Mbbs, BDS, B-Pharma Notes: Care of the Client Experiencing Preterm Labor

Sunday 22 July 2012

Care of the Client Experiencing Preterm Labor

Lecture Twelve: Care of the Client Experiencing Preterm Labor

NURS 2208
T. Dennis RNC, MSN
Preterm Labor (pg 398)

Labor that occurs between 20 to 37 completed weeks of pregnancy.
Prematurity continues to be the number one perinatal and neonatal problem in the US.
Risk factors that play a role in the development of preterm labor include: obstetric, medical, and sociodemographic.
The rate of preterm births has not changed much over the last 40 years despite progress in scoring systems, tocolytic drugs, and home monitoring systems.

Risks (pg 398-399)

Maternal Risks:

Psychological stress
side effects of tocolytics
side effects of prolonged bedrest
cause of labor (hemorrhage due to placenta previa, etc.)

Fetal-Neonatal risks:

Mortality increases
respiratory immaturity is the most significant risk to the newborn
some circumstances dictate extrauterine life to be more viable than intrauterine life.

Clinical Therapy (pg 399-405)

Symptoms of Preterm labor:

Abdominal pain
Back pain
Pelvic pain
Menstrual-like cramps
Vaginal bleeding
Increased vaginal discharge (may be pink)
Pelvic pressure
Urinary frequency
Diarrhea

Clinical Therapy (pg 399-405)

Diagnostic tools:

fFN (fetal fibronectin): an extracelluar matrix protein that is normally found in the fetal membranes and the decidua. After 20 weeks, presence is abnormal until near term.Valuable predicting birth within 7 days of testing.
Cervical length: assessed by transvaginal ultrasonography. A cervical length of 3 cms is considered within normal range for the non preterm labor client.
Speculum exam determines dilatation of cervix.
Fetal monitoring aides in determining contraction pattern.
Urinalysis: urinary tract infection is often associated with preterm labor.

Clinical Therapy (pg 399-405)

The following conditions are reasons not to stop preterm labor:

Fetal demise
Lethal fetal anomaly
Severe preeclampsia/eclampsia
Hemorrhage (abruptio placentae)
Chorioamnionitis
Maternal cardiac disease
Poorly controlled diabetes mellitis, hypertension, or thyrotoxicosis
Fetal maturity
Acute fetal distress

Clinical Therapy (pg 399-405)

Goal:

To prevent preterm labor from advancing to a point that no longer responds to medical treatment.

Initial management:

maintain good uterine profusion
detect uterine contractions
assess fetal well being

Laboratory studies:

CBC , CRP, UA, vaginal, uterine, and amniotic fluid culture

Clinical Therapy (pg 399-405)

Hydration is used to decrease the frequency of uterine contractions.
Tocolysis is the use of medications to stop labor.

Medications (400)

Magnesium Sulfate (MgSO4)
Ritodrine (Yutopar)
Terbutaline sulfate (Brethine)
Nifedipine (Procardia)
Betamethasone
Dexamethasone
Indomethacin

Magnesium Sulfate (MgSO4)

A calcium antagonist and central nervous system depressant, relaxes the smooth muscle of the uterus through calcium displacement.
Crosses the placenta
To control seizures in toxemia of pregnancy due to eclampsia or preeclampsia.
4 Gm bolus IV over 20 to 30 minutes initially then 1 to 2 Gm/hr per infusion pump. Titrated by levels and labor. Serum levels range from 5 to 8 mg/dL to be effective.
Side effects include: flushing, HA, nausea, lethargy, metallic taste, hypotension, depressed reflexes, confusion, magnesium toxicity (respiratory depression and arrest).
Calcium Gluconate is the antidote (10mg IV push over3 minutes). Calcium chloride may be used.

Magnesium Sulfate (MgSO4) Nursing Interventions

Monitor vs every ½ hr and FHR every 15 minutes.
Respirations should be above 12/min or she may be toxic.
Monitor I&O every hour. Report if urinary output is less than 30ml/h.
Check breath and bowel sounds every 4 hours.
Assess reflexes prior to initiation of therapy and then every hour. Notify health care provider of change.
Weigh daily.
Monitor serum Mag levels. Therapeutic level is 5 to 8 mg/dL.
Have Calcium gluconate or calcium chloride available as antidote.
Observe neonate for 24 to 49 hours for toxicity.

Ritodrine (Yutopar)

Beta-sympathomimetic drug acts by stimulating the beta2 receptors in smooth muscle.
Ritodrine is the only Beta-sympathomimetic drug approved by FDA for use in preterm labor.
Pulmonary edema is a risk.
Common therapy is 150 mg in 500cc of fluid and initial rate of 10 to 20 ml per hour.
Side effects include: tremors, malaise, dyspnea, tachycardia, chest pain, N&V, pulmonary edema, dysrythmias, ketoacidosis and anaphylactic shock.

Ritodrine (Yutopar) Nursing Interventions

Monitor maternal and fetal vs every 15 minutes during IV administration. Report if systolic BP<90 or >140, if diastolic BP< 50 or if pulse >120 bpm.
Auscultate breath sounds every 4 hrs. Notify physician if resp rate >30 or if there is a change in quality (wheezes, rales, coughing).
Report auscultated cardiac dysrhythmias.
Monitor daily weight to assess for fluid overload.
Place in trendelenburg position and increase primary IVF’s.

Terbutaline sulfate (Brethine)

Sympathomimetic beta2 adrenergic agonist
Dosage: 0.25mg SQ initially may repeat every every 15 minutes
Action onset is within 15 minutes IV or SQ and 35 to 40 minutes PO.
Not approved by FDA for use in preterm labor.
May be used with low-dose SQ pumps or PO for maintenance dose.

Terbutaline Nursing Interventions

Monitor maternal and fetal vs every 15 minutes during IV administration. Report if systolic BP<90 or >140, if diastolic BP< 50 or if pulse >120 bpm.
Auscultate breath sounds every 4 hrs. Notify physician if resp rate >30 or if there is a change in quality (wheezes, rales, coughing).
Report auscultated cardiac dysrhythmias.
Monitor daily weight to assess for fluid overload.
Place in trendelenburg position and increase primary IVF’s.

Nifedipine (Procardia)

Calcium Channel blocker
Acts by in the myometrial smooth muscle thereby inhibiting contractile activity.
May be given orally or sublingually.
Side effects include: hypotension, tachycardia, facial flushing and headache.
Co-administration with terbutaline may prove effective.
Should not be administered with magnesium sulfate due to maternal side effects.

Betamethasone (Celestone, Soluspan)

Corticosteroid
Dosage: 12 mg IM every 12 hours x 2 doses
Given to prevent respiratory distress syndrome in infants by injecting mother prior to delivery to stimulate surfactant production in the fetal lung.
Most effective if given at least 24 hr but less than seven days prior to delivery.
Onset of action is one to three hours.
Side effects include: seizures, HA, vertigo, edema, hypertension, increased sweating, and facial erythema.

Betamethasone Nursing Interventions

Observe for respiratory difficulties
Maintain accurate I & O records
Shake the suspension well, Avoid exposing to excess heat or light.
Inject in large muscle mass, not the deltoid, to avoid high incidence of local atrophy.
Check blood glucose if used for the diabetic client.
Assess lab data for electrolyte values.

Dexamethasone (Decadron)

Corticosteroid
Dosage: 6 - 12 mg IM every 12 hours x 2 doses
Given to prevent respiratory distress syndrome in infantsby injecting mother prior to delivery to stimulate surfactantproduction in the fetal lung.
Most effective if given at least 24 hr but less than seven days prior to delivery.
Onset of action is one to three hours.
Side effects include: seizures, HA, vertigo, edema, hypertension, increased sweating, and facial erythema.

Indomethacin (Indocin)

Prostaglandin synthetase inhibitor
Inhibits prostaglandin synthesis: closure of patent ductus arteriosis
Crosses placental barrier
Adverse reactions: dizziness, drowsiness, HA, nausea & vomiting, closure of patent ductus arteriosis (not recommended after 32 wks gestation). Arrythmias, edema

Nursing Assessment and Diagnosis

Note presence of predisposing factors:multiple gestation, known cervical incompetence, fetal abnormality, history of pyelonephritis, previous preterm birth, previous preterm labor with termbirth, abdominal trauma.

Diagnosis:

Knowledge deficit related to lack of information about causes, identification, and treatment of preterm labor
Fear related to early labor and birth
Ineffective individual coping related to need for constant attention to pregnancy.

Client Education (pg 402-405)

Rest 2 to 3 times a day lying on the left side.
Drink 2 to 3 quarts of water each day
Avoid caffeine
Empty your bladder at least every 2 hours during waking hours
Avoid lifting heavy objects
Avoid prenatal preparation of the breasts
Pace necessary activities to avoid overexertion
Eliminate or decrease sexual activity
Evaluate contraction activity once or twice a day
Report ctxs that occur evey ten minutes for 1 hour.

Signs and Symptoms

Uterine contractions that occur every 10 minutes or less with or without pain
Mild menstrual like cramps felt low in the abdomen
Constant intermittent feelings of pelvic pressure that may feel like the baby pressing down
Rupture of membranes
Low, dull backache, which may be constant or intermittent
A change in vaginal discharge (an increase in amount, a change to more clear and watery, or a pinkish tinge)
Abdominal cramping with or without diarrhea

Client Education (pg 402-405)

Empty the bladder
Lie down tilted toward her side
Drink 3 to 4 (8oz) cups of fluid
Palpate for uterine contractions, notify care provider if they occur 10 min apart or less for 1 hour
Rest for 30 minutes after symptoms have subsided, and gradually resume activity.
Call heath care provider if symptoms persist, even if uterine contractions are not palpable.

Hospital Care (pg 404-405)

Bedrest
Monitor vital signs frequently depending on contraction pattern, medication administration
Measure intake and output
Continuous EFM of contractions and fetal heart rate
Place on left side
Keep vaginal exam to a minimum (preferably speculum exam)
Keep patient informed of treatments and progress
In the event of imminent birth, the client should be offered ongoing explanations to prepare them for the actual birth process and the events following the birth.