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Preterm

Labor/Birth
T Stone-Godena, CNM,
MSN
N344 Fall, 2015
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Preterm Labor(PTL)/Birth (PTB)


Definition PTL:
Regular rhythmic uterine contractions
Occurring between 20 36+6 weeks
gestation resulting in cervical change of > 2
cm dilation, and/or > 80% effacement
Definition PPROM. Preterm (< 37 weeks
Premature Rupture of membranes (prior to
the onset of contractions

Definition Preterm Birth PTB


Birth prior to completion of 37
gestational weeks
Very Early PTB
Early PTB
Late PTB= occurring between 3436.6 gestational weeks^. Accounts
for 75% of PTB
^ Text says 36 weeks but since term is 37 weeks, preterm is
through 36.6 weeks.
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Why is PTB important


1 in 8 births ( 12%) and rising d/t
AMA and multiple births (50% twins,
90% triplets)
Leading cause of neonatal mortality
( 35%).
Economic burden of >$26 billion in
2005*

*Societal Costs of Preterm Birth. 2007 National Academy of Science. http://www.ncbi.nlm.nih.gov/books/NBK11358/

Preterm versus low birthweight

Overlapping but not identical sets


Low birthweight can be at any gestation
Low BWT
Very low BWT
Extremely low BWT

< 2500 grams


< 1500 grams
< 1000 grams

PTB= greater health problems

How are we doing in


prevention of PTB?
No improvement with most interventions!
Group prenatal care has shown some
improvement in preterm birth rate especially
among black women.*
Gradual decrease in iatrogenic PTB by waiting
to 39 weeks for elective inductions.

Morbidity & Mortality:


Most serious morbidity occurs among 16% of
preemies born before 32 weeks gestation.
70% of infant deaths occur in infants <2500 g.

Picklesimer A et al. (2012). The effect of Centering Pregnancy group prenatal care on preterm birth in a lowincome population. AJOG. E415 http://www.centeringhealthcare.org/forms/bibliography/Picklesimer_2012.pdf

Who is at risk?
Women with the greatest associated
risk factor are those with a Previous
Preterm Birth
Women of African American descent
are at significant risk
Women with second trimester
bleeding
Women with a family history of
preterm birth.
These are nonmodifiable risks

Modifiable risks for spontaneous PTB


Infection (BV, trichomonas, GBS, UTI,
Chorioamnionitis, periodontal dz)
Smoking
Domestic violence
Lack of prenatal care
Closely-spaced pregnancies
Extremes of reproductive age
Low socioeconomic status
Poor nutrition/ low pre-pregnancy weight*
High stress, strenuous work

Identified by Iams and Romero as one of the top 4 risk factors

Conditions partially modifiable


Multiples. Selective reduction is an option
though most women decline
Uterine abnormality: insufficient cervix,
bicornuate or fibroid uterus. Fibroids can be
removed, insufficient cervix can be treated
with cerclage. A uterine septum can be
removed.
Diabetes and Chronic Hypertension can be
controlled
Polyhydramnios can be reduced
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Indicated prematurity
20% of PTB is clinically indicated
Conditions associated with intentional
early labor/birth:
Preeclampsia
IUGR
PPROM
Placenta previa or abruptio
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Predicting PTB
If we know who gets it, why cant we stop it?
50% of PTB occurs to women with no known
risk. Risk scoring systems havent worked
There is no ONE identifiable pathophysiology.
What has helped?
Sonographic Cervical Length Measurement.
Strong inverse relationship between cervical
length < 1.5 cm at 18-24 weeks and PTB.
Biochemical tests. fFN. Negative is strongly
correlated with decreased
risk for PTB within 1 week.
If positive only predictive about 1/3.
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Signs/symptoms
Persistent low back ache
Pelvic pressure, cramping
+ Urinary frequency, diarrhea, vaginal
discharge
Contractions (may be painless) >6x/hour x
>1 hour
Cervical change in dilation or effacement
+ PROM
Can be hard to distinguish preterm labor
from preterm contractions without cervical
change!

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Current treatments
With a history of preterm birth,
Progesterone has been shown in some
studies to prolong pregnancy. 17p-alphahydroxyprogesterone-caproate as a
injection or micronized crystals orally or
vaginally beginning between 16-20 weeks
through end of 36th week. life of
progesterone is 7 days, so it is
administered weekly.

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Strategies to increase survival of


premature infants
Corticosteroids for lung maturation
Neonatal resuscitation
Newborn Intensive Care Units

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PPROM
Management: expectant vs. active, depends
on gestational age and comorbidities
Risk of infection (chorioamnionitis,
endometritis & neonatal sepsis):
Increased with >18 or 24 hours from PROM to
delivery (depending on study)
Increased with more vaginal exams

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Clinical application
Marge L. is a 38 year old African American G3
P1102 who is pregnant with twins.
At 30 weeks gestation, she begins
to experience low backache and
lower abdominal cramping,
plus diarrhea.
What are her risk factors for
preterm labor?
What other signs and symptoms
should you ask her about?
H/O PTB, African-American, twins,
AMA
SROM, increased vaginal discharge, spotting,
urinary frequency.

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Nursing responsibility

History including risk factors


Physical assessment including VS
Fetal assessment
Assist with collection fFN prior to cervical exam
and cervical/vaginal cultures + cervical exam
Collect urine for
culture and UA
Assist with TVUS
Hydration

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Clinical application cont.


Marge L. arrives at triage.
What is your assessment in order?
Notify provider
Obtain urine
Apply EFM
Maternal Vital signs
Send fFN for stat analysis
Assist US and or cervical exam
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Results
Urinalysis negative, spec. gravity 1.025.
FHR tracing reassuring.
10 contractions in an hour.
Vital signs are all WNL
fFN positive, cervical ultrasound pending.
Cervix 1/50%.

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How do you interpret these


results?
No evidence of a UTI. Urine a little
concentrated.
Regular contractions. Cervix not
dilated enough to consider it PTL but
fFN positive.

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What do you expect the


management might be?
Continued monitoring in the hospital.
Administration of steroids. Tocolysis
for the duration of steroid
administration. Explanation of the
predictive rate of the fFN test.

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PTL PTB
About 1/3 stop contracting
spontaneously
50% who are treated give birth at
term
If 23-34 weeks steroids indicated
Tocolysis used only to have time for
steroids to work (24-48 hrs).
No other measures are evidence
based
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Tocolysis
Terbutaline

Beta-adrenergic agonist (betamimetic). Relaxes uterine smooth muscle


0.25 mg subq every 1-4 hours, max 24 hours
Side Effects:
Tachycardia, palpitations, arrhythmias,
pulmonary edema
Tremors, dizziness, HA, nervousness
N/V, hyperglycemia, hypotension, hypokalemia
Fetal tachycardia, hyperinsulinemia,
hyperglycemia
Contraindications:
h/o cardiac dz, DM, severe PEC, hyperthyroidism
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Magnesium sulfate
CNS depressant; Relaxes uterine smooth muscle
Loading dose 4-6 g IV over 20-30 min, then 14g/hour. Piggyback, 40 g in 1L, by infusion pump
only.
D/C within 24-48 hours.
Side Effects:
Diaphoresis, hot flushes, burning at infusion
site, N/V, Drowsiness, HA, blurred or double
vision, dry mouth, SOB, transient hypotension,
lethargy, weakness
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MgSO4 cont.
Evidence supporting use as tocolytic is
not conclusive, but especially for
diabetics it is an alternative. Plus
evidence supports improved outcomes
of cerebral palsy in premies.
Nursing responsibilities same as when
used for PEC.

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Nifedipine
Calcium channel blocker
10-20 mg po q3-6 hours until contractions
rare, then long acting formulation for 48
hours
Side Effects:
hypotension, flushing, HA, dizziness,
nausea
Avoid giving with Mag sulfate (skeletal
muscle block) or terbutaline
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Indomethacin
NSAIDblocks prostaglandins

Use only if <32 weeks, if other tocolytics fail.


50 mg po loading dose, then 25-50 mg po q 6 hrs x 48
hours. Give with food.

Side Effects:
N/V, heartburn, HA, blurred vision
Prolonged bleeding time, thrombocytopenia (risk
postpartum hemorrhage), asthma if aspirin-sensitive
Pulmonary edema: CP, SOB, respiratory distress,
wheezing, crackles, productive cough w/ blood tinged
sputum
Fetal/NB: constriction ductus arteriosus, oligohydramnios,
neonatal pulmonary HTN
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Clinical application cont.


Marge L. is given Terbutaline 0.25 mg subq.
Before giving her this med, what common side
effects will you warn her about?
15 minutes later, the FHR is 170 with marked
variability. How do you interpret this?
Her cervical length is 25 mm on ultrasound. How
do you interpret this?
Her contractions decrease to 4-6 per hour on the
terbutaline, but when you recheck her cervix in 2
hours, it is now 2/80%.
What do you expect the next intervention to be?

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Wrap up
If PTL cant be stopped, GBS prophylaxis will
be administered.
Fetal monitoring is continuous
Anticipate complications:
malpresentation/malposition, prolapsed cord
with ROM, newborn resuscitation
If not at tertiary care center, transfer
Pediatrician present for birth

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