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

1. Nursing Care for Women with Preterm Labor, Premature Rupture of Membranes, and Fetal Distress 徐丽华 上海交通大学护理学院

2. 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

3. 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)

4. Perterm Labor and Low Birth Weight • Perterm Labor: < 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

5. 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

6. 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

7. Risk Factors for Perterm Labor • Bacterial Vaginosis 40 % increased risk • Syphilis and gonorrhea 50% increased risk • Asymptomatic bacteria 50% increased risk

8. 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

9. Suppression of Uuterine Aactivity Tocolytics Therapy： • Ritodrine（Yutopar） • Terbutaline • Magnesium Sulfate • Indomethacin

10. 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

11. Contraindications to Tocolysis Fetal Factors: • Estimated gestational age > 37 weeks • Dilation of > 4 cm • Estimated weight of birth > 2500 grams • Fetal Demise • Lethal fetal anomaly • Chorioamnionitis • Acute Fetal Distress • Chronic IUGR

12. 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

13. Nursing care for women with tocolytic therapy • Position on Lf side for better placenta perfusion • Assess blood pressure, pulse (not > 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

14. 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 > 35 weeks of pregnancy.

15. 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

16. Signs of Perterm Labor • Uterine contractions every 5 minutes or less • Vaginal bleeding • Odorous vaginal discharge • Fluid leaking from the vagina

17. Premature Rupture of Membrane (PROM )胎膜早破 • 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.

18. 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.

19. 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

20. 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

21. 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 baby’s 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.

22. 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 < 4 Manning, 1995

23. Amniotic Fluid Index Measurement To determine: • Normal value 5-19 cm. • Oligohydramnios-amniotic fluid packet of fluid in two perpendicular planes is < 5 cm • Polyhyramnios-amniotic fluid packet fluid in two perpendicular planes is > 20cm, with fetal floating, free movement of limbs

24. 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

25. Discharge Criteria for Women with PPROM • Documented PPROM > 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)

26. 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

27. 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

28. Complication during labor-fetal distress • Intrauterine pressure > 75 mmHg • Contraction > 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

29. Prolapsed of cord during labor • Fetal bradycardia • Membranes ruptured • Cord lies below the presentation part of the fetus • Need to do emergency delivery

30. 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)

31. 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 Ultrasonography in Third Trimester for Aassessing Fetus

32. 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

33. 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)

34. Question and Answer Thank for your attention! Please review the case study and be ready for next discussion