Premature labour

Premature labour

1. Premature LaborPremature Labor
OR OR
Preterm labourPreterm labour

2. Premature labourPremature labour
((Preterm labour)Preterm labour)

3. INTRODUCTIONINTRODUCTION
Premature labour is generally a labour Premature labour is generally a labour
that occurs after 20 wks & before that occurs after 20 wks & before
37 completed wks of gestation37 completed wks of gestation

4. DEFINITIONDEFINITION
Preterm labour Preterm labour
(PTL) is defined (PTL) is defined
as one where the as one where the
labour starts labour starts
before the 37before the 37
thth

completed week completed week
(<259 days), (<259 days),
counting from the counting from the
11
stst
day of the last day of the last
menstrual periodmenstrual period

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

6. INCIDENCEINCIDENCE
Approx. 10% of deliveries in public Approx. 10% of deliveries in public
hospital occur before the 37hospital occur before the 37
thth
week week
A much smaller %age is involved in A much smaller %age is involved in
the 24-32 weeks period.the 24-32 weeks period.
The prevalence widely varies and The prevalence widely varies and
ranges between 5-10%ranges between 5-10%

7. ETIOLOGYETIOLOGY
In 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
COMPLICATIONS
In Present
Pregnancies
IATROGENIC
IDIOPATHIC

8. 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 statuslow socio-economic & nutritional status

9. MalpresentationsMalpresentations
Previous abortion historyPrevious abortion history

10. 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 tract
infection
Medical & surgical
illness

11. INFECTIONINFECTION PRE ECLAMPSIAPRE ECLAMPSIA

12. Incompetent cervixIncompetent cervix malformation of uterusmalformation of uterus

14. 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

16. Conti..Conti..
IATROGENIC:IATROGENIC:
-Elective induction with wrong -Elective induction with wrong
estimation of gestational period. estimation of gestational period.
-IDIOPATHICIDIOPATHIC: :
-Premature effacement of cervix with -Premature effacement of cervix with
hyper-irritable uterus hyper-irritable uterus
-Early engagement of head-Early engagement of head

17. ETIOPATHOGENESISETIOPATHOGENESIS
ACTIVATION 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

18. 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

19. 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

20. 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

21. Excessive alcohol during pregnancyExcessive alcohol during pregnancy
 babies with birth defectsbabies with birth defects

22. 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

23. Cont..Cont..
Increased pressure in pelvisIncreased pressure in pelvis
Increased vaginal bleedingIncreased vaginal bleeding
Regular uterine activityRegular uterine activity
Vaginal spottingVaginal spotting
Pelvic pressurePelvic pressure

24. DIAGNOSIS
Regular uterine contractions with or without Regular uterine contractions with or without
pain pain (at least one in every 10 mins.)(at least one in every 10 mins.)
DilatationDilatation((≥2cm) ≥2cm) & Effacement & Effacement (80%)(80%) of the of the
cervixcervix
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.

25. INVESTIGATIONSINVESTIGATIONS
Full blood countFull blood count
Routine urineRoutine urine-analysis,culture & -analysis,culture &
senstivity senstivity
Cervicovaginal SwabCervicovaginal Swab- -
culture,FIBRONECTINculture,FIBRONECTIN
Serum electrolytes & glucose levels Serum electrolytes & glucose levels
when tocolytic agents are to be when tocolytic agents are to be
usedused

26. USGUSG-fetal well being, -fetal well being,
cervical length & cervical length &
placental placental
localizationlocalization

27. FIBRONECTINFIBRONECTIN
A A PROTEINPROTEIN that binds that binds
the the FETALFETAL MEMBRANESMEMBRANES
to to DECIDUADECIDUA
Normally found in Normally found in
CERVICOVAGINALCERVICOVAGINAL
dischargedischarge beforebefore 22wks22wks & &
again again afterafter 37wks37wks of of
pregnancypregnancy
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

29. MANAGEMENTMANAGEMENT
It includesIt includes



Prevention,if possible
Arrest of preterm
Labour, if not
contraindicated
Appropriate management
Neonatal care

30. Prevention of Preterm Prevention of Preterm
LabourLabour
Primary 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 detection includes screening tests for early detection
& prophylactic treatment & prophylactic treatment (e.g. tocolytics)(e.g. 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)

31. Cont..Cont..
Seek regular prenatal careSeek regular prenatal care
Eat a healthy dietEat a healthy diet
Gain weight wiselyGain weight wisely
Avoid risky substancesAvoid risky substances
Consider pregnancy spacingConsider pregnancy spacing
Be cautious when using assisted Be cautious when using assisted
reproductive technology (ART)reproductive technology (ART)

32. Taking preventive medications , who has Taking preventive medications , who has
short cervix( Progesterone)short cervix( Progesterone)
Restricting sexual activity.Restricting sexual activity.
Limiting certain physical activities.Limiting certain physical activities.
Managing chronic conditions such as DM, Managing chronic conditions such as DM,
Increased BP.Increased BP.

33. ARRESTING PRETERM ARRESTING PRETERM
LABOURLABOUR
BED RESTBED REST--Left lateral position Left lateral position
ADEQUATE HYDRATIONADEQUATE HYDRATION
PROPHYLACTIC ANTIBIOTICPROPHYLACTIC ANTIBIOTIC
TOCOLYTIC AGENTSTOCOLYTIC AGENTS -Eg.-Eg.TERBUTALINETERBUTALINE
INDOMETHACININDOMETHACIN
NIFEDIPINEsNIFEDIPINEs
short termshort term long termlong term

34. 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 to mother to
enhance 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

35. GLUCOCORTICOIDGLUCOCORTICOID
THERAPYTHERAPY
Advocated in pregnancy less than 34 Advocated in pregnancy less than 34
wks.wks.
Helps in fetal lung maturationHelps in fetal lung maturation
Reduces incidence of RDS & IVHReduces incidence of RDS & IVH
RISKSRISKS
PROM with evidence of infectionPROM with evidence of infection
IDDM where patients needs insulin dose IDDM where patients needs insulin dose
readjustmentreadjustment

36. Conti..Conti..
CONTRA-INDICATIONSCONTRA-INDICATIONS
MATERNAL FETAL
OTHERS

37. Gestational Gestational
diabetesdiabetes
Placenta praviea.Placenta praviea.
In case of In case of
placental placental
abnormalitiesabnormalities..

38. APPROPRIATE APPROPRIATE
MANAGEMENTMANAGEMENT
There are basically 2 principles:There are basically 2 principles:
To prevent birth asphyxia & development To prevent birth asphyxia & development
of RDS of RDS
To prevent birth trauma To prevent birth trauma

39. 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 intensive Labour should be watched by intensive
clinical monitoring clinical monitoring
In case of delay, caesarean section In case of delay, caesarean section
should be performedshould be performed

40. 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 to
minimize head compression if there is perineal minimize head compression if there is perineal
resistanceresistance
Tendency to delay Tendency to delay is curtailed by low forceps. Routine is curtailed by low forceps. Routine
forceps is not indicatedforceps 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

41. IMMEDIATE IMMEDIATE
MANAGEMENTMANAGEMENT
The cord is to be clamped quicklyThe cord is to be clamped quickly
The cord length is kept long in case exchange The cord length is kept long in case exchange
transfusion is requiredtransfusion 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 in The baby should be wrapped including head in
a sterile warm towel a sterile warm towel

42. NURSING MANAGEMENTNURSING MANAGEMENT
1.1.Assess the mother’s condition to evaluate Assess the mother’s condition to evaluate
signs of labour.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

43. 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 Place the client on bed rest in the side
lying position.lying position.
Prepare for possible ultrasongraphy, Prepare for possible ultrasongraphy,
amniocentesis, tocolytic drug therapy or amniocentesis, tocolytic drug therapy or
steroid therapy.steroid therapy.

44. Administer tocoltyic agent as prescribed.Administer tocoltyic agent as prescribed.
Assess for side effects of tocolytic therapyAssess for side effects of tocolytic therapy
Decreased maternal Blood pressureDecreased maternal Blood pressure
DyspneaDyspnea
Chest painChest pain
FHS >180beats/minFHS >180beats/min

45. Cont..Cont..
4- provide physical and emotional support 4- provide physical and emotional support
5- Provide adequate hydration5- Provide adequate hydration
6- Provide client and family education.6- Provide client and family education.

46. PROGNOSISPROGNOSIS
Results 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%

47. CLIENT CLIENT
EDUCATIOEDUCATIO
NN
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 cramping-menstrual-like cramping
-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