Nursing Care for Women with Preterm Labor, Premature Rupture of Membranes, and Fetal Distress

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Nursing Care for Women with Preterm Labor,
Premature Rupture of Membranes, and Fetal
Distress

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Learning Objectives

• Define the key terms preterm labor, premature
  rupture of membranes, fetal distress
• Understand the difference in perterm birth and
  low birth weight
• Identify risks factors of perterm labor
• Understand the current intervention to treat
  preterm labor
• Discuss the nursing care for women experienced
  perterm labor, perterm rupture of membranes, and
  fetal distress

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Pertem Labor

• Definition Cervical change and uterine
  contractions occurring between 20 weeks an 37
  weeks of pregnancy
• Perterm birth lead 75 of the perinatal mortality
• Perterm birth also is the second leading death of
  infants in the USA, next to CHD.
• 
  (Comerford Freda, 2000)

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Perterm Labor and Low Birth Weight

• Perterm Labor lt 37 weeks of gestational age
• Low birth weight weight at time of birth is less
  than or equal to 2500 grams.
• Intrauterine growth retardation IUGR

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Risk Factors of Preterm Labor

• Demographic Risks young mother, low
  socioeconomic status, unmarried, low level of
  education
• Medical risk history of preterm birth, multiple
  abortions, uterine anomalies, low pregnancy
  weight, DM, Hypertension,multiple gestation,
  infection, incompetent cervix, UTI, bleeding,
  placenta previa or abruptio placenta, anemia,
  fetal anomalies

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Behavioral and Environmental Risk for Preterm
Labor

• Diethylstilbestrol (DES) Exposure
• Smoking
• Poor Nutrition
• Alcohol or other substance use, especially
  cocaine
• Late or no prenatal care
• Stress, uterine irritability, long working hours,
  inability to rest

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Risk Factors for Perterm Labor

• Bacterial Vaginosis 40 increased risk
• Syphilis and gonorrhea 50 increased risk
• Asymptomatic bacteria 50 increased risk

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Symptoms of Preterm Labor20-37 weeks of
gestational age

• Pelvic pressure feels like the baby is pushing
  down
• Low, dull backache
• Menstrual-like cramps
• Change or increase in vaginal discharge
• Uterine contractions (hardness), every 10 minutes
  or more often with or without pain
• Intestinal cramping with or without diarrhea

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Suppression of Uuterine Aactivity

• Tocolytics Therapy
• Ritodrine(Yutopar)
• Terbutaline
• Magnesium Sulfate
• Indomethacin

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Contraindications to Tocolysis

• Maternal factor
• Severe PIH or eclampsia
• Active vaginal bleedings
• Intrauterine infection
• Cardiac distress
• Medical or obstetric condition that
  contraindicates continuation of pregnancy

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Contraindications to Tocolysis

• Fetal Factors
• Estimated gestational age gt 37 weeks
• Dilation of gt 4 cm
• Estimated weight of birth gt 2500 grams
• Fetal Demise
• Lethal fetal anomaly
• Chorioamnionitis
• Acute Fetal Distress
• Chronic IUGR

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Nursing Diagnosis for Perterm Labor

• Knowledge deficit related to-recognition of
  preterm symptoms
• Risk for maternal or fetal injury related to
  preterm labor and birth
• Anxiety related to perterm birth and family
  consequences
• Impaired mobility related to prescribed bed rest
• Anticipatory grieving related to preterm labor
  and birth

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Nursing care for women with tocolytic therapy

• Position on Lf side for better placenta perfusion
• Assess blood pressure, pulse (not gt 120/min), and
  respiratory rate
• Assess signs of pulmonary edema (chest pain,
  shortness of breath, crackles, rhonchi)
• Assess urinary output q1h, monitor for ketonuria
• Limit fluid intake to 2500-3000 ml/day
• Provide psychosocial support and release anxiety
• Monitor electrolyte, blood glucose level

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Promoting Fetal Lung Maturity

• Antenatal glucocorticoid therapy betamethasone,
  dexamethasone
• Action stimulates fetal lung maturation by
  promoting release of enzymes that induce
  production and or release of lung surfactant
• Nursing consideration Assess signs of infection,
  pulmonary edema, blood glucose level, lung sound,
  takes 24 hours for drug to effective, not to give
  women gt 35 weeks of pregnancy.

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Health Teaching for pertem labor prevention

• When perterm labor occur
• Lie down on your left side for 1 hour
• Drink 2-3 glasses of water or juice
• Palpate for contractions
• If no contraction, assume light activity, if
  symptom come back, need to notify health care
  professionals.
• Life style modification

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Signs of Perterm Labor

• Uterine contractions every 5 minutes or less
• Vaginal bleeding
• Odorous vaginal discharge
• Fluid leaking from the vagina

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Premature Rupture of Membrane (PROM )????

• Definition
• Rupture of the amniotic sac and leakage of
  amniotic fluid beginning at least 1 hours before
  the onset of labor at any gestational age.

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PROM-Incidence

• Preterm premature rupture of the membranes
  (PPROM) it is membranes rupture before 37 weeks
  of gestation
• 25 of all cases of preterm labor
• Infection precedes PPROM
• Complains of sudden gush of fluid from the vagina
  or slow leak of fluid from the vagina.

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PPROM-Infection

• Infection is the serious side effect of PPROM
• Chorioamnionitis intraamniotic infection of the
  chorion and amnion that can harm the fetus and
  newborn

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Incidence of PPROM and Preterm Birth

• 3-30 of women with PPROM will have positive
  amniotic fluid culture
• May lead to sepsis, congenital pneumonia,
  meningitis of the newborn due to intrauterine
  infection caused by RPROM
• 
  

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Fetal Surveillance-counting fetal movement

• Teaching for fetal movements kick count
• Choose a time of day for quiet moment
• Starting at certain time and count the babys
  movement until reach 10. If not count 10 in 12
  hours, need to see physician.
• Or count 4 movements after each meals, should
  have 4 movement in 1 hour, if by end of 2 hours,
  still less than 4 movement, need to see
  physician.

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Biophysical Profiles for Fetus

• Fetal breathing movements
• Gross body movement
• Fetal tone
• Reactive fetal heart rate
• Qualitative amniotic fluid volume
• Score normal 8-10 equivocal 6
• abnormal lt 4

Manning, 1995
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Amniotic Fluid Index Measurement

• To determine
• Normal value 5-19 cm.
• Oligohydramnios-amniotic fluid packet of fluid in
  two perpendicular planes is lt 5 cm
• Polyhyramnios-amniotic fluid packet fluid in two
  perpendicular planes is gt 20cm, with fetal
  floating, free movement of limbs

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Nursing care for women with PPROM

• Fetus surveillance count fetal movement at least
  BID, 10 fetal movements in a 12-hours period.
• Understand the volume of amniotic fluid remained
  in the amniotic sack
• Signs of stress on Fetal monitor
• Stick prevention of infection due to amniotic sac
  is ruptured and bacterial may enter the uterus to
  infect fetus.
• Relieve psychological stress due to prolonged bed
  rest and possibility of premature birth

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Discharge Criteria for Women with PPROM

• Documented PPROM gt 72 hr
• Cervical dilation ? 3 cm
• No sign of chorioamnionitis/pyelonephritis
• No sign or symptoms of preterm labor
• Client willingness to comply with strict pelvic
  rest
• No breech or transverse presentation (chances of
  proplapse cord)

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Health Teaching for women with PPROM

• Take temperature Q4h when awake, Report if more
  than 380C
• Remain on modified bed rest
• Insert nothing in the vagina
• No sexual activity, No tub baths
• Assess for uterine contraction fetal movement
• Watch for foul-smelling vaginal discharge
• Wipe front to back after urinating or having a
  bowel movement
• Take antibiotics if prescribed

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Fetal Distress Maternal Risk Factors

• Pregnancy Induced Hypertension
• Cardiac Diseases
• Hyperemesis gravidarum
• STI, vaginal infection
• Perterm labor
• DM, Anemia, Substance abuse
• Placenta previa, abruptio
• Prolonged labor or difficulty birth
• Abnormal fetal presentation
• Traumatic labor or birth

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Complication during labor-fetal distress

• Intrauterine pressure gt 75 mmHg
• Contraction gt 90 seconds
• Contraction occurring 2 min or less apart
• Fetal bradycardia, tachycardia, or decreased
  variablity
• Irregular FHR
• Meconium-stained amniotic fluid
• Arrest in progress of the labor
• Maternal fever
• Foul-smelling vaginal discharge
• Vaginal Bleeding

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Prolapsed of cord during labor

• Fetal bradycardia
• Membranes ruptured
• Cord lies below the presentation part of the
  fetus
• Need to do emergency delivery

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Nursing Intervention for Prolapsed Cord

• Position change, trendelenburg or modified sims
  position
• Sterile towel wrap the cord
• Oxygen 8-10 L/min
• IV fluid
• Monitoring FHR
• Do not place cord back into cervix
• Prepare emergency birth (vaginal or cesarean)

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Ultrasonography in Third Trimester for Aassessing
Fetus

• Gestational age
• Viability
• Detect macrosomia
• Detect congenital anomalies
• Detect IUGR
• Detect placenta maturity

• Determine Fetal Position
• Detect Placenta previa or abruptio
• Visualization for amniocentesis
• Biophysical profile and amniotic volume
  assessment

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Fetal Distress during Labor

• FHR late deceleration as shown in the Fetal
  monitoring
• Indicating ultraplacenta insufficiency, maternal
  uterine hyperactivity, supine hypotion, epidural
  or spinal anesthesia, placenta previa, abruptio,
  hyperensive disorders, postmaturity, IRGR, DM,
  infection

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Nursing Intervention for Fetal Distress as shown
in FHR

• Change maternal position
• Correct maternal hypotension by elevating legs
• Increase rate of maintenance IV
• Administer oxygen at 8-10L/min
• Fetal scalp or acoustic simulation
• Assess with birth (CS or vaginal birth)

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Question and Answer

• Thank for your attention!
• Please review the case study and be ready for
  next discussion