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PRE-TERM LABOR

Garlitos, Roanne May A.

Perez, Maria

Marcha, Don

Dizon, Kaeo

Submitted to:

Mrs. Jo-Anne Kristine L. Lucero

January 21, 2020


PRE-TERM LABOR

I. Brief Description of the Disease

Preterm labor can be defined as regular contractions of the uterus resulting in changes in

the cervix that start before 37 weeks of pregnancy. Changes in the cervix include effacement (the

cervix thins out) and dilation (the cervix opens so that the fetus can enter the birth canal). In some

cases preterm labor can lead to a baby being born too soon.

II. Prevalence and Statistics

Preterm labor usually results to spontaneous preterm birth or preterm rupture of fetal

membranes. Every year, an estimated 15 million babies are born preterm (before 37 completed

weeks of gestation), and this number is rising. Locally, the Philippines is ranked eighth worldwide

in terms of preterm birth and second in Southeast Asia with a total of 348 900 estimated preterm

births per year.

III. Anatomy and Physiology

The physiology of labor initiation has not been completely explained. However,

researchers found that labor initiation is species-specific, and the mechanisms in human labor are

unique. The first phase is quiescence and represents that time in utero before labor begins when

uterine activity is suppressed by the action of progesterone, prostacyclin, relaxin, nitric oxide,

parathyroid hormone–related peptide, and possibly other hormones. During the activation phase,

estrogen begins to facilitate expression of myometrial receptors for prostaglandins (PGs) and

oxytocin, which results in ion channel activation and increased gap junctions. This increase in the

gap junctions between myometrial cells facilitates effective contractions. In essence, the activation

phase readies the uterus for the subsequent stimulation phase, when uterotonics, particularly PGs
and oxytocin, stimulate regular contractions. In the human, this process at term may be protracted,

occurring over days to weeks. The final phase, uterine involution, occurs after delivery and is

mediated primarily by oxytocin. The first three phases of labor require endocrine, paracrine, and

autocrine interaction between the fetus, membranes, placenta, and mother.

IV. Pathophysiology

Three main components contribute to labor: cervical changes, persistent uterine contractions, and

activation of the decidua and membranes. The difference between labor at term and preterm is that

the former occurs via a normal physiologic process and the latter is pathological. Some processes

are acute, and can take several weeks leading up to preterm labor.

One of the key events to occur in preterm labor that is pathological is the fetal inflammatory

response syndrome (FIRS) which involves systemic inflammation and elevation of fetal plasma

interleukin-6, typically in response to a trigger such as chorioamnionitis. A signal is sent by the

fetal hypothalamus leading to secretion of CRH, stimulating the release of ACTH and therefore

cortisol production by the fetal adrenal glands, which triggers the parturition pathway to activate.

An influx of inflammatory cells into the cervical stroma leads to the release of cytokines and

prostaglandins which stimulate cervical ripening. These changes influence the structures of the

collagen and glycosaminoglycans that make up cervical tissue. Estrogen stimulates collagen

degradation whereas progesterone inhibits it. Therefore, progesterone is used to prevent or delay

ripening. Both hormones are implicated in regulating the gap-junction formation and the

upregulation of connexin 43 proteins which contribute to parturition.

Additionally, contractions are crucial in contribution to labor. The change from

uncoordinated myometrial contractions to coordinated uterine contractions is attributed to neural


control. Oxytocin plays an essential role in the circadian rhythm of these contractions. The

degradation of the extracellular matrix is assessed by fetal fibronectin detection in cervicovaginal

secretions and is also part of the parturition process. When detected between 22 and 37 weeks

gestational age, it indicates the disruption of the decidual-chorionic interface and increased risk of

preterm labor. Evidence implicates apoptosis as a critical factor leading in the above process.

V. Assessment

A. Clinical Manifestations

Signs of a condition are things someone else can see or know about you. Symptoms are

things you feel yourself that others can’t see, like feeling dizzy. If you have any of these signs or

symptoms before 37 weeks of pregnancy, you may be having preterm labor:

 Change in your vaginal discharge (watery, mucus or bloody) or more vaginal discharge than

usual

 Constant low, dull backache

 A sensation of pelvic or lower abdominal pressure

 Belly cramps with or without diarrhea

 Regular or frequent sensations of abdominal tightening (contractions)

 Your water breaks


B. Diagnostic Findings

If you're experiencing regular uterine contractions and your cervix has begun to soften, thin

and open (dilate) before 37 weeks of pregnancy, you'll likely be diagnosed with preterm labor.

Tests and procedures to diagnose preterm labor include:

 Pelvic exam. Your health care provider might evaluate the firmness and tenderness of your

uterus and the baby's size and position. If your water hasn't broken and there's no concern

that the placenta is covering the cervix (placenta previa), he or she might also do a pelvic

exam to determine whether your cervix has begun to open. Your health care provider might

also check for uterine bleeding.

 Ultrasound. A transvaginal ultrasound might be used to measure the length of your cervix.

An ultrasound might also be done to check for problems with the baby or placenta, confirm

the baby's position, assess the volume of amniotic fluid, and estimate the baby's weight.

 Uterine monitoring/Tocometer. Your health care provider might use a uterine monitor to

measure the duration and spacing of your contractions.

 Lab tests. Your health care provider might take a swab of your vaginal secretions to check

for the presence of certain infections and fetal fibronectin — a substance that acts like a glue

between the fetal sac and the lining of the uterus and is discharged during labor. These results

will be reviewed in combination with other risk factors. You'll also provide a urine sample,

which will be tested for the presence of certain bacteria.


VI. Management

A. Pharmacologic Therapy

Once you're in labor, there are no medications or surgical procedures to stop labor, other

than temporarily.

Corticosteroids. Corticosteroids can help promote your baby's lung maturity. If you are

between 23 and 34 weeks, your doctor will likely recommend corticosteroids if you are thought to

be at increased risk of delivery in the next one to seven days. Your doctor may also recommend

steroids if you are at risk of delivery between 34 weeks and 37 weeks.You might be given a repeat

course of corticosteroids if you're less than 34 weeks pregnant, at risk of delivering within seven

days, and you had a prior course of corticosteroids more than 14 days previously.

Magnesium sulfate. Your doctor might offer magnesium sulfate if you have a high risk of

delivering between weeks 24 and 32 of pregnancy. Some research has shown that it might reduce

the risk of a specific type of damage to the brain (cerebral palsy) for babies born before 32 weeks

of gestation.

Tocolytics. Your health care provider might give you a medication called a tocolytic to

temporarily slow your contractions. Tocolytics may be used for 48 hours to delay preterm labor to

allow corticosteroids to provide the maximum benefit or, if necessary, for you to be transported to

a hospital that can provide specialized care for your premature baby. Tocolytics don't address the

underlying cause of preterm labor and overall have not been shown to improve babies' outcomes.
Your health care provider won't recommend a tocolytic if you have certain conditions, such as

pregnancy-induced high blood pressure (preeclampsia).

B. Surgical Procedures

Cervical cerclage

During this procedure, the cervix is stitched closed with strong sutures. Typically, the

sutures are removed after 36 completed weeks of pregnancy. If necessary, the sutures can be

removed earlier. Cervical cerclage might be recommended if you're less than 24 weeks pregnant,

you have a history of early premature birth, and an ultrasound shows your cervix is opening or

your cervical length is less than 25 millimeters.

C. Prevention

Progesterone Therapy

Progesterone is a hormone known for its role in maintaining pregnancy. In the early stage

of the pregnancy, this hormone is produced by the corpus luteum. Progesterone concentrations in

peripheral blood drop before the onset of labor in most mammalian species. Nevertheless, this

mechanism is not present in human. It is known that administration of progesterone receptor

antagonists to pregnant women causes cervical ripening and shortening and can lead to onset of

labor. For this reason, it has been proposed that progesterone administration can prevent preterm

cervical ripening.
Cervical pessary

The cervical pessary is a soft and flexible silicone device. It is folded and put around the

cervix by a simple vaginal examination without causing any pain. Although the exact working

mechanism is still unknown, pessaries may distribute the weight of the uterus on to the vaginal

floor and relieve pressure on the internal os. Therefore, a pessary might prevent premature

dilatation of the cervix and preterm rupture of the membranes. In addition, a pessary might support

the immunological barrier between the chorion and vaginal microbiological flora, which helps to

prevent PTB.

To promote a healthy, full-term pregnancy.

 Seek regular prenatal care. Prenatal visits can help your health care provider monitor your

health and your baby's health. Mention any signs or symptoms that concern you. If you have

a history of preterm labor or develop signs or symptoms of preterm labor, you might need to

see your health care provider more often during pregnancy.

 Eat a healthy diet. Healthy pregnancy outcomes are generally associated with good nutrition.

In addition, some research suggests that a diet high in polyunsaturated fatty acids (PUFAs)

is associated with a lower risk of premature birth. PUFAs are found in nuts, seeds, fish and

seed oils.

 Avoid risky substances. If you smoke, quit. Ask your health care provider about a smoking

cessation program. Illicit drugs are off-limits, too.


 Consider pregnancy spacing. Some research suggests a link between pregnancies spaced less

than six months apart, or more than 59 months apart, and an increased risk of premature birth.

Consider talking to your health care provider about pregnancy spacing.

 Be cautious when using assisted reproductive technology (ART). If you're planning to use

ART to get pregnant, consider how many embryos will be implanted. Multiple pregnancies

carry a higher risk of preterm labor.

 Manage chronic conditions. Certain conditions, such as diabetes, high blood pressure and

obesity, increase the risk of preterm labor. Work with your health care provider to keep any

chronic conditions under control.

VII. Nursing Process

Assessment

 Assess the signs and symptoms of term labor and pre-term labor

o Regular or frequent sensations of abdominal tightening (contractions)

o Constant low, dull backache

o A sensation of pelvic or lower abdominal pressure

o Mild abdominal cramps

o Vaginal spotting or light bleeding

o Preterm rupture of membranes — in a gush or a continuous trickle of fluid after the

membrane around the baby breaks or tears

o A change in type of vaginal discharge — watery, mucus-like or bloody

 Know the difference between true and false labor

 Review the obstetric history of the patient and know the patient’s risk factors
Diagnosis

 Suspected pre-term labor

 When diagnosing the patient it is best to know that some signs and symptoms of pre-term

labor are very subtle.

 Acknowledge the patient’s feelings of confusion and doubt when should she reach for help.

 Diagnosis for pre-term labor is difficult and some cases may be uncertain and may cause a

misdiagnosis of the pre-term labor.

Intervention

 Do not perform digital vaginal exam on the patient

o Sterile speculum exam should be done

 To rule out pre-term rupture of the membranes

 To obtain swab of fetal fibronectin (if available)

 Note the pcp and perform the initial assessments

 Confirm accurate dating

 Palpate contractions- frequency, duration, intensity, and resting tone

 Have the woman empty her bladder and get the urinalysis of the patient

 Begin electronic fetal monitoring to assess fetal response and contractions

o Do not rely solely on contraction assessment and external electronic fetal monitor

alone

 Initiate IV- antibiotics, hydration, and other medication


Planning

Anxiety

 Patient will be relieved of anxiety related to the situational crisis that is on the patient

 Patient will be able to verbalize the understanding of the individual situation and outcome

 Patient will appear relaxed and have the maternal vital signs within the normal limits

Risk for fetal injury

 Patient will maintain pregnancy at least within the point of fetal maturity

Acute pain

 Patient will be able to verbalize discomfort

 Patient will use relaxation techniques to ease discomfort

Evaluation

 Intended outcomes: appropriate management of pre-term labor

 Women who experience multiple episodes of preterm labor will be encouraged to seek help

and assessment for each new episodes.

Sample evaluation for anxiety:

Explain the procedures, nursing Information and knowledge of the reasons of these

interventions, and treatment regimen. activities can decrease fear of the unknown.

Keep communication open; discuss with

the client the possible side effects and

outcomes while maintaining an

optimistic attitude.
Orient client and partner to labor suite Helps client and/or significant others feel at ease

environment and more comfortable in their surroundings.

Answer questions honestly, especially Provision of clear information can help the client or

information regarding contraction pattern couple understand what is happening and may

and fetal status. reduce anxiety.

Encourage use of relaxation techniques. Enables the client to obtain maximum benefit from

rest periods; prevents muscle fatigue and improves

uterine blood flow.

Encourage verbalization of fears or Can help reduce anxiety and stimulate identification

concerns. of coping behaviors.

Monitor maternal and fetal vital signs. Vital signs of client and fetus may be altered by

anxiety. Stabilization may reflect reduction anxiety

level.

Assess support systems available to the The assistance and caring of significant others,

client or couple, whether the client including caregivers, are extremely important

remains hospitalized or is to return home during this time of uncertainty and stress. If the

to await delivery. client is to return home, additional support will be


required to meet self-care needs and homemaker

activities as well as child care, as appropriate.

Administer sedative if other measures are Provides soothing and tranquilizing effect.

not successful.

References:

American College of Obstetricians and Gynecologists. (2019, January). Preterm Labor and Birth.

Blencowe H, Cousens S, Oestergaard M, Chou D, Moller AB, Narwal R, Adler A, Garcia CV,

Rohde S, Say L, Lawn JE. National, regional and worldwide estimates of preterm birth.

The Lancet, June 2012. 9;379(9832):2162-72.

Gibson, J. (2011). Pharmacologic Management of Preterm Labor and Prevention of Preterm Birth.

Retrived from: https://www.uspharmacist.com/article/pharmacologic-management-of-

preterm-labor-and-prevention-of-preterm-birth

Institute of Medicine. 2007. Preterm Birth: Causes, Consequences, and Prevention. Washington,

DC: The National Academies Press. https://doi.org/10.17226/11622.

Kilpatrick, Sarah & Garrison, E.. (2007). Normal Labor and Delivery. 10.1016/B978-0-443-

06930-7.50014-1

Uy, J. R. (2015). More preterm babies surviving, but more being born too. Lifestyle.
VON DER POOL, B. Preterm Labor: Diagnosis and Treatment. Retrived from:

https://www.aafp.org/afp/1998/0515/p2457.html