Jeff Patterson 03/06/1436 37

1. PRETERM LABOR
BY:
NAWAL GALET AL-MATERY

2. 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

3. :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

4. 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

5. 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

7. 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

8. PREVENTING PRETERM LABOR
 Community Education
Ideally, 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

9. 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

10. 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

11. 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.

12. 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.

13. 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.

14. 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

15. 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

16. 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.

17. 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

18. 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

19. Cont…
1. Initial measures
2. Identifying and treating
infections
3. Identifying other causes for
preterm contractions
4. Limiting activity
5. Hydrating the woman

20. 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

21. Identifying and treating infections
Infections, both systemic and
local, has a strong association
with preterm birth and
premature rupture of the
membranes.

22. 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

23. 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

24. 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

25. Hydrating the woman
 Definition:
Hydration to stop preterm
contractions has not been shown
to be beneficial for all women

26. 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.

27. ‫صورة‬ ‫الجدول‬

28. 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

29. 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

30. Nursing diagnoses:
 Nursing diagnoses that may apply to the woman with
PTL
include the following:
• Readiness for Enhanced Knowledge related to an
expressed desire to understand the causes,
identification, and treatment
of PTL and its implications
• Fear related to early labor and birth
• Ineffective Coping related to need for constant
attention to
pregnancy

31. 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.

32. Cont..
Other nursing diagnoses that may be used for the woman
with
PPROM include the following:
 • Risk for Infection related to premature preterm
rupture of
membranes
 • 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

33. 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.

34. 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.

35. 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 of
numerous 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.

36. Reference:
 FOUNDATION OF MWTERNAL-NEWBORN AND WOMENS
HEALTH NURSING
5th edition 2010
Publishing services manager Jeff Patterson Author: Murrag,
Sharon Smith Chapter27 Page 706-721
 METERNAL-CHILD NURSING
FORTH EDITION 2013
Publishing services manager Jeff Patterson
Author: Emily Slone McKinney,MSN,RN,C
Susan Rowen James,PhD,RN
Sharon Smith Murray,MSN,RN
Kristine Ann Nelson,RN
Jean Weiler Ashwill,MSN,RN 03/06/1436
36

37. Reference:
 OLDS METERNAL-NEWBORN NURSIND &
womens health across the lifespam
Ninth edition 2012
Author: Michele R. Davidson, PhD, CNM, CFN,
RN
Marcia L. London, RN, MSN, APRN, CNS,
NNP-BC
Patricia A. Wieland Ladewig, PhD, RN