Preterm Labor

Nursing responsibilities in pre term labor

-Assessment/vitals -ID S&S of PTL -Educate women on S&S of PTL -Collect urine for dipstick and culture -0 VE -Prepare for speculum -Gather FFN swab (if ruptured, 0 VE, & 0 sex within 24 hours) and delivery not imminent (cx<3cm) -BV, STI, C+S, GBS swabs -EFM -Palpate strength of contraction, characteristics, and document -Assess PV loss (infection?, show?) -Leopolds (note if tender) -Communicate with MRP -Emotional support -Confirm EDD -Administer meds appropriately -Check equipment and keep nearby

Assessment of PTL

-Determining gestational age -Abdominal palpation (Leopold's) to assess position and presentation of the fetus. (Because of their smaller size, it is not unusual for preterm infants to be in a breech presentation or transverse lie, which has implications for the mode of delivery.) -Assessment of the frequency, strength, and duration of contractions (remember that women may describe cramps, tightenings, pressure rather than contractions) -Assessment of fetal well-being (given increased vulnerability, continuous electronic monitoring is indicated, as is assessment of fetal movement) -Maternal vital signs -Assessment of any vaginal bleeding or fluid loss -No VE until fetal fibronectin test performed

Contradictions for collecting Fetal fibronectin?

-ROM, -active vaginal bleeding, -vaginal exam or vaginal intercourse in the past 24 hours

six needs of parents of a neonate in the NICU:

-accurate information in order to participate in decision making -to be vigilant and protect the infant -contact with the infant -a need to be positively perceived by the nursery staff -individualized care -a need for therapeutic relationship with the staff

Strategies workuing toward promoting infant growth and development

-altering the environmental and caregiving stressors that interfere with physiologic stability -promoting individual neurobehavioral organization and maturation by identifying and facilitating stable behaviors and reducing stressful behaviors -conserving energy -teaching parents to interpret infant behavior and -promoting infant -parent interaction and caregiving

Risk of late preterm infants

-because of their size and physical maturity, many of are not recognized and cared for as vulnerable, preterm infants -much greater risk of experiencing: -respiratory distress, -apnea and bradycardia, -sepsis, -hypoglycemia, -thermal instability, -feeding difficulties, and -hyperbilirubinemia

short- and long-term benefits of breastfeeding the preterm infant:

-protection from necrotizing enterocolitis -protection from infection -increased feeding tolerance -earlier attainment of full enteral feedings -decreased risk for later allergy -improved retinal function -improved neurocognitive development -suppression of oxidative stress -reduced heart disease later in life

Fetal fibronectins

-proteins that are found in fetal membranes and decidua during pregnancy -Fetal fibronectins can be found in vaginal secretions up until 22 weeks gestation, then not again until within two weeks of labor starting

Indications for fetal fibronectin testing include:

-threatened PTL between 24-34 weeks gestation -intact amniotic membranes -cervix less than 3 cm dilated -established fetal well-being

Cervical length less than ___ as measured by transvaginal ultrasound, is associated with a high risk for preterm birth

1.5cm

Cervical length of greater than __ has a high negative predictive value for delivery less than 34 weeks

3cm meaning conservative treatment is all that is needed

if a woman presents with symptoms of PTL and she tests negative for fetal fibronectin, there is a __% likelihood of remaining undelivered for the 14 days following the test

99%

Follow up with negative FFN

A negative test suggests that tocolytics are probably not necessary, nor is transfer. However, follow-up should be arranged and should include cervical length ultrasound as well as re-evaluation of preterm labor symptoms

Tx of positive FFN

A positive result suggests a woman should be treated and transferred to a tertiary care center if not in a center capable of caring for a preterm infant

Treatment plan for PROM

At term (>37 weeks), there is evidence supporting the induction of labour to reduce the time interval between PROM and delivery to decrease the risk for maternal infection

Recommended Tocolytic until 32 w

Indomethacin is recommended for use up until 32 weeks gestation (Farquarhson et al., 2005). There is increased risk of premature closure of the ductus arteriosus with use after 32 weeks gestation . The recommended l dose of 100mg rectal suppository, followed by a maintenance dose of 25-50 mg orally or rectally, every 4 to 6 hours for duration of 24-48 hours

Sweet

Low energy stores, high expenditures and often difficult feeding = low calorie intake

Labor support for PTL

Most non-pharmacologic methods are good options to consider. Water therapy in terms of shower or bath may not be good options in the case of preterm rupture of membranes. Pharmacologic pain relief options must take gestational age and concern for fetal/neonatal well-being into consideration. A narcotic can further compromise the preterm infant at delivery

Assessments for PROM

Ongoing assessments for fluid leakage, signs of infection, and uterine contractions are necessary. Assessment for PROM includes: -a thorough history from the woman -a sterile speculum exam to confirm fluid leakage (ferning) -nitrazine test -collection of swabs for Group B Strep (GBS). While most women who experience pre-labor ROM will go into labor, some may not.

Nursing priorities for late preterm infant

Pink, warm, sweet

PROM

Pre labor rupture of membrane (regardless of GA)

Most common cause of preterm birth

Pre-labor rupture of membrane

PPROM

Preterm, pre-labor rupture of membranes

Prolonged ROM

ROM >24h

Preterm labor

Regular uterine contractions that cause cervicle changes that happens between 20 and 36+6 weeks

Tocolytic

Suppress preterm labor so steroids and transport are in place (not affective long term)

How should swabs be collected for Fetal Fibronectin?

Swabs for fetal fibronectin testing should be collected prior to any digital exams or transvaginal ultrasounds, and no lubricants should be used on the sterile speculum

Corticosteroid name and dose info

The treatment should consist of two 12 mg doses of Betamethasone given IM 24 hours apart (12mg, q24h, X 2 doses)

Pink

Warmth and oxygenation (thermogenesis causes O2 consumption)

Influence PTL

altered uterine and cervical factors placental ischemia inflammation stress

PTL Eetiology/risk factors

behavioral/psychosocial factors neighborhood characteristics environmental exposures medical conditions infertility treatments genetics biologic factors Numerous epidemiologic studies have shown the association of poverty, limited maternal education, young maternal age, unmarried status, and inadequate prenatal care with increased risk of preterm birth and low birth weight

The threshold for viability is considered to be:

between 22 and 25 weeks gestation

Why take corticosteroids?

corticosteroids has been shown to reduce perinatal mortality, respiratory distress syndrome, and intraventricular hemorrhage

Contraindication to tocolysis

fetal compromise lethal fetal anomaly intrauterine death intraamniotic infection severe gestational hypertension with adverse conditions significant bleeding intrauterine growth restriction related to an unfavorable intrauterine environment

Side effects of indomethacin

gastrointestinal irritation and bleeding, thrombocytopenia, nausea, vomiting, headache, dizziness, and allergic reactions. Because of its strong anti-inflammatory action, Indomethacin may mask the underlying inflammation associated with infection, which is important to remember when there is PPROM. There are potential neonatal effects related to Indomethacin use which are related to cardiopulmonary circulation, GI function, and platelet activity

Late preterm infants

immature neonates born between 34 and 36 6/7 weeks gestation

Magnesium Sulphate (MgSO4) in preterm labor

in the past has been used as a tocolytic. Presently it is being used as a neuroprotective agent for the neonate. Cerebral palsy (abnormality of tone with motor dysfunction) and cognitive dysfunction are the most frequent neurological impairments for infants born preterm

Other risksOther risks associated with prelabor ROM include:

infection prolapse of the umbilical cord cord compression

Nifedipine

is used in some centers as a tocolytic and there is ongoing research regarding risks/benefits and outcomes related to its use. Typical Loading dose of Nifedipine may be 10 mg po q30 min until contractions stop. Maximum dose of 40 mg in 2 hours. Then Nifedipine XL 30 mg, po, q12h for 48 hours. Blood pressure and heart rate are monitored frequently (q 15 min during loading dose and for 2 hours after). Check unit specific policy and procedures for dose and monitoring requirements.

Risk factors

multiple gestations preterm rupture of membranes polyhydramnios antepartum hemorrhage intra-abdominal surgery tobacco or cocaine use severe maternal infection physical or emotional trauma

The treatment plan for PPROM

must consider gestational age, maternal and fetal well-being, any evidence of infection, and the need for transfer if the woman presents in a facility not equipped to care for a preterm infant

assessment findings in infant experiencing hypothermia

pale mottled skin acrocyanosis respiratory distress apnea bradycardia irritability initially then lethargy hypotonia weak cry metabolic acidosis hypoglycemia

Recommendations for MgSO4

recommend the MgSO4 should be considered for women with imminent preterm birth at < 31+6 weeks gestation. Imminent birth is defined as a high likelihood of delivery within 24 hours

preterm birth accounts for nearly 75-80% of all neonatal morbidity and mortality. While all systems of the preterm infant are immature, key potential health consequences for the infant include:

respiratory distress asphyxia hyperbilirubinemia metabolic disturbances fluid and electrolyte imbalance neurologic and behavioural problems infection nutritional deficits feeding problems ineffective thermoregulation cardiovascular disturbances hematologic disturbances

If membranes rupture before 23-26 weeks of gestation and marked oligohydramnious results, the fetus is at an increased risk (20%-50%) for:

skeletal compression deformities, amniotic band syndrome, and pulmonary hypoplasia.

Who should receive cortico steroids?

the SOGC recommends all pregnant women between 23-33 weeks gestation who are at risk of preterm delivery within seven days should receive corticosteroids

Warm

thin skin, large surface area relative to body mass, limited brown fat for thermogenesis, decreased subcutaneous tissue, and an immature nervous system

S&S of preterm labor

vague, mimic other health issues like flu & constipation (likely to pass off as something else) Signs of PTL include: Menstrual cramps painful or painless contractions backache pelvic pressure diarrhea urinary frequency increased vaginal discharge