. use of corticosteroids)
- 31. Cont.. ●Seek regular prenatal care ●Eat a healthy diet ●Gain weight wisely ●Avoid risky substances ●Consider pregnancy spacing ●Be cautious when using assisted reproductive technology (ART)
- 32. ●Taking preventive medications , who has short cervix( Progesterone) ●Restricting sexual activity. ●Limiting certain physical activities. ●Managing chronic conditions such as DM, Increased BP.
- 33. ARRESTING PRETERM LABOU R ●BED REST-Left lateral position ●ADEQUATE HYDRATION ●PROPHYLACTIC ANTIBIOTIC ●TOCOLYTIC AGENTS-Eg.TERBUTALINE INDOMETHACIN NIFEDIPINEs short term long term
- 34. Conti.. ●SHORT TERM THERAPY Most successful therapy OBJECTIVES: -TO DELAY delivery for 48hrs for glucocorticoid therapy to mother to enhance enhance fetal lung maturation -IN UTERO TRANSFER of the patient to a unit more able to manage a preterm neonate
- 35. GLUCOCORTICOID THERAPY ●Advocated in pregnancy less than 34 wks. ●Helps in fetal lung maturation ●Reduces incidence of RDS & IVH RISKS ●PROM with evidence of infection ●IDDM where patients needs insulin dose readjustment
- 37. ❑Gestational diabetes ❑Placenta praviea. ❑In case of placental abnormalities.
- 38. APPROPRIATE MANAGEMENT There are basically 2 principles: To prevent birth asphyxia & development of RDS To prevent birth trauma
- 39. FIRST STAGE ❑Patient is put to bed to prevent PROM ❑To ensure adequate fetal oxygenation ❑Strong sedative avoided ❑Epidural analgesia is of choice ❑Labour should be watched by intensive clinical monitoring ❑In case of delay, caesarean section should be performed
- 40. SECOND STAGE ❖ The birth should be gentle & slow to avoid rapid compression & decompression of head ❖ Episiotomy may be done under local anesthesia to minimize head compression if there is perineal resistance ❖ Tendency to delay is curtailed by low forceps. Routine forceps is not indicated ❖ The cord is to be clamped immediately at birth to prevent HYPERVOLEMIA & HYPERBILIRUBINEMIA ❖ To shift the baby to intensive neonatal care unit under care of NEONATOLOGIST
- 41. IMMEDIATE MANAGEMENT ● 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
- 42. 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
- 43. Cont.. 2.Evaluate the factors for distress, size and maturity. (sonography & lecithin-sphingomyelin ratio) 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.
- 44. ●Administer tocoltyic agent as prescribed. Assess for side effects of tocolytic therapy ❖Decreased maternal Blood pressure ❖Dyspnea ❖Chest pain ❖FHS >180beats/min
- 45. Cont.. ●4- provide physical and emotional support ●5- Provide adequate hydration ●6- Provide client and family education.
- 46. PROGNOSIS ●Results in high -perinatal mortality -perinatal morbidity • With intensive neonatal care unit, survival rate of the baby weighing b/w 1000 to 1500 gm is more than 90% • WITH USE OF SURFACTANT, survival rate of infants born at 26wks is about 80%
- 47. EDUCATIO N ❑All PREGNANT women should recognize following S/S ‘s:- -uterine contractions every 10-15 minutes or less -menstrual-like cramping -dull backache -lower abdominal pressure -diarrhea -increase or change in vaginal discharge -vaginal bleeding