Preterm Labor (Sneha)

Case Presentation
on
Preterm Labor
Prepared By
Sneha Bakuli
Gnm 3rd year student
Introduction
Preterm labor leading to preterm birth is a major clinical problem,
especially in developing countries that have limited resources to handle
the problems of the premature neonates. More than 60% of preterm birth
occurs in Africa and south Asia, but preterm birth is a global problem. It is
the direct cause of neonatal death worldwide and the second most
common cause of death for children under the age of five.
Threatened preterm labor is diagnosed when there are uterine

contractions but no change in the cervix
Incidence
 Of all pregnancies 5-18% end in preterm labor. Within developing

countries, families in the lower socio-economic class are at a higher risk
for preterm birth. Among the total 27 million babies born annually,
3.6million babies are born preterm.
 The premature Labor effects almost 23% pregnancies in India
 Africa and south Asia 60% premature babies develop
 Europe 5-9%
Normal Labor
 Series of events that take place in the genital organs in an effort to

expel expel the viable products of conception (fetus, placenta and the
membranes) out of the womb through the vagina into the outer world
is called Labor.
 Labor is called Normal if it fulfills the following criteria:-
1. Spontaneous in onset and at term
2. With Vertex Presentation
3. Without undue prolongation
4. Natural termination with minimal aids
5. Without having any complications affecting the health of mother and
Definition
 Preterm Labor is defined as one where the labor starts dilatation of

the cervix, prior in 37 weeks gestation the 37th completed week<259
days), counting from the first day of the last menstrual period
Preterm labor is defined as the presence of uterine contractions of
sufficient frequency and intensity to result in progressive effacement and
dialtation of the cervix, prior 37 weeks gestation
Classification
 Extremely Preterm: < 28 weeks

 Very early Preterm : 28 to < 32 weeks
 Early Preterm : 32 to < 34 weeks
 Late Preterm : 34 to <37 weeks
Etiology
High Risk Factors Associated with PTL:

A .History : a. Previous History of preterm delivery induced on
spontaneous abortion
b. Pregnancy following assisted reproductive techniques
c. Recurrent urinary tract infections
d. Smoking habits
e. Low socio-economic and nutritional status
f. Maternal stress
g. Genetic- mother, born preterm ,has high risk of delivery her baby
preterm
PREVIOUS ABORTION
MALPRESENTATION HISTORY
 B.Complications in present pregnancy: Due to maternal,fetal or placental
Maternal:-
a. Pregnancy complications :- preeclampsia , PROM,APH, Polyhydraminos
b. Uterine anomalies:- Cervical incompetence, malformations of uterus
c. Medical and surgical illness:- acute fever, diarrhoea , severe anemia, low
body mass index, acute diabetes
d. Genital tract infections:- Bacterial vaginosis, betahaemolytic streptococcus, bacterioides
Fetal multiple pregnancy, congenial malformations & intrauterine death

Placental: Infarction, thrombosis, placenta Previa
Malformation of uterus Incompetent cervix
C. Iatrogenic:- indicated Preterm delivery due to medical (Severe
preeclampsia) or obstetric complications (APH)
D. Idiopathic:- Majority- premature effacement of the cervix with
irritable uterus and early engagement of the head are often associated,
in the absence of any complicating factors
Clinical Manifestations
 Uterine contractions in every 10 min

 Vaginal bleeding
 Increased Pelvic Pressure
 Dull Back ache
 Increased Vaginal discharge
 Cervical effacement and dialtation
 Lower Abdominal Cramping
Diagnostic Evaluation
 History Taking
 Physical Examination
 Complete Blood count
 Speculum examination of cervix
 USG evaluation
 Tocodynamometry
Differential Diagnosis:-
General Examination: Pulse, Bp , Temperature , FHR
 Fetal Fibronectin Testing
 Amniocentesis
 Serum electrolytes & glucose levels when toclytic agents are to be
used
Complications
Fetal:-
 Breathing Difficulties
 Intraventricular hemorrhage
 Severe intestinal inflammation
 Patent ductus ateriosus
 Hypotension
 Anemia
 Disseminated intravascular Coagulopathy
 Necrotizing Enterocolitis
 Hypocalcemia
 Hyperglycemia
 Retinopathy of Prematurity
 Hypotonia
 Renal Glysuria
 Edema
Long term complications:-
Long term Complications
 Recurrent Hospitalization
 Bronchopulmonary Displasia
 Poor Growth due to feeding problems, vit & iron deficiency
 CNS dysfunctions, CP, Learning difficulties, deafness, hydrocephalus
Maternal Complications:-
 Anxiety
 Post traumatic Stress Disorder
 PPH
 Chorioamnionitis
 Retained Placenta
Prediction of preterm labor
Clinical predictors
1. Multiple pregnancy
2. History of preterm birth
3. Presence of Genital tract infection
4. Bleeding
5. Symptoms of PTL
Biophysical Predictors
6. Uterine contractions <4/hr
7. Bishop score> 4
8. Cervical length< 25 mm
Biochemical Predictors :-
1. Fetal fibronectin( fFN) in cervico vaginal discharge
 Fibronectin:- A protein that binds the fetal Membranes to decidua

 Normally find in cervico vaginal discharge Before 22 weeks and again after
37 weeks Of Pregnancy.
 Presence of fibronectin In cvd B/W Before 24 weeks & 34 weeks Predicts
Preterm Labor
Management of preterm Labor
 To prevent preterm onset of preterm Labor

 To arrest preterm Labor, if not contraindicated
 Appropriate Management of labor
 Effective Neonatal Care
Prevention of preterm Labor
 Primary care:- to reduce the incidence of preterm Labor by reducing

the high risk factors(e.g. infection etc.)
 Secondary care:- Includes the screening test for early detection &
prophylactic treatment (e.g- tocolytic)
 Tertiary care:- To reduce the perinatal morbidity & mortality after
diagnosis(e.g- use of corticosteroids)
Cont…
1. Seek Regular Perinatal care
2. Eat healthy diet
3. Avoid risky substances
4. Consider pregnancy spacing
5. Managing chronic conditions such as DM, increased BP
6. Gain weight wisely
7. Restricting Sexual activity
8. Taking preventive medication who has short cervix
Arresting preterm labor, If not
Contraindicated
 Bed Rest : left lateral position
 Adequate hydration
 Prophylactic antibiotic : Ampicillin
 Tocolytic agents :- e.g – Terbutaline, nifedipine
it should be administrator to inhibit uterine contractions.it should be
used as short term or long term therapy
Short term therapy
 Most successful therapy
Objectives- To delay delivery for 48 hours for glucocorticoid therapy to
mother to enhance fetal lung maturation
In utero Transfer to the patient to a unit more able to manage preterm
neonate
Glucocorticoid therapy
 Advocated in pregnancy less than 34 weeks

 Helps in Fetal lung maturation
 Reduces incidence of RDS & IVH
Appropriate Management
There are basically 2 principles:-

1. To prevent Birth asphyxia and development of RDS
2. To prevent Birth Trauma
First stage
 patient is to put to bed first for prevent early rupture of membrane
 To ensure adequate foetal oxyegenation by giving oxygen mask to
the mother
 Epidural anaesthesia is of choice
 Labor should be carefully monitored with Continuous EFM
 Ceaserean delivery Is done for obstetric reasons only
 Nicu is a sin-quanom for Good outcome
Second stage
 The birth should be gentle and slow to avoid rapid compression and
decompression Of the heal
 Episiotomy done to minimal under local anaesthesia
 Tendency delayed is curtailed by forceps
 Cord is to be clamped
 To Shift the baby to intensive care unit
Immediate Management
 The Cord is to be clamped quickly

 The cord length is kept long in case exchange transfusion required
 Air passage should be cleared of mucus
 Adequate oxygenation
 Aqueous solution of vit k 1mg given to IM to prevent hemorrhagic
manifestation
 Baby should be wrapped including head in a sterile towel
 Shift the baby to NICU if critical situation arises
Nursing Diagnosis
 Anxiety and Fear related to unexpected Labor

 Risk for infection related to poor immune system
 Knowledge deficit of mother related to disease conditions and
treatment of the baby
 Anxiety related to prognosis of the baby
Prognosis
 Results in high – perinatal morbidity

Perinatal Mortality
 With intensive neonatal care unit : survival rate of the baby

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Case Presentation

Threatened preterm labor is diagnosed when there are uterine

 Of all pregnancies 5-18% end in preterm labor. Within developing

 Series of events that take place in the genital organs in an effort to

 Preterm Labor is defined as one where the labor starts dilatation of

 Extremely Preterm: < 28 weeks

High Risk Factors Associated with PTL:

Fetal multiple pregnancy, congenial malformations & intrauterine death

 Uterine contractions in every 10 min

 Fibronectin:- A protein that binds the fetal Membranes to decidua

 To prevent preterm onset of preterm Labor

 Primary care:- to reduce the incidence of preterm Labor by reducing

 Advocated in pregnancy less than 34 weeks

There are basically 2 principles:-

 The Cord is to be clamped quickly

 Anxiety and Fear related to unexpected Labor

 Results in high – perinatal morbidity

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