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Labor/Birth
T Stone-Godena, CNM,
MSN
N344 Fall, 2015
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Picklesimer A et al. (2012). The effect of Centering Pregnancy group prenatal care on preterm birth in a lowincome population. AJOG. E415 http://www.centeringhealthcare.org/forms/bibliography/Picklesimer_2012.pdf
Who is at risk?
Women with the greatest associated
risk factor are those with a Previous
Preterm Birth
Women of African American descent
are at significant risk
Women with second trimester
bleeding
Women with a family history of
preterm birth.
These are nonmodifiable risks
Indicated prematurity
20% of PTB is clinically indicated
Conditions associated with intentional
early labor/birth:
Preeclampsia
IUGR
PPROM
Placenta previa or abruptio
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Predicting PTB
If we know who gets it, why cant we stop it?
50% of PTB occurs to women with no known
risk. Risk scoring systems havent worked
There is no ONE identifiable pathophysiology.
What has helped?
Sonographic Cervical Length Measurement.
Strong inverse relationship between cervical
length < 1.5 cm at 18-24 weeks and PTB.
Biochemical tests. fFN. Negative is strongly
correlated with decreased
risk for PTB within 1 week.
If positive only predictive about 1/3.
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Signs/symptoms
Persistent low back ache
Pelvic pressure, cramping
+ Urinary frequency, diarrhea, vaginal
discharge
Contractions (may be painless) >6x/hour x
>1 hour
Cervical change in dilation or effacement
+ PROM
Can be hard to distinguish preterm labor
from preterm contractions without cervical
change!
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Current treatments
With a history of preterm birth,
Progesterone has been shown in some
studies to prolong pregnancy. 17p-alphahydroxyprogesterone-caproate as a
injection or micronized crystals orally or
vaginally beginning between 16-20 weeks
through end of 36th week. life of
progesterone is 7 days, so it is
administered weekly.
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PPROM
Management: expectant vs. active, depends
on gestational age and comorbidities
Risk of infection (chorioamnionitis,
endometritis & neonatal sepsis):
Increased with >18 or 24 hours from PROM to
delivery (depending on study)
Increased with more vaginal exams
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Clinical application
Marge L. is a 38 year old African American G3
P1102 who is pregnant with twins.
At 30 weeks gestation, she begins
to experience low backache and
lower abdominal cramping,
plus diarrhea.
What are her risk factors for
preterm labor?
What other signs and symptoms
should you ask her about?
H/O PTB, African-American, twins,
AMA
SROM, increased vaginal discharge, spotting,
urinary frequency.
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Nursing responsibility
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Results
Urinalysis negative, spec. gravity 1.025.
FHR tracing reassuring.
10 contractions in an hour.
Vital signs are all WNL
fFN positive, cervical ultrasound pending.
Cervix 1/50%.
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PTL PTB
About 1/3 stop contracting
spontaneously
50% who are treated give birth at
term
If 23-34 weeks steroids indicated
Tocolysis used only to have time for
steroids to work (24-48 hrs).
No other measures are evidence
based
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Tocolysis
Terbutaline
Magnesium sulfate
CNS depressant; Relaxes uterine smooth muscle
Loading dose 4-6 g IV over 20-30 min, then 14g/hour. Piggyback, 40 g in 1L, by infusion pump
only.
D/C within 24-48 hours.
Side Effects:
Diaphoresis, hot flushes, burning at infusion
site, N/V, Drowsiness, HA, blurred or double
vision, dry mouth, SOB, transient hypotension,
lethargy, weakness
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MgSO4 cont.
Evidence supporting use as tocolytic is
not conclusive, but especially for
diabetics it is an alternative. Plus
evidence supports improved outcomes
of cerebral palsy in premies.
Nursing responsibilities same as when
used for PEC.
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Nifedipine
Calcium channel blocker
10-20 mg po q3-6 hours until contractions
rare, then long acting formulation for 48
hours
Side Effects:
hypotension, flushing, HA, dizziness,
nausea
Avoid giving with Mag sulfate (skeletal
muscle block) or terbutaline
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Indomethacin
NSAIDblocks prostaglandins
Side Effects:
N/V, heartburn, HA, blurred vision
Prolonged bleeding time, thrombocytopenia (risk
postpartum hemorrhage), asthma if aspirin-sensitive
Pulmonary edema: CP, SOB, respiratory distress,
wheezing, crackles, productive cough w/ blood tinged
sputum
Fetal/NB: constriction ductus arteriosus, oligohydramnios,
neonatal pulmonary HTN
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Wrap up
If PTL cant be stopped, GBS prophylaxis will
be administered.
Fetal monitoring is continuous
Anticipate complications:
malpresentation/malposition, prolapsed cord
with ROM, newborn resuscitation
If not at tertiary care center, transfer
Pediatrician present for birth
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