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Premature/Preterm Labor

A.  General information

1.  Labor that occurs before the end of the 37th

week of pregnancy. 

2.  Cause is frequently unknown, but the following conditions are associated with premature labor. 

a.  Cervical incompetence

b.  Preeclampsia/eclampsia

c.  Maternal injury

d.  Infection (urinary tract infection)e.  Multiple gestation, polyhydramnios

f .  Placental disorders

3.  Preterm labor: Prevention

a.  Minimize or stop smoking: a major factor in preterm labor and birth. 

b.  Minimize or stop substance abuse/chemical dependency. 

c.  Early and consistent prenatal care. 

d.  Appropriate diet/weight gain. 

e.  Minimize psychological stressors. 

f .  Minimize/prevent exposure to infections. 

g.  Learn to recognize signs and symptoms of preterm labor. 

4.  Incidence of preterm labor is between 5% and 10% in all pregnancies and is major cause of perinata

mortality. 

B.  Medical Management

1.  Unless labor is irreversible, or a condition exists in which the mother or fetus would be jeopardized

by the continuation of the pregnancy, or the membranes have ruptured, the usual medical

intervention is to attempt to arrest the premature labor (tocolysis). 

2.  Medications used in the treatment of premature labor

a.  Magnesium sulfate

1) Stops uterine contractions with fewer side effects than beta-adrenergic drugs. 

2) Interferes with muscle contractility. 

3) Administered IV for 12 to 24 hours, PO form of magnesium may be used for

maintenance. 

a)  Loading dose of 4-6 grams IV over 20-30 minutesb)  Maintenance dose IV 1-3g/hr (piggyback)

c)  Must monitor client for magnesium toxicity

4) Few serious side effects; initially client feels hot, flushed, sweats, may c/o

headache, nausea, diarrhea, dizziness, nystagmus, and lethargy

5) Most serious side effect: respiratory depression. 

6) Most common fetal side effect is hypotonia. 

b.  Beta-adrenergic drugs Terbutaline and Ritodrine. 

1) Decreases effect of calcium on muscle activation to slow or stop uterine

contractions. 

2) Initially give IV, then PO brethine (terbutaline) for maintenance. 

3) Terbutalinea)  1-8 mg/min x 8-12 hrs

b)  2.5 5 mg PO q4 4-8 hrs

4) Ritodrine

a)  0.05-0.1 mg/min increased to 0.35 mg/min until contractions stop. 

b)  10-20 mg q 2 h for 24 hours

5) Side effects: increased heart rate, nervousness, tremors, nausea and vomiting,

decrease in serum K+ level, cardiac arrhythmias, pulmonary edema. 

c.  Nifedipine

1) Calcium channel blockers

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2) 10-30 mg loading dose, oral or sublingual; second dose may be given in 30 min if 

contractions persist; 1020 mg orally q hr for maintenance. 

3) Side effects: facial flushing, mild hypotension, reflex tachycardia, headache, nausea

d.  Indomethacin

1) Prostaglandin synthetase inhibitor

2) Loading dose: 50-100 mg PO or rectally: 25 mg q 4-6 hr for 24-48 hr maintenance

3) Side effects: nausea, vomiting, dyspepsia

3.  When premature labor cannot or should not be arrested and fetal lung maturity needs to be

improved, the use of betamethasone (celestone) can improve the L/S ratio of the lung surfactants. Itis administered IM to the mother, usually every 12 hr times 2, then weekly until 34 weeks gestation. 

C.  Nursing interventions

1.  Keep client at rest, side-lying position. 

2.  Hydrate the client and maintain with IV or PO fluids. 

3.  Maintain continuous maternal/fetal monitoring. 

a.  Maternal/fetal vital signs every 10 minutes; be alert for abrupt changes. 

b.  Monitor maternal I & O. 

c.  Monitor urine for glucose and ketones. 

d.  Watch cardiac and respiratory status carefully. 

e.  Evaluate lab test results carefully. 

4.  Administer drugs as ordered/indicated. 

a.  Terbutaline

1) Position client on side as much as possible. 

2) Apply external fetal monitor. 

3) Complete maternal/fetal assessment before each can increase in dosage rate. 

4) Special maternal assessment includes respiratory status, blood pressure, pulse,

I&O, lab values. 

5) Notify physician of significant changes. 

6) Support client through stressful period of treatment and uncertainty. 

7) Teach client necessity of continuing oral medication at home if discharged. 

b.  Magnesium sulfate: carefully monitor respirations, reflexes, and urinary output. 

5.  Keep client informed of all progress/changes. 

6.  Identify side effects/complications as early as possible. 7.  Carry out activities designed to keep client comfortable. 

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Postmature/Prolonged Pregnancy

A.  General information

1.  Defined as those pregnancies lasting beyond the end of the 42nd

week. 

2.  Fetus at risk due to placental degeneration and loss of amniotic fluid (cord accidents)

3.  Decreased amounts of vernix also allow the drying of the fetal skin, resulting in a dry, parchment like

skin condition. 

B.  Medical management

1.  Directed toward ascertaining precise fetal gestational age and condition, and determining fetalability to tolerate labor

2.  Induction of labor and possibly cesarean birth

C.  Assessment findings

1.  Measurements of fetal gestational age for fetal maturity

2.  Biophysical profile

D.  Nursing interventions

1.  Perform continual monitoring of maternal/fetal vital signs. 

2.  Support mother through all testing and labor

3.  Assist with amnio-infusion if ordered to increase cushion for cord. 

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Prolapsed Umbilical Cord

A.  General information

1.  Displacement of cord in a downward direction, near or ahead of the presenting part, or into the

vagina. 

2.  May occur when membranes rupture, or with ensuing contractions

3.  Associated with breech presentations, unengaged presentations, and premature labors

4.  Obstetric emergency: if compression of the cord occurs, fetal hypoxia may result in CNS damage or

death. B.  Assessment findings: vaginal exam identifies cord prolapsed into vagina

C.  Nursing interventions

1.  Check fetal heart tones immediately when membranes rupture, and again after next contraction,

or within 5 minutes; report decelerations. 

2.  If fetal bradycardia, perform vaginal examination and check for prolapsed cord. 

3.  If cord prolapsed into vagina, exert upward pressure against presenting part to lift part off cord,

reducing pressure on cord. 

4.  Get help to move mother into a position where gravity assists in getting presenting part off cord

(knee-chest position or severe (Trendelenburgs)

5.  Administer oxygen, and prepare for immediate cesarean birth. 

6.  If cord protrudes outside vagina, cover with sterile gauze moistened with sterile saline while

carrying out above tasks. Do not attempt to replace cord. 

7.  Note physician.