Preterm Labor

I. Introduction

Preterm labor occurs when regular contractions begin to open your cervix before 37 weeks of pregnancy. A full-term pregnancy should last about 40 weeks.If preterm labor can't be stopped, your baby will be born early. The earlier premature birth happens, the greater the health risks for your baby. Many premature babies (preemies) need special care in the neonatal intensive care unit. Preemies can also have long-term mental and physical disabilities.While the specific cause of preterm labor often isn't clear, certain risk factors may up the odds of early labor. But, preterm labor can also occur in pregnant women with no known risk factors. Still, it's a good idea to know if you're at risk of preterm labor and how you might help prevent it.

ComplicationsMany women treated for preterm labor deliver at or near term. Sometimes, however, preterm labor can't be stopped or an infection or other complications make an early delivery safer for mother or baby.If preterm labor can't be stopped, your baby will be born prematurely. This could pose a number of health concerns, such as low birth weight, breathing difficulties, underdeveloped organs and vision problems. Children who are born prematurely also have a higher risk of learning disabilities and behavioral problems.

PreventionYou might not be able to prevent preterm labor but there's much you can do to promote a healthy, full-term pregnancy. For example: 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, even if you think they're silly or unimportant. 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 for exams and tests. Eat a healthy diet.During pregnancy, you'll need more folic acid, calcium, iron and other essential nutrients. A daily prenatal vitamin ideally starting a few months before conception can help fill any gaps. Avoid risky substances.If you smoke, quit. Smoking might trigger preterm labor. Illicit drugs are off-limits, too.In addition, medications of any type even those available over-the-counter deserve caution. Get your health care provider's OK before taking any medications or supplements. Consider pregnancy spacing.Some research suggests a link between pregnancies spaced less than six 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.If your health care provider determines that you're at increased risk of preterm labor, he or she might recommend taking additional steps to reduce your risk, such as: Taking preventive medications.If you have a history of premature birth, your health care provider might suggest weekly shots of a form of the hormone progesterone called hydroxyprogesterone caproate (Makena) during your second trimester. In addition, new research shows that treatment with a vaginal progesterone gel during the second and third trimesters might decrease the risk of premature birth in women who have short cervixes. These findings have encouraged doctors to pay closer attention to the length of the cervix in women with risk factors for preterm birth and in those who appear to have a shortened cervix on a routine ultrasound. Limiting certain physical activities.If you're at risk of preterm labor or develop signs or symptoms of preterm labor, your health care provider might suggest avoiding heavy lifting or spending too much time on your feet. Managing chronic conditions.Certain conditions, such as diabetes and high blood pressure, increase the risk of preterm labor. Work with your health care provider to keep any chronic conditions under control.If you have a history of preterm labor or premature birth, you're at risk of a subsequent preterm labor. Work with your health care provider to manage any risk factors and respond to early warning signs and symptoms.

II. Personal and Social History of the Patient

Norma Cayno is a 38 year-old pregnant woman who is admitted with a diagnosis of Preterm Labor. She is Gravida 5 Para 4 (G5P4) with a gestational age of 33 weeks and 3 days.Patient encountered this premature labor before during her third baby but stopped because of medicine that her OB-Gyne gave her. She is drinking coffee and soda during the fifth month of pregnancy. No history of Diabetes Mellitus, Hepatitis B, Tuberculosis but a Urinary Tract Infection ever since she was not pregnant.

III. Diagnosis

Identification of the symptoms of preterm labor will help ensure that the patient can be evaluated, diagnosed and treated appropriately. The signs and symptoms that appear to predict preterm labor include frequent contractions (more than four per hour), cramping, pelvic pressure, excessive vaginal discharge, backache and low back pain. A diagnosis of preterm labor should be made in a patient between 20 weeks and 36 weeks, six days of gestation if uterine contractions occur at a frequency of four per 20 minutes or eight per 60 minutes, and are accompanied by one of the following: PROM, cervical dilation greater than 2 cm, effacement exceeding 50 percent, or a change in cervical dilation or effacement detected by serial examinations.

IV. Predisposing Factor

Preterm labor can affect any pregnancy and many women who have preterm labor have no known risk factors. Many factors have been associated with an increased risk of preterm labor, however, including: Previous preterm labor or premature birth, particularly in the most recent pregnancy or in more than one previous pregnancy Pregnancy with twins, triplets or other multiples Certain problems with the uterus, cervix or placenta Smoking cigarettes or using illicit drugs Certain infections, particularly of the genital tract Some chronic conditions, such as high blood pressure and diabetes Being underweight or overweight before pregnancy, or gaining too little or too much weight during pregnancy Stressful life events, such as the death of a loved one Red blood cell deficiency (anemia), particularly during early pregnancy Too much amniotic fluid (polyhydramnios) Pregnancy complications, such as preeclampsia Vaginal bleeding during pregnancy Presence of a fetal birth defect Little or no prenatal care An interval of less than six months since the last pregnancyAlso, having a short cervical length or the presence of fetal fibronectin a substance that acts like a glue between the fetal sac and the lining of the uterus in your vaginal discharge has been linked to an increased risk of preterm labor.While some past research suggested that gum disease might be linked with premature birth, treatment of periodontal disease during pregnancy hasn't been proved to reduce the risk of premature birth.V. Laboratory Test/Diagnostic ProcedureTestResultNormal Range

Hemoglobin140M: 140 - 180 F: 120 - 160 gms/L

Hematocrit0.40M: 0.40 - 0.50 F: 0.36 - 0.48

RBC Count4.183.5 5.5 X 10^12/L

MCV91.580.0 99.0 fl

MCH28.026.0 32.0 pg

MCHC33.032.0 36.0 g/dl

RDW17.411.5 14.5

Platelet count279140 350 x 10^9/L

MPV8.57.4 10.4 fl

PDW9.910.0 17.0

WBC Count8.35-10 x 10^9/L

Differential Count

Granulocytes74.855 65 %

Lymphocytes23.520 40 %

Mid-sized4.01 15 %

Automated Complete Blood Count

Urinalysis ResultMacroscopic:Reference RangeResult

ColorStraw Yellow to yellowYellow

TransparencyClear to slightly cloudyClear

Ph4.6 8.05.8

Specific Gravity1.002 1.0301.030

ProteinNegativeNegative

SugarNegativeNegative

Microscopic:

WBC0 2 / hpf15-20

RBC0 2 / hpf2-4

Epithelial CellsOccasional to fewFew

BacteriaOccasional to fewFew

Amorphous SedimentsOccasional to few

Ultrasound ReportIMPRESSION:Single live intrauterine pregnancy in cephalic presentation with average ultrasonic age of 33 weeks and 6 days and estimated fetal weight of 1205 grams.Anterior placenta with grade I maturity.AFI of 17.3 cm. Suggestive of Normohydramnios.No gross fetal anomalies. No evidence of previa.EFW Appropriate for LMP correlated gestational age.

VI. Patient Management

Symptoms of preterm labor are warning signs. They don't necessarily mean that you'll have a preterm birth.If you're less than 37 weeks pregnant and you're having more or stronger contractions than usual, try these things: Drink 2 or 3 glasses of water or juice. Not having enough liquids can cause contractions. Stop what you are doing, and empty your bladder. Then lie down on your left side for at least 1 hour. If your contractions get worse during the hour, call your doctor or nurse-midwife, or go to the hospital. Try to remember what you were doing when the symptoms started so that you can avoid starting the contractions again later.Although stress isn't thought to be a direct cause of preterm labor, do what you can to reduce stress in your life. Try to do less, ask for help, and eat well.

VII. Drug StudyGeneric NameBrand NameIndicationsContraindicationsNursing Intervention

ISOXSUPRINE HCl10 mg Tablet5mg/ml (10mg/2ml) Solution for Injection (IM or IV)

Duvadilan Circulatory disturbances Peripheral vascular insufficiency with a spastic component showing symptoms such as: coldness and numbness of the limbs, intermittent claudication, color changes, and ischemic ulcers. Uterine hypermotilityUncomplicated premature labor. Isoxsuprine is contraindicated following recent arterial hemorrhage, in patients with known heart disease, or in severe anemia. It should not be administered parenterally to patients with hypotension, tachycardia, premature detachment of the placenta or immediately postpartum.

Monitor for therapeutic effectiveness: Response to treatment of peripheral vascular disorders may take several weeks. Evaluate clinical manifestations of arterial insufficiency. Monitor BP and pulse; may cause hypotension and tachycardia. Supervise ambulation.Observe both mother and baby for hypotension and irregular and rapid heartbeat if isoxsuprine is used to delay premature labor.

VIII. Outcome Evaluation

Although the diagnosis and treatment of preterm labor are fraught with controversy, there are areas of consensus. Preconception counseling and early prenatal care that identifies and treats risk conditions can optimize pregnancy outcome. The physician must try to accurately date a patient's pregnancy, attempt to diagnose preterm labor at an early stage and make the appropriate management decision for the patient. This decision may include transfer to a tertiary site or management with appropriate consultation. Documented infections such as sexually transmitted diseases, urinary tract infections and vaginitis should be treated. Tocolytic therapy should be used to delay delivery in order to administer corticosteroids. At present, corticosteroid therapy is the only treatment shown to improve fetal survival and outcome. Further studies are needed to find a marker with a high positive predictive value for preterm labor. Intervention studies are also needed to evaluate outcomes.

IX. Learning ExperienceExperiencing this kind of case is not easy. When I am assisting the mother to delivery her baby, I felt something nervousness. Why? Because Id never encountered that before. I am skilled for those normal delivery and in term. I know what to do based on the DOH protocols. But for this premature baby, I dont know what to do next. Luckily, a resident midwife in LMC is in my back to help me. I therefore conclude that assisting mother to deliver her baby that is in preterm labor is a difficult one. Midwife can help but needed an immediate resuscitation just in case and an accompanied doctor or paediatrician.