B.

Sc DEGREE COURSE IN NURSING (BASIC)

Midwifery and Obstetrical Nursing

Unit: VIII- Assessment and management of

Abnormal Labor
Pre mature Labor (Pre term Labor)
[Link],
Principal Incharge

29.4.2020- Forenoon
 LEARNING OBJECTIVES
• At the end of the class the students will be
able to:
• define Premature Labor
• list out the Incidence & Risk factors
• explain the etiopathogenesis.
• delineate the diagnosis of Premature labour
• enumerate the Predictors of Premature labour
• discuss the Management of Preterm Labour
including Nursing Management
 INTRODUCTION

• Pre mature labor and birth is the most Serious

Complications of Pregnancy because they lead to
about 90 % of all Neonatal deaths with more than
75 % of these death occurring in babies born at
fewer than 32 weeks of gestation.
• It is associated with Significant long term
disability & Morbidity.
• WHO has developed new guidelines with
recommendations for improving outcomes of
preterm births..
 OVERVIEW
 Introduction  Diagnosis
 Definition  Predictors
 Incidence  Management
 Etiology • Principles
 Risk Factors • Prevention
• History • Measures to arrest
• Complications in Preterm Labour
Present Pregnancy • Appropriate
• Idiopathic Management of Labour
• Iatrogenic • Effective Neonatal Care
 Etiopathogenesis • Nursing Management
 DEFINITION

• Premature Labour or Preterm labor (PTL) is

defined as one where the labor starts before
the 37th completed week (< 259 days),
counting from the first day of the last menstrual
period. D.C Dutta
 INCIDENCE

The prevalence widely varies and ranges

between 5–10%.

ETIOLOGY
• In about 50%, the cause of Preterm labor is not
known.
• Often it is multifactorial.
 HIGH RISK FACTORS

COMPLICATIONS IN
HISTORY PRESENT PREGNANCY
Maternal, Fetal or Placental

RISK FACTORS

IDIOPATHIC IATROGENIC
(Majority)
 HISTORY
Previous history of induced or
spontaneous abortion or preterm
delivery
Pregnancy following assisted
reproductive techniques (ART)

Asymptomatic bacteriuria or
recurrent urinary tract infection;

Smoking habits

Low socioeconomic and nutritional

status

Maternal stress.
 COMPLICATIONS IN PRESENT
PREGNANCY - MATERNAL
Pregnancy Uterine Medical & Genital tract
Complications anomalies surgical illness infection
• Preeclamps • Cervical • Acute fever, • Bacterial
• Acute
ia incompeten vaginosis
pyelonephritis,
• Antepartum ce • Diarrhea, • beta-
hemorrhage • Malformatio • Acute hemolytic
• premature n of uterus appendicitis, streptococc
• Toxoplasmosis us,
rupture of
• Abdominal • bacteroides
the operation.
membranes • Chronic ,
• polyhydram diseases: • chlamydia,
nios Hypertension, • mycoplasm
• Nephritis,
• diabetes, a
• decompensated
heart lesion,
• severe anemia,
• low body mass
index (LBMI)
 COMPLICATIONS IN PRESENT
PREGNANCY - FETAL

Multiple Congenital Intra uterine

Pregnancy Malformations Death
 COMPLICATIONS IN PRESENT
PREGNANCY - PLACENTAL

Placeta Abrubtio
Infarction Thrombosis
Praevia placenta
Contd…

Iatrogenic
• Elective induction with wrong estimation of
gestational age
• Indicated preterm delivery due to medical or
obstetric complications.
Contd…

Idiopathic: (Majority)
• Premature effacement of the cervix with
irritable uterus and early engagement of the
head are often associated.
• Early engagement of head
ETIOPATHOGENESIS
 Pathologic uterine
Activation of distention
maternal/Fetal Inflammation Decidual  Multiple
HPA axis  Infections:
Haemorrhage pregnancy
 Maternal – fetal  Chorio-Decidual  Abruption  Poly hydramnios
stress  Systemic  Uterine
abnormality

TNF
Biochemical Thrombin
mediators IL-1
IL-6 Mechanical
CRH
IL-8 stretch
Cortisol
Gap junction
Oxytocin
Decidua membrane receptor
PG synthase

Protease Uterotonus
Common
pathway
Cervical change Preterm Uterine
Rupture of delivery contractions
membrane
 DIAGNOSIS

al i tal s
d
i
om ion
n D i g
v ic Tran al
l n
Ab
i n at p e
a t i on vagi ound
exam ex a m in
ul t r as
Abdominal examination

Regular uterine
contractions
with or without
pain

(At least one in

every 10
minutes)
 Digital pelvic examination
Assess for cervical changes
 Digital pelvic examination

Cervix 80% Cervix > 80% Cervix < 80%

effaced dilation effaced dilation effaced dilation
> 3cm > 1 but < 3cm < 1cm

Advanced Early preterm Trans vaginal

preterm labour labour USG

Cervical length <

2.5cm Cervical length >
Threatened 2.5cm
preterm labour False labour
Trans vaginal ultrasound

Cervical
length
Measure
by
TVS < 2.5
CM
and funn
elling
of interna
l OS
 INVESTIGATIONS

Urine for routine Cervicovaginal

Full blood count analysis, culture swab for culture
and sensitivity and fibronectin

Ultrasonography Serum electrolytes

for fetal well being, and glucose levels
cervical Length and when tocolytic agents
placental are used
localization
 PREDICTORS OF PRETERM LABOR

Clinical Biophysical Biochemical

predictors predictors predictors
• Multiple • Uterine • Fetal
pregnancy contractions fibronectin
• History of (UC) > 4/hr (fFN) in
preterm birth • Bishop score cervico
• Presence of >4 vaginal
genital tract • Cervical discharge
infection length (TVS) between 24
• Symptoms of < 25 mm. and 34 weeks
PTL • Others IL-6,
IL-8, TNF-a.
PREVENTION OF PRE TERM LABOUR
• Primary care • Secondary • Tertiary care
care
• Education of at
risk women • Prophylactic • Preventing
• Antibiotics treatment perinatal
• Improved
access to • Prophylactic morbidity and
prenatal care
circlage mortality
• Bed rest
• Activity • Prophylactic
modification
• Investigations medications
 MANAGEMENT

To prevent preterm To arrest preterm

onset of labor, if labor, if not
possible contraindicated

MANAGEMENT

Appropriate Effective neonatal

management of care
labor
 PRINCIPLES
 Glucocorticoids to the mother to reduce neonatal RDS,
IVH and NEC
 Antenatal transfer of the mother with fetus in utero to
a center equipped with NICU
 Tocolytic drugs to the mother for a short period unless
contraindicated
 Antibiotics to prevent neonatal infection with Group B
Streptococcus (GBS)
 Careful intrapartum monitoring, minimal trauma and
presence of a neonatologist during delivery
 Vaginal delivery is preferred, unless otherwise indicated
for cesarean birth
 MEASURES TO ARREST PRETERM
LABOR
• The patient is to lie preferably in left lateral
Bed rest position though the benefits are doubtful .

• is maintained
Adequate hydration
• not routinely given
Prophylactic • It is recommended when infection is evident or
antibiotic culture report suggests.

• for women with prior preterm birth and short

Prophylactic cervical cervix in the present pregnancy may be
circlage beneficial.
• Various drugs including progesterone (micronized) have
been used to inhibit uterine contractions ( e.g Mgso4,
Tocolytic agents Terbutaline, Ritodrine Hydrochloride, Indo methacin)
• can be used as short term (1–3 days) or long-term therapy.
• Preferably avoided as there is no clear Benefit.
 SHORT-TERM
THERAPY(GLUCOCORTICOIDS)
• It is commonly employed with success.
The objectives are
 To delay delivery for at least 48 hours for
glucocorticoid therapy to the mother to enhance
fetal lung maturation
 In utero transfer of the patient to a unit with an
advanced neonatal intensive care unit (NICU).
 CONTRAINDICATIONS OF
GLUCOCORTICOIDS

MATERNAL FETAL OTHERS

• Uncontrolled • Fetal distress • Rupture of
diabetes membranes,
• Fetal death • chorioamnionitis
• Thyrotoxicosis
• severe • Congenital • cervical dilatation
hypertension, malformation more than 4 cm.
• cardiac disease • Pregnancy
• Hemorrhage in beyond 34
pregnancy, e.g. weeks
placenta previa
or abruption.
 GLUCOCORTICOID THERAPY
 Maternal administration of
• Benefit persists as long
glucocorticoids is
as 18days.
advocated where the
pregnancy is • Either betamethasone
• Less than 34 weeks. This (Betnesol) 12 mg IM
helps in fetal lung 24 hours apart for
maturation so that the two doses or
incidence of RDS, IVH and • Dexamethasone 6
NEC are minimized. mg IM every12 hours
• This is beneficial when the for 4 doses is given.
delivery is delayed beyond • Betamethasone is the
48 hours of the first dose. steroid of choice.
RISKS OF ANTENATAL CORTICOSTEROID
USE

Premature rupture of
the membranes

Insulin dependent
diabetes mellitus

Transient reduction of
fetal breathing and
body movements.
 MANAGEMENT OF PRETERM LABOR

 The principles in management of preterm

labor are:

To prevent birth asphyxia and development of

RDS

To prevent birth trauma. Duration of labour is

usually short
MANAGEMENT DURING FIRST
STAGE
The patient is put to bed to prevent early
rupture of the membranes
To ensure adequate fetal oxygenation by
giving oxygen to the mother by Mask
Labor should be carefully monitored
prefer-ably With continuous EFM
Cesarean delivery is done for obstetric
reasons only

NICU is a sin-quanon for Good outcome

MANAGEMENT DURING SECOND STAGE

The birth should be gentle and slow to avoid rapid

compression and decompression of the head
Episiotomy may be done to minimize head
compression if there is Perineal resistance
Tendency to delay is curtailed by low forceps. Routine
forceps is not indicated
The cord is to be clamped immediately at birth to
prevent hypervolemia and hyperbilirubinemia
To shift the baby to neonatal intensive care unit under
the care of a neonatologist
 PLACE OF CESAREAN SECTION

 Routine cesarean delivery is not

recommended.
 Preterm fetuses before 34 weeks presented
by breech are generally delivered by cesarean
section.
 Lower segment vertical or ‘J’ shaped
incision
• to minimize trauma during delivery.
• due to poor formation of the lower uterine
segment.
IMMEDIATE MANAGEMENT OF
PRETERM FOLLOWING BIRTH
The cord is to be clamped quickly to prevent
hypervolemia & hyperbilirubinemia

The cord length is kept long (about 10–12 cm) in case,

exchange Transfusion is required.

The air passage should be cleared of mucus promptly &

gently using a mucous sucker

Adequate oxygenation through mask or nasal catheter in

Concentration not exceeding 35%

The baby should be wrapped including head in a sterile

warm towel (normal temperature 36.5– 37.5°C).

Aqueous solution of vitamin K 1 mg is to be injected Intra

muscularly to prevent Hemorrhagic Manifestations
 PROGNOSIS

with neonatal
Results in high intensive care unit,
survival rate of the
Perinatal mortality baby weighing
and morbidity between1000–1500 g
is more than 90%.

With the use of

surfactant survival
rate of infants born
at 26 weeks is
about 80 percent.
 COMPLICATIONS

 Asphyxia
P
 Hypothermia R • Anuria
 Pulmonary E
• Infection
T
syndrome E • Retinopathy of
R
 Cerebral M prematurity
haemorrhage • Jaundice
B
 Fetal shock A • Dehydration
B
 Heart failure y and acidosis
 Oliguria
 NURSING MANAGEMENT

• Assess for the Presence of Risk factors

• Plan Prevention Strategies that address risk factors.
• Educate the Mother about the warning signs of
Preterm Labour
• Educate woman to report rupture of Membranes,
Vaginal bleeding, low back ache, & pelvic Pressure.
• Teach woman how to monitor fetal activities &
uterine Contractions.
• Encourage bed rest in Left Lateral Position.
• Educate mother to Limit activities
 Contd…

• Assess for the occurrence of symptoms with any

particular lifestyle behaviour.
• Counseling About life style modifications such as
Sexual activity, Long travel, Heavy house hold work,
Hard physical activities, & prolonged standing
• Encourage woman in Health Promoting activities like
Good nutrition, Exercise & stress management.
• educate mother to monitor weight, diet, fluid intake &
vital signs on a daily basis.
Contd…

Nursing care during Tocolytic Therapy :

• explain the purpose & side effects of Therapy.
• Monitor Vital signs , FHR & Labor Status
• Assess mother & fetus for signs of any Adverse
• Reactions.
• Weight monitoring & IO Chart.
• Advice mother to report any side effects
immediately.
• Psychological Support & encourage mother to
practice Relaxation Techniques.
Contd…

Management of inevitable Preterm Birth –

labour Progressed to 4cm
 Timely administration of Antenatal Cortico
steroids.
 Transfer Mother – if needed
 Prepare the mother for Delivery & encourage,
Educate & Support her .
 Reassure Mother & Family by providing ongoing
Feedback.
 Make Child birth a Positive Experience
 CONCLUSION

 Preterm birth is an important perinatal health

problem across the globe.
 It not only involves considerable risks for the
mother, but is the primary cause of death of
many babies.
 The goal of all attempts to prevent and treat
preterm labor is to improve preterm infants’
chances of surviving with as few complications
as possible.
 REFERENCES

• Dutta, D. C. (2013).Text book of obstetrics. (7th

ed.). Calcutta: New central book agency (p) LTD.

• Lowdermilk, Deitra., and Perry Shannon. (2007).

Maternity and Woman’s health care (9th ed.).
Missouri: Mosby Publications.

• Pillitteri, Adele. (2007). Maternal and Child health

nursing: Care of the child bearing and child rearing
family (5th ed.). Philadelphia: Lippincott Williams and
Wilkins.
 ASSIGNMENT

• Write Four Nursing Diagnosis for Preterm

Labour.
Thank