exam 2 preterm labor

Question 1

What is early and late preterm labor?

Answer 1

Premature Preterm Rupture of Membranes
Incompetent Cervix
Bleeding in Pregnancy

Early
Therapeutic Abortion/Miscarriage
Molar Pregnancy
Ectopic Pregnancy
Late
Placental Previa
Placental Abruption
Adherent Retained Placenta

Question 2

what is preterm labor?

Answer 2

(PTL)- Cervical changes and uterine contractions occurring between 20 and 36 6/7 weeks gestation

***Just because a client has preterm labor does not mean she will have a preterm delivery BUT if a client has a preterm delivery, they had to have preterm labor!! Think how this effects the Gs & Ps

Question 3

what is preterm birth?

Answer 3

Any birth that occurs between 20 0/7 and 36 6/7 weeks gestation

Question 4

what is low birth weight?

Answer 4

Low birth weight (2500 grams or less) does not necessarily mean a preterm birth has occurred. An infant can be born with a low birth weight at term. This is called Intrauterine Growth Restriction (IUGR) and occurs when there has been complications of pregnancy that interferes with uteroplacental
profusion.

Question 5

what is the weight classifications for infants?

Answer 5

Infants are classified as:
low birth weight if they are born weighing less than 2500 grams (about 5.5 pounds)

very low birth weight if they weigh less than 1500 grams (about 3.3 pounds).

extremely low birth weight (ELBW) infants–those weighing less than 1000grams (2.2 pounds).

Question 6

what are the causes of PTL?

Answer 6

Multifactorial –>
Multiple pathologic processes leading to:
Contractions/Cervical change/ROM
Placental implantation bleeding (1st or 2nd trimester)
Maternal/Fetal Stress
Uterine over-distention
Allergic reaction
↓ progesterone level

infection: cervical, bacterial, urinary tract

Infection is the only factor KNOWN to be associated with preterm labor.

Some evidence:
Periodontal Dx
Placental implantation bleeding (1st or 2nd Tri)
Inflammation
Maternal & neonatal stress
Uterine over-distention
Allergic reaction
Low progesterone levels

No single cause for preterm labor has been identified.

Infection is thought to be a major factor in the development of preterm labor

25% of preterm births are classified as “iatrogenic”
-fetus was intentionally delivered prematurely due to maternal or fetal health reasons.

25% of preterm births are a result of preterm premature rupture of membranes

50% are “idiopathic” which means it occurs spontaneously and may be preventable

At least 50% of all women who deliver prematurely have no identifiable cause or risk factor

Question 7

what are the factors thought to play into the development of PTL?

Answer 7

Chronic HTN
GDM
Preeclampsia
OB disorders in previous pregnancies
Placental disorders
Medical disorders
HX of previous preterm birth
Nonwhite race
Genital tract infection
Multifetal gestation
2nd trimester bleeding
Low pregnancy weight
Maternal HIV
Obesity
Advanced for Maternal age
Fetal disorders
Congenital fetal anomalies

Question 8

what are the S/S of PTL?

Answer 8

Uterine contractions occurring more frequently than every 10 minutes persisting for 1 hour or more
Change in type of vaginal discharge – (watery, mucus, bloody)
Increase in amount of D/C
Pelvic or lower abdominal pressure
Constant low backache
Mild abdominal cramps (with or without diarrhea)
Regular or frequent contractions (painful or painless)
ROM
Urinary frequency

Question 9

what are the education associated with PTL?

Answer 9

Identify risk factors –A woman is assessed for risk factors at the first prenatal visit and every subsequent visit throughout her pregnancy.

Educate and provide interventions for modifiable risk factors- If modifiable risk factors education and interventions should be provided and assessed for effectiveness at the time of identification and then at each subsequent prenatal visit

Educate on signs and symptoms of PTL and what to do if experience signs and symptoms. Since every woman is “at-risk” for preterm labor all women should be educated on the signs and symptoms and what to do if symptoms occurs.

Question 10

what is important to remember about preterm labor?

Answer 10

Key to prevention of premature birth is the patient’s identification of signs and symptoms of premature labor so that the necessary interventions can be implemented to prolong the pregnancy.

All women, not just those who have identifiable risk factors, need to be educated early in their pregnancy on signs and symptoms of preterm labor and what to do if they occur.

Many times women confuse the signs of preterm labor with the usual discomforts of pregnancy. They need to be educated that if any symptoms occur it is best to be evaluated and sent back home than to let them continue unchecked and therefore arrive to labor and delivery too late for successful intervention.

Many women report feeling the baby “balling up”. They should be educated that this could be contractions and warrants closer attention.

Question 11

What is some more education for PTL?

Answer 11

Self-Management
Empty bladder
Drink 2/3 glasses of H20
Lie down on side for 1 hour
Palpate for contractions

Call your provider/go to the birthing facility:
Contractions
-Cramping/Abdominal/Suprapubic/Pelvic -Pain/Pressure
-Low, dull backache
-< q 10 mins w/wo pain ≥ 1 hour

Vaginal bleeding
malodorous vaginal discharge
Fluid leaking from the vagina

Question 12

what is important to remember with fetal fibronectin (fFN)?

Answer 12

Obtain swab of vaginal secretions for FF between 24-34 weeks. Protein can be found in vaginal secretions when the fetal membrane integrity is lost.
A negative result is more powerful than a positive result. A negative results indicates a <95% chance of delivering prematurely.
Positive results indicate the onset of labor in 1 to 3 weeks
Test used if at risk for preterm labor, before 37 weeks’ gestation

a.Client placed in lithotomy position for sterile speculum exam
b.Cervical secretions are obtained with cotton swab
c.Laboratory tests for the presence of fibronectin

Question 13

what is important to remember with endocervical length?

Answer 13

More powerful when used together in predicting spontaneous preterm birth
vaginal ultrasound that measures the cervical length. Shortened = preterm labor
A cervical length of <30mm in a singleton pregnancy can predict some instances of preterm labor

Question 14

What lifestyle modifications for PTL?

Answer 14

The nurse caring for a woman with preterm labor should help her identify activities that precipitate the symptoms of preterm labor and then assist the woman in lifestyle modifications to avoid these activities.
Some activities associated with symptoms of preterm labor are
-Sexual activity (not contraindicated in pregnancy unless symptoms of preterm labor)
-Riding or standing for long periods of time
-Lifting and carrying heavy loads such as small children or laundry
-Strenuous physical work
-Infrequent rest periods

home uterine activity monitoring: ordered by the physician to aid in the detection of contractions.

Question 15

What is important to know about bedrest?

Answer 15

Bedrest used to decrease pressure on the cervix and to promote blood flow to the uterus
The nurse caring for a patient on bedrest (BR) needs to know adverse effects. It has been found to cause
-Decreased muscle tone
-Weight loss
-Calcium loss
-Glucose intolerance
-Constipation
-Thrombophlebitis
-Fatigue
-Depression
-Anxiety

Prescribed in/out of the hospital
Commonly used
Not benign
No evidence to support its effectiveness

Question 16

what are the nursing interventions for bedrest used in PTL?

Answer 16

Assess for adverse effects of bedrest and initiate and administer appropriate interventions
Psychological support for both patient and support system with referral to appropriate resources
Other appropriate referrals [chaplain, nutritionist, social worker]
assist the patient in planning activities to aid in self-care and decrease boredom [Journaling
Scrapbook , passive exercise, knitting etc.]
Refer to support groups- www.sidelines.org , Moms of Multiples
Nurses caring for patients that have been on prolonged bedrest should be aware that the adverse effects can carry over into the postpartum period. They have a longer recovery time due to the decreased endurance and muscle wasting. They also are at a higher risk for postpartum depression and other psychological issues like feelings of guilt for not being able to carry their baby to term. All of which can effect infant bonding.

Bedrest in the side-lying position- [promotes uteroplacental perfusion]

Question 17

What are interventions for active PTL?

Answer 17

Hydration:
Dehydration can contribute to uterine contractions, therefore, hydration may
be the first intervention used to suppress contractions.
Caution should be used when hydrating a patient currently being treated with tocolytics due to the increased risk of pulmonary edema [magnesium sulfate and the beta-adrenergic agonists]
Total PO and IV fluid intake should be kept between 1500-2400ml/24 hours
Nursing Action when using hydration:
-Monitor respiratory status and breath sounds
-Accurate I & 0
-Daily weights

Tocolytics to suppress uterine activity

Antenatal glucocorticoids
promote fetal lung maturity and reduce complications of prematurity such as necrotizing enterocolitis and cerebral hemorrhage

*Antibiotic therapy- If Beta Strep status is unknown prophylactic treatment with antibiotics usually PCN to prevent neonatal sepsis in event of delivery

Question 18

What are tocolytics?

Answer 18

Medication used to suppress uterine activity- They also can be used as maintenance therapy or rescue therapy once preterm labor has been halted (either way is just as effective)

Terbutaline Beta adrenergic agonists (relaxes smooth muscles, inhibit uterine activity & cause bronchodilation. Do not give if pulse is > 125

Procardia- Calcium Channel Blocker (to relax smooth muscles) Take BP before giving. It will decrease BP

Indocin- NSAID (relaxes smooth muscles by inhibiting prostaglandins not used so much due to premature closing of the ductus arteriosis

Magnesium Sulfate – Lots of nursing interventions done given for PTL, but mainly for PIH/Preeclampsia

They have not been effective in decreasing the premature birth rate

Major benefit is the prolongation of pregnancy of at least 48hours so that antenatal glucocorticoids can be given and benefit received.

Initiation of tocolytic therapy- Responsible for dosage method of action and administration, side effects, nursing responsibilities for each drug in the medication guide

Question 19

what is magnesium sulfate?

Answer 19

class: CNS depressant
action: relaxes smooth muscle, including uterus
dosage and route: IV, loading dose 4-6 G/30 M maintenance does 1-4 G/H
SE: hot flashes, N/V, HA, lethargy, dyspnea, hypocalcemia, blurred vision
Fetal SE: decreased breathing movement, reduced variability, non-reactive NST

Nursing considerations:
-Assess women and fetus for baseline
-Drug almost always given IV
-Monitor serum mag levels, therapeutic range between 4-7.5.
-Be prepared to d/c if intolerable side effects occur (respiratory rate <12, pulmonary edema, absent DTRs, chest pain, hypotension, altered level of consciousness, urine output less than 25-30 ml</hr, serum mag levels of 10 or >)
-Strict I&O
-Total IV intake at 125/hr
-Calcium gluconate/calcium chloride readily available to reverse mag toxicity

Question 20

what is terbutaline (brethine)?

Answer 20

class: Beta2-adrenergic agonist (beta1-stimulated cardiopulmonary & beta2-stimulated metabolic effects)
action: Relaxes smooth muscles, inhibiting uterine activity by stimulating beta2-receptors
dosage: Subcutaneous injection of 0.25 mg every q 4 hours
SE: tachycardia and hyperglycemia

Contraindications:
HR > 130 beats/minute
Heart Dx
Severe Preeclampsia/Eclampsia
Gestational Diabetes
Hyperthyroidism

Question 21

what is nifedipine (procardia)?

Answer 21

class: calcium channel blockers
actions: relaxes smooth muscles including the uterus by blocking calcium entry
dosage and route: initial 10-20 mg PO, then q 3-6 hrs until contractions are rare
SE: usually mild, hypotension, headache, flushing, dizziness, nausea
Contraindications: should not be given concurrently with mag or terbutaline.

Question 22

what are indomethacin (indocin)?

Answer 22

Class-Prostaglandin synthetase Inhibitors
Action-relaxes uterine smooth muscle by inhibiting prostaglandins
Dosage & Route-50 mg PO then 25-50 mgs q 6 hrs x 48 hrs
Side effects-N&V, heartburn, less common-GI bleeding, prolonged bleeding time, thrombocytopenia
Nursing considerations-used only if gestational age is <32 weeks. Only administer for 48 hrs. Do not use in presence of renal/hepatic disease, active peptic ulcer disease, poorly controlled HTN, asthma or coagulation disorders

Question 23

what are the maternal contraindications to tocolytics?

Answer 23

Severe Preeclampsia
Eclampsia
Bleeding with hemodynamic instability
Contraindications to specific medications

Question 24

what are the fetal contraindications to tocolytics?

Answer 24

Intrauterine fetal demise
Lethal fetal anomaly
Non-reassuring fetal status
Chorioamnionitis
Preterm premature ROM (PPROM)

Question 25

What is the purpose of administering antenatal glucocorticoids?

Answer 25

Stimulates fetal lung maturation by promoting release of enzymes that induce production of lung surfactant. Aids in fetal lung maturity

Question 26

When should antenatal glucocorticoids be given?

Answer 26

Women between 24 – 34 weeks who are at risk for preterm birth within 7 days.
Optimal benefit begins 24 hours after first application

Question 27

when is antenatal glucocorticoids give and how?

Answer 27

Betamethasone 12 mg Deep IM 2 doses 24 hours apart or Dexamethasone 6 mg Deep IM 2 doses 12 hours apart

Question 28

what are the antenatal glucocorticoids contraindications?

Answer 28

Pulmonary edema, maternal diabetes or hypertension

Question 29

what are the nursing interventions for antenatal glucocorticoids?

Answer 29

Give deep IM, (this is a painful injection) teach signs of pulmonary edema, assess lung sounds & blood glucose (will increase BS levels)
Will increase WBCs for about 72 hours
May see FHT as minimal variability or decrease to no accelerations for 24-72 hours

Question 30

what happens if inevitable PTB?

Answer 30

Transfer to a tertiary center if possible
- NICU
-Peri-Neonatologist
Start Steroid therapy ASAP

Question 31

what happens with PPROM?

Answer 31

Occurs when a patients amniotic sac ruptures prior to 37 weeks gestation, PROM rupture of sac and leakage of fluid before the onset of labor at any gestational age.
The cause of PPROM is unknown, however infection is thought to be a major contributor
Chorioamnionitis is a major complication of PPROM
-Chorioamnionitis is an infection of the chorion and amnion- It can be life-threatening for both fetus and mother
Other risk factors associated with PPROM
- Cord prolapse
- Cord compression
- Placental abruption

Question 32

what is the treatment for PPROM?

Answer 32

Antenatal glucocorticoids if no sign of infection
Prophylactic antibiotics to prevent infections- unknown effectiveness amp/pcn, gent

Rupture after 32 weeks may be offered immediate birth, active pursuit of labor if rupture between 34 and 36 weeks.

Question 33

what is the expected management for PPROM?

Answer 33

rupture before 32 weeks Hospital or home
- Observe for infection- fever, abdominal tenderness, vaginal discharge with foul odor or change in color, elevated WBC’s
- Frequent biophysical profiles to monitor fetal status and amniotic fluid volume
- Frequent non-stress tests- This can be done with home monitoring if patient
discharged
- Instructions on signs and symptoms that warrant immediate medical attention [Infection, decreased fetal movement, signs of labor, vaginal bleeding]
- Instructions on self-care
*Ways to decrease risk of infection- no tub baths, nothing in vagina, proper
hygiene after BM, frequent pad changes, monitoring of temperature
*Fetal kick counts

Delivery if Chorioamnionitis
ACOG recommends delivery at 34 weeks if PPROM