Preterm Labor

uterine contractions and cervical changes that occur between 20 and 37 weeks of gestation

• *Infections of the urinary tract, vagina, or chorioamnionitis (infection of the amniotic sac)
• *previous preterm birth
• *multifetal pregnancy
• *hydramnios (excessive amniotic fluid)
• *age below 17 or above 35
• *low socioeconomic status
• *smoking
• *substance abuse
• *domestic violence
• *history of multiple miscarriages or abortions
• *diabetes mellitys or hypertension
• *Lack of prenatal care
• *incompetent cervix
• *Placenta previa or abruptio placentae
• *preterm premature rupture of membranes
• *short interval between pregnancies
• *uterine abnormalities
• *Diethylstilbestrol (DES) exposure in utero (DES was an agent widely used to prevent miscarriage)

• Subjective data:
• *persistent low backache
• *pressure in the pelvis and cramping
• *gastrointestinal cramping, sometimes with diarrhea
• *urinary frequency
• vaginal discharge

• Objective data:
• *increase, change, or blood in vaginal discharge
• *change in cervical dilation
• *regular uterine contractions with a frequency of every 10 min or greater, lasting 1 hr or longer
• *premature rupture of membranes

• Laboratory test:
• *obtain a vaginal swab for fetal fibronectin testing (fern test)
• *assist with a collection of cervical cultures
• *perform a CBC
• *perform a urinalysis

*Test for fetal fibronectin, a protein in the amniotic fluid that appears between 24 and 34 weeks of gestation, can be found in the vaginal secretions when the fetal membrane integrity is lost

*Measure endocervical length with an ultrasound to assess for a shortened cervix, which is suggested in certain studies to precede preterm labor

*Use home uterine activity monitoring (HUAM), which is a uterine contraction monitoring device that can be used by the patient at home

*HUAM is not considered to be effective in preventing preterm labor

*Obtain cervical cultures to detect if there is a presence of infectious organisms. Culture and sensitivity results guide precription of an appropriate antibiotic, if indicated

*Perform a biophysical profile and/or nonstress test to provide information about the fetal well-being

• Nursing care:
• Focusing on stopping uterine contractions

• Activity restriction:
• *instruct the patient to remain on modified bed rest with bathroom privileges
• *encourage the patient to rest in the left lateral position to increase blood flow to the uterus and decrease uterine activity
• *tell the patient to avoid sexual intercourse
• Ensuring hydration:
• *Dehydration stimulates the pituitary gland to secrete an antidiuretic hormone and oxytocin. Preventing dehydration will prevent the release of oxytocin, which stimulates uterine contractions
• Identifying and treating any infection:
• *Have the patient report any vaginal discharge, noting color, consistency, and odor
• *Monitor maternal vital signs and temperature
• Chorioamnionitis should be susected with the occurrence of elevated maternal temperature and tachycardia
• Monitor FHR and contraction pattern
• *Fetal tachycardia, a prolonged increase in the FHR greater than 160/min may indicate infection, which is frequently associated with preterm labor

• *beta-adrenergic agonist
• *relaxes the uterine smooth muscle by stimulating beta-2 receptors thus inhibiting uterine activity
• *monitor patient closely, Tocolytic therapy should be discontinued immediately if the patient exhibits signs and symptoms of pulmonary edema (chest pain, shortness of breath, respiratory distress, audible wheezing and crackles, and/or a productive cough containing blood-tinged sputum)

• Vital signs:
• *monitor pulmonary function
• *monitor daily weight
• *restrict fluid to 1,500-2,400mL/24hr (reduces the risk for pulmonary edema)
• *record the patient's respiratory effort
• *withhold the medication and contact the physician if maternal heart rate is 120 to 140 per/min, or if the patient reports chest pain or cardiac arrhythmias
• *Observe the injection site for infection if administered subcutaneously

• Patient education:
• *what to report to physician
• *oral medication is frequently prescribed to take while at home

• *Tocolytic
• *relaxes the smooth muscle of the uterus and thus inhibits uterine activity by suppressing contractions
• *Monitor the patient closely, tocolytic therapy should be discontinued immediately if the patient exhibits signs and symptoms of pulmonary edema (chest pain, shortness of breath, respiratory distress, audible wheezing and crackles, and/or a productive cough containing blood-tinged sputum)

Monitor for Magnesuim sulfate toxicity and discontinue for any of the following adverse effects (loss of deep tendon reflexes, urinary output less than 30 mL/hr, resiratory depression less than 12/min, pulmonary edema, and/or cheat pain)

Administer calcium gluconate as an antidote for magnesuim sulfate toxicity

• Contraindications for tocolysis
• *active vaginal bleeding
• *dilation of the cervix greater than 6 cm
• *choioamnionitis
• *greater than 34 weeks gestation
• *acute fetal distress
• *severe pregnancy induces hypertention
• *eclampsia

• *Nonsteroidal anti-inflammatory (NSAID)
• *suppresses preterm labor by blocking the production of prostaglandins thus inhibiting uterine contractions
• *monitor patient closely, Tocolytic therapy should be discontinued immediately if the patient exhibits signs and symptoms of pulmonary edema (chest pain, shortness of breath, respiratory distress, audible wheezing and crackles, and/or a productive cough containing blood-tinged sputum)
• *Indomethacin treatment should not exceed 48 hrs
• *Indomethacin should only be used if gesational age is less than 32 weeks of gestation
• *Monitor the patient for postpartum hemorrhage related to reduced platelet aggregation
• *administer indomethacin with food or rectally to decrease gastrointestinal distress
• *notify the nurse if the client reorts blurred vision, headache, nausea, vomiting, or difficulty breathing
• *Monitor the neonate at birth

• *glucocorticoid
• *administered IM and requires 24 hrs to be effective
• *enhance fetal lung maturity and surfactant production
• *administer the betamethasone deep into the patients gluteal muscle 24-48 hr priot to birth of a preterm neonate
• *Monitor the mother and neonate for pulmonary edema by assessing lung sounds
• *monitor for maternal and neonate hyperglycemia
• *monitor the neonate for heart rate changes
• Patient education:
• signs and symptoms of pulmonary edema (chest pain, shortness of breath, and crackles)

• Expected outcomes:
• *patient will maintain pregnancy until
• term
• *patients pregnancy will continue to promote fetal lung maturity