Premature Premature LaborLaborOR OR

Preterm labourPreterm labour

Premature Premature labourlabour

((Preterm labour)Preterm labour)

INTRODUCTIONINTRODUCTION Premature labour is generally a Premature labour is generally a

labour that occurs after 20 wks & labour that occurs after 20 wks & before before

37 completed wks of gestation37 completed wks of gestation

DEFINITIONDEFINITIONPreterm labour Preterm labour (PTL) is defined as (PTL) is defined as one where the one where the labour starts labour starts before the 37before the 37thth completed week completed week (<259 days), (<259 days), counting from the counting from the 11stst day of the last day of the last menstrual periodmenstrual period

DEFINITIONDEFINITION

Pre term labour is defined by Pre term labour is defined by WHO as onset of labour prior to WHO as onset of labour prior to the completion of 37 weeks of the completion of 37 weeks of gestation in a pregnancy beyond gestation in a pregnancy beyond 20 weeks of gestation20 weeks of gestation..

INCIDENCEINCIDENCEApprox. 10% of deliveries in Approx. 10% of deliveries in public hospital occur before the public hospital occur before the 3737thth week week

A much smaller %age is involved A much smaller %age is involved in the 24-32 weeks period.in the 24-32 weeks period.

The prevalence widely varies and The prevalence widely varies and ranges between 5-10%ranges between 5-10%

ETIOLOGYETIOLOGYIn about 50%, the cause of preterm In about 50%, the cause of preterm labour is not knownlabour is not known

But some of the But some of the high risk factors are:high risk factors are:

HISTORY

COMPLICATIONSIn Present

Pregnancies

IATROGENIC

IDIOPATHIC

Conti..Conti..HISTORYHISTORY-- --previous history of abortion or previous history of abortion or

preterm delivery preterm delivery

--recurrent UTI recurrent UTI

--smoking habitssmoking habits

--low socio-economic & nutritional low socio-economic & nutritional statusstatus

MalpresentationsMalpresentationsPrevious abortion historyPrevious abortion history

ContiConti....COMPLICATIONS IN PRESENT COMPLICATIONS IN PRESENT

PREGNANCYPREGNANCY- - It may be due to 3 It may be due to 3 causes:-MATERNAL causes:-MATERNAL

-FETAL-FETAL

-PLACENTAL-PLACENTAL

A) A) MATERNAL MATERNAL ::

Pregnancy

Uterine anomalies

Genital tractinfection

Medical & surgicalillness

INFECTIONINFECTION PRE ECLAMPSIAPRE ECLAMPSIA

Incompetent cervixIncompetent cervix malformation of uterusmalformation of uterus

ContiConti....FETAL FETAL : : - Multiple pregnancy- Multiple pregnancy

- - Congenital malformations Congenital malformations - IUD- IUD

PLACENTALPLACENTAL :- :- InfarctionInfarction -Thrombosis-Thrombosis - Placenta praevia or - Placenta praevia or

abruption abruption

Conti..Conti.. IATROGENIC:IATROGENIC:

-Elective induction with wrong -Elective induction with wrong estimation of gestational estimation of gestational

period.period.- IDIOPATHICIDIOPATHIC: :

-Premature effacement of cervix -Premature effacement of cervix with with hyper-irritable uterus hyper-irritable uterus

-Early engagement of head-Early engagement of head

ETIOPATHOGENESISETIOPATHOGENESISACTIVATION OF FETAL ACTIVATION OF FETAL HPA HPA AXIS AXIS

CRH, CRH, Cortisol Cortisol PGEPGE22, F, F22αα

TXATXA22,,

LeukotrienesLeukotrienes

↓ ↓ PG DehydrogenasePG Dehydrogenase

choriodecidual bacterial choriodecidual bacterial proteases proteases

Colonisation Colonisation TNF, TNF,

IL-1,6,8 IL-1,6,8

myometrialmyometrial

PATHOLOGIC UTERINE ENLARGEMENTPATHOLOGIC UTERINE ENLARGEMENT contraction contraction

(Polyhydramnios , multiple pregnancy)(Polyhydramnios , multiple pregnancy) cervical cervical

Mechanical stretch, Mechanical stretch, IL8 ripening IL8 ripening

Gap junction, Gap junction, PG Synthesis PG Synthesis

preterm labour and preterm labour and

delievery delievery

Chorion, amnion &

decidua

Risk factorsRisk factors

Low BMILow BMI Short maternal heightShort maternal height History of spontaneous pre term birthHistory of spontaneous pre term birth Bacterial vaginitis.Bacterial vaginitis. Asymptomatic bacteriuriaAsymptomatic bacteriuria Low socio economic statusLow socio economic status Short cervical lengthShort cervical length

Factors influencing during Factors influencing during pregnancypregnancy

Multiple pregnancyMultiple pregnancy Use of fertility medicationUse of fertility medication High blood pressureHigh blood pressure Pre –eclampsiaPre –eclampsia Maternal diabetes mellitusMaternal diabetes mellitus AsthmaAsthma Thyroid diseaseThyroid disease

Cont..Cont.. Heart diseasesHeart diseases Uterine malformationsUterine malformations Placenta praeviaPlacenta praevia Abruptio placentaAbruptio placenta Poly hyrdaminosPoly hyrdaminos OligohydramniosOligohydramnios Anxiety & depressionAnxiety & depression Use of tobacco, cocaineUse of tobacco, cocaine

Excessive alcohol during pregnancyExcessive alcohol during pregnancy babies with birth defectsbabies with birth defects

SIGN AND SYMPTOMSSIGN AND SYMPTOMS

BackacheBackache Contractions every 10 minutes are more Contractions every 10 minutes are more

oftenoften Cramping in lower abdomenCramping in lower abdomen Menstrual like cramps( feel like gas pain Menstrual like cramps( feel like gas pain

, not a/w diarrhea), not a/w diarrhea) Fluid leaking from vaginaFluid leaking from vagina Flu like symptoms- nausea, vomiting, Flu like symptoms- nausea, vomiting,

diarrheadiarrhea

Cont..Cont..

Increased pressure in pelvisIncreased pressure in pelvis Increased vaginal bleedingIncreased vaginal bleedingRegular uterine activityRegular uterine activityVaginal spottingVaginal spottingPelvic pressurePelvic pressure

DIAGNOSIS Regular uterine contractions with or Regular uterine contractions with or

without pain without pain (at least one in every 10 (at least one in every 10 mins.)mins.)

DilatationDilatation((≥2cm) ≥2cm) & Effacement & Effacement (80%)(80%) of of the cervixthe cervix

Length of cervix Length of cervix ≤≤2.5cm2.5cm Funnelling of internal OSFunnelling of internal OS Pelvic pressure, backache or vaginal Pelvic pressure, backache or vaginal

discharge or bleding. discharge or bleding.

INVESTIGATIONSINVESTIGATIONSFull blood countFull blood countRoutine urineRoutine urine-analysis,culture & -analysis,culture &

senstivity senstivityCervicovaginal SwabCervicovaginal Swab- -

culture,FIBRONECTINculture,FIBRONECTINSerum electrolytes & glucose levels Serum electrolytes & glucose levels

when tocolytic agents are to be usedwhen tocolytic agents are to be used

USGUSG-fetal well -fetal well being, cervical being, cervical length & length & placental placental localizationlocalization

FIBRONECTINFIBRONECTINA A PROTEINPROTEIN that binds that binds the the FETALFETAL MEMBRANESMEMBRANES to to DECIDUADECIDUANormally found in Normally found in CERVICOVAGINALCERVICOVAGINAL dischargedischarge beforebefore 22wks22wks & again & again afterafter 37wks37wks of pregnancy of pregnancy

PRESENCE OF PRESENCE OF FIBRONECTIN IN CVD FIBRONECTIN IN CVD B/W 24Wks & 34 Wks B/W 24Wks & 34 Wks PREDICTS PREDICTS PRE-TERM PRE-TERM LABOURLABOUR

MANAGEMENTMANAGEMENTIt includesIt includes

Prevention,if possible

Arrest of preterm Labour, if not

contraindicated

Appropriate management

Neonatal care

Prevention of Prevention of Preterm LabourPreterm LabourPrimary CarePrimary Care – –

to reduce the incidence of preterm to reduce the incidence of preterm labour by reducing the high risk factorslabour by reducing the high risk factors (e.g. (e.g. infection etc.)infection etc.)

Secondary CareSecondary Care includes screening tests for early includes screening tests for early

detection & prophylactic treatment detection & prophylactic treatment (e.g. (e.g. tocolytics)tocolytics)

Tertiary careTertiary care-- to reduce the perinatal morbidity & to reduce the perinatal morbidity &

mortality after the diagnosis mortality after the diagnosis (e.g. use of (e.g. use of corticosteroids)corticosteroids)

Cont..Cont..

Seek regular prenatal careSeek regular prenatal careEat a healthy dietEat a healthy dietGain weight wiselyGain weight wiselyAvoid risky substancesAvoid risky substancesConsider pregnancy spacingConsider pregnancy spacingBe cautious when using assisted Be cautious when using assisted

reproductive technology (ART)reproductive technology (ART)

Taking preventive medications , who Taking preventive medications , who has short cervix( Progesterone)has short cervix( Progesterone)

Restricting sexual activity.Restricting sexual activity.Limiting certain physical activities.Limiting certain physical activities.Managing chronic conditions such as Managing chronic conditions such as

DM, Increased BP.DM, Increased BP.

ARRESTING PRETERM ARRESTING PRETERM LABOURLABOUR

BED RESTBED REST--Left lateral position Left lateral position ADEQUATE HYDRATIONADEQUATE HYDRATION PROPHYLACTIC ANTIBIOTICPROPHYLACTIC ANTIBIOTICTOCOLYTIC AGENTSTOCOLYTIC AGENTS-Eg.-Eg.TERBUTALINETERBUTALINE INDOMETHACININDOMETHACIN NIFEDIPINEsNIFEDIPINEs short termshort term long termlong term

Conti..Conti..SHORT TERM THERAPY SHORT TERM THERAPY Most successful therapyMost successful therapy

OBJECTIVES: OBJECTIVES:

-TO DELAY delivery for 48hrs for -TO DELAY delivery for 48hrs for glucocorticoidglucocorticoid t therapyherapy to mother to enhance to mother to enhance

fetal lung maturation fetal lung maturation

-IN UTERO TRANSFER of the patient to a -IN UTERO TRANSFER of the patient to a unit more able to manage a preterm neonate unit more able to manage a preterm neonate

GLUCOCORTICOIDGLUCOCORTICOID THERAPYTHERAPY

Advocated in pregnancy less than 34 Advocated in pregnancy less than 34 wks.wks.

Helps in fetal lung maturationHelps in fetal lung maturationReduces incidence of RDS & IVHReduces incidence of RDS & IVH

RISKSRISKSPROM with evidence of infectionPROM with evidence of infection IDDM where patients needs insulin dose IDDM where patients needs insulin dose

readjustmentreadjustment

Conti..Conti..CONTRA-CONTRA-

INDICATIONSINDICATIONSMATERNAL FETAL OTHERS

Gestational Gestational diabetesdiabetes

Placenta Placenta praviea.praviea.

In case of In case of placental placental abnormalitiesabnormalities..

APPROPRIATE APPROPRIATE MANAGEMENTMANAGEMENT

There are basically 2 principles:There are basically 2 principles:

To prevent birth asphyxia & To prevent birth asphyxia & development of RDS development of RDS

To prevent birth trauma To prevent birth trauma

FIRST FIRST STAGESTAGE Patient is put to bed to prevent PROMPatient is put to bed to prevent PROM To ensure adequate fetal oxygenationTo ensure adequate fetal oxygenation Strong sedative avoidedStrong sedative avoided Epidural analgesia is of choiceEpidural analgesia is of choice Labour should be watched by Labour should be watched by

intensive clinical monitoring intensive clinical monitoring In case of delay, caesarean section In case of delay, caesarean section

should be performedshould be performed

SECOND SECOND STAGESTAGE The The birthbirth shouldshould bebe gentlegentle && slow to avoid rapid slow to avoid rapid

compression & decompression of head compression & decompression of head EpisiotomyEpisiotomy may be done under may be done under locallocal anesthesiaanesthesia

to minimize head compression if there is perineal to minimize head compression if there is perineal resistanceresistance

Tendency to delay Tendency to delay is curtailed by low forceps. is curtailed by low forceps. Routine forceps is not indicatedRoutine forceps is not indicated

The cord is to be clamped The cord is to be clamped immediately at birth to immediately at birth to prevent HYPERVOLEMIA & HYPERBILIRUBINEMIA prevent HYPERVOLEMIA & HYPERBILIRUBINEMIA

To shift the baby to intensive neonatal care unit To shift the baby to intensive neonatal care unit under care of under care of NEONATOLOGISTNEONATOLOGIST

IMMEDIATE IMMEDIATE MANAGEMENTMANAGEMENT

The cord is to be clamped quicklyThe cord is to be clamped quickly The cord length is kept long in case The cord length is kept long in case

exchange transfusion is requiredexchange transfusion is required The air passage should be cleared of mucusThe air passage should be cleared of mucus Adequate oxygenationAdequate oxygenation Aqueous solution of vit.k 1mg given I/M to Aqueous solution of vit.k 1mg given I/M to

prevent hemorrhagic manifestationsprevent hemorrhagic manifestations The baby should be wrapped including head The baby should be wrapped including head

in a sterile warm towel in a sterile warm towel

NURSING MANAGEMENTNURSING MANAGEMENT1.1. Assess the mother’s condition to Assess the mother’s condition to

evaluate signs of labour.evaluate signs of labour. Obtain a through obstetrics historyObtain a through obstetrics history Determine the frequency , duration,& Determine the frequency , duration,&

intensity of uterine contraction.intensity of uterine contraction. Determine the cervical dilatation and Determine the cervical dilatation and

effacement.effacement. Assess the status of membranes, and Assess the status of membranes, and

bloody showbloody show

Cont..Cont..2.Evaluate the factors for distress, size and 2.Evaluate the factors for distress, size and

maturity.maturity.

(sonography & lecithin-sphingomyelin ratio)(sonography & lecithin-sphingomyelin ratio)

3. Perform measures to manage or stop pre 3. Perform measures to manage or stop pre term labour.term labour.

Place the client on bed rest in the side lying Place the client on bed rest in the side lying position.position.

Prepare for possible ultrasongraphy, Prepare for possible ultrasongraphy, amniocentesis, tocolytic drug therapy or amniocentesis, tocolytic drug therapy or steroid therapy.steroid therapy.

Administer tocoltyic agent as Administer tocoltyic agent as prescribed.prescribed.

Assess for side effects of tocolytic Assess for side effects of tocolytic therapytherapy

Decreased maternal Blood pressureDecreased maternal Blood pressure DyspneaDyspnea Chest painChest pain FHS >180beats/minFHS >180beats/min

Cont..Cont..

4- provide physical and emotional 4- provide physical and emotional support support

5- Provide adequate hydration5- Provide adequate hydration6- Provide client and family 6- Provide client and family

education.education.

PROGNOSISPROGNOSISResults in Results in high high

-perinatal mortality-perinatal mortality

-perinatal morbidity-perinatal morbidity• With intensive neonatal care unitWith intensive neonatal care unit, ,

survival rate of the baby weighing b/w survival rate of the baby weighing b/w 1000 to 1500 gm is more than 90%1000 to 1500 gm is more than 90%

• WITH USE OF SURFACTANTWITH USE OF SURFACTANT, survival , survival rate of infants born at 26wks is about rate of infants born at 26wks is about 80%80%

CLIENT CLIENT EDUCATIEDUCATIONON

All PREGNANT women All PREGNANT women should recognize should recognize following following S/S ‘s:-S/S ‘s:- -uterine contractions -uterine contractions every 10-15 minutes or every 10-15 minutes or lessless -menstrual-like -menstrual-like crampingcramping -dull backache-dull backache -lower abdominal -lower abdominal pressurepressure -diarrhea-diarrhea -increase or change in -increase or change in vaginal dischargevaginal discharge -vaginal bleeding-vaginal bleeding