Preterm labor (PTL) refers to labor that occurs after the completion of the 20th week and before the beginning of the 37th week of gestation. In order to be considered PTL, the uterine contractions must occur at a frequency of four in 20 minutes or eight in 60 minutes. Spontaneous rupture of the membranes often occurs in PTL. If the membranes are intact, documented cervical change (80% effacement or 1 cm dilation) must be noted during a vaginal examination for the situation to be classified as PTL.
Preterm labor has a poorly understood etiology, unclear mechanisms, and an absence of medical consensus related to diagnosis and treatment. This is unfortunate because preterm birth is the second highest cause of the high infant morbidity and mortality rate in the United States (birth defects is the first). From 8% to 10% of all births in the United States are preterm, and the risk of having a recurrent preterm birth after one, two, or three occurrences is 15%, 30%, and 45%, respectively. The major fetal risk of preterm delivery is related to immaturity of the lungs and respiratory system. Preterm infants can have many other problems as well, such as neurological complications, thermoregulation problems, and immaturity of major organ systems. Maternal risks of PTL are related to the pharmacologic treatment involved in stopping the labor.
In many cases, the cause cannot be identified. Preterm premature rupture of membranes occurs in about one-third of the cases, but its causes are also unknown. Intrauterine, genital tract, and/or periodontal infection can precede or follow premature rupture of membranes. Infectious processes that occur prior to and early in pregnancy are thought to be linked to PTL/rupture of membranes owing to the inflammatory response that weakens the fetal membranes. There is also evidence that an idiopathic, undiagnosed PTL leads to microbial invasion owing to a breakdown in the cervical barrier function, and this eventually manifests itself as chorioamnionits and true clinical PTL.
Nursing care plan assessment and physical examination
Ask the date of the patient’s last menstrual period to estimate delivery date. If the patient reports using cigarettes, alcohol, or other harmful substances, determine the amount and frequency. Ask about the onset of contractions and their frequency, duration, and intensity.
Have the patient describe the contractions; sometimes false labor is felt in the lower abdomen and is irregular. Ask if the patient feels the baby move. Ask about any medical problems because some pharmacologic treatment may be contraindicated in certain instances (cardiac disease, hypertension, renal disease, uncontrolled diabetes, and asthma).
A thorough initial examination is needed to help determine if the patient is in PTL or in false labor. Apply a fetal monitor to determine the frequency and duration of contractions. Palpate the fundus of the uterus; if the patient is having PTL, note uterine firmness. Obtain the fetal heart rate with an electronic fetal monitor, noting baseline, presence or absence of accelerations or decelerations, and variability. After checking with the physician, perform a sterile vaginal examination to determine dilation, station, and effacement. Note any vaginal bleeding, bloody show, or leakage of amniotic fluid. Nitrazine (pH) paper can be used during the examination to detect if the membranes have ruptured (paper turns blue because pH is alkaline). Note that an elevated temperature indicates infection or dehydration.
The reality of a premature delivery and a sick newborn in a neonatal intensive care unit (NICU) creates a tremendous amount of stress and emotion for the parents and significant others. Assess the patient’s and the significant others’ abilities to cope. The patient may experience guilt, suspecting that she did something wrong during the pregnancy to precipitate the labor.
Nursing care plan primary nursing diagnosis: Fear related to uncertainty of outcome and complexity/effects of treatments.
Nursing care plan intervention and treatment plan
The goals of treatment are to stop the contractions and to prevent the cervix from dilating, thereby avoiding delivery until at least 34 weeks. Once the cervix reaches 4 cm in dilation, treatment is stopped and the delivery is allowed to occur. Ideally, delivery is in a hospital with the expertise necessary to treat a preterm neonate.
Although the first strategies often employed to halt PTL, bedrest, hydration, and sedation are not supported in the literature as effective means of stopping PTL. Intravenous (IV) fluids, usually a crystalloid such as lactated Ringer’s solution and a sedative if the patient is anxious, are used. Terbutaline sulfate is often given subcutaneously, along with hydration. If the contractions stop and the labor is not progressing, patients are discharged home on complete bedrest. Home monitoring of uterine contractions with transmission of data to the physician is possible. Also, patients may be discharged with a terbutaline pump, which infuses 3 to 4 mg of terbutaline subcutaneously each day; evidence of the effectiveness of use of the pump is being evaluated.
If labor continues, IV medications are indicated. Tocolysis (inhibition of uterine contractions) is contraindicated in cases of maternal infection, pregnancy-induced hypertension, hypovolemia, and fetal distress. During the initial period of infusion of beta-adrenergic drugs, auscultate the patient’s lungs for rales and rhonchi; observe for dyspnea and chest discomfort; determine the fetal heart rate, maternal pulse, blood pressure, and respiratory rate; and monitor the status of contractions every 10 minutes. Fluid restriction, accurate monitoring of intake and output, and daily weights are indicated to monitor fluid balance.
Administer glucocorticoids concurrently with tocolytics. The incidence of respiratory distress is lower if the birth is delayed for at least 24 hours after the initiation of glucorticoids; The effects on the lung maturity persists for 1 week after the therapy is completed. If glucocorticoids are administered concurrently, monitor the patient for signs and symptoms of pulmonary edema. If magnesium sulfate is used for tocolysis, closely monitor deep tendon reflexes; hyporeflexia occurs if the patient is becoming toxic and precedes respiratory depression. If tocolysis is successful, and contractions are under control, the infusion is discontinued by gradually decreasing the rate and converting to oral administration.
Monitor the fetal heart rate variability and for the absence or presence of accelerations and decelerations. If signs of fetal stress occur, turn the patient on her left side, increase the rate of the IV hydration, administer oxygen at 10 L/min per mask, and notify the physician.
Delivery of the preterm infant can be done vaginally or by cesarean. The decision for the method of delivery is often made jointly by the physician, neonatologist, and parents. If the fetus is very premature, often the neonatologist suggests a cesarean to prevent trauma to the fetal head and an increased risk of intraventricular hemorrhage.
Prevention of PTL is an important function of the nurse. During the initial prenatal visit, educate the patient on the signs and symptoms of PTL and ask the patient on subsequent visits if she is experiencing any of these indicators. If a patient reports alcohol, cigarette, or drug use any time during the pregnancy, work with her to modify her behavior. A referral to a drug treatment, smoking cessation, or alcohol counseling program may be indicated. Encourage patients to stay well hydrated, especially during the warm weather, because dehydration can cause contractions. In addition, nurses can become involved in community education of adolescents and women about the symptoms, risk factors, and consequences of PTL.
Admission to the hospital for PTL is often a first hospitalization for many young patients. Provide emotional support and educate the patient on simple procedures that may seem routine (drawing laboratory work, frequent assessments done by nurses and physicians, mealtimes and menus). Discuss the implications and expectations of preterm delivery. Be realistic in the discussions and, if possible, arrange for a visit to the NICU and a talk with the neonatologist. Include the family in conversations with the patient, and encourage them to assist with caring for the patient while she is on bedrest. Often, the patient is on bedrest for several days in the hospital and at home. While she is in the hospital, suggest diversional activities, such as videos, special visitors, and games. Encourage the woman to lay on her side to increase placental perfusion and reduce pressure on the cervix.
Nursing care plan discharge and home health care guidelines
Discuss the importance of maintaining bedrest in the lateral position. Teach the patient to remain well hydrated, take all medications exactly as prescribed, and report any uncomfortable side effects to the physician. Teach the patient to avoid any activity that could possibly initiate labor (sexual intercourse, nipple stimulation). Explain that the patient should check daily to determine whether the fetus is moving or the uterus is contracting. Teach the patient how to palpate the fundus and judge the intensity of a contraction. Teach the patient how to use the home monitor for uterine contractions and the terbutaline pump if ordered. Review the warning signs of PTL and when she should call the physician.
Teach the patient to be aware of signs and symptoms that indicate postpartum complications: a hard, reddened area on the breast; pain in the calf of the leg; increase in bleeding; foul odor to vaginal discharge; fever; burning with urination; or persistent mood change. Teach her not to lift anything heavier than the baby and not to drive until after the postpartum checkup with the physician. Encourage her to maintain a healthy diet and adequate nutrition and to schedule rest time around the baby’s sleeping times. Elicit the help of family members if needed.