Premature labour

1. Premature LaborPremature Labor
OROR
Preterm labourPreterm labour

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

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

4. DEFINITIONDEFINITION
Preterm labourPreterm labour
(PTL) is defined(PTL) is defined
as one where theas one where the
labour startslabour starts
before the 37before the 37thth
completed weekcompleted week
(<259 days),(<259 days),
counting from thecounting from the
11stst
day of the lastday of the last
menstrual periodmenstrual period

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

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

7. ETIOLOGYETIOLOGY
In about 50%, the cause of pretermIn about 50%, the cause of preterm
labour is not knownlabour is not known
But some of theBut 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 orprevious history of abortion or
preterm deliverypreterm delivery
--recurrent UTIrecurrent UTI
--smoking habitssmoking habits
--low socio-economic & nutritional statuslow socio-economic & nutritional status

9. MalpresentationsMalpresentations Previous abortion historyPrevious abortion history

10. ContiConti....
COMPLICATIONS IN PRESENTCOMPLICATIONS IN PRESENT
PREGNANCYPREGNANCY-- It may be due to 3It may be due to 3
causes:-MATERNALcauses:-MATERNAL
-FETAL-FETAL
-PLACENTAL-PLACENTAL
A)A) MATERNALMATERNAL ::
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....
FETALFETAL :: - Multiple pregnancy- Multiple pregnancy
-- Congenital malformationsCongenital malformations
- IUD- IUD
PLACENTALPLACENTAL :-:- InfarctionInfarction
-Thrombosis-Thrombosis
- Placenta praevia or- Placenta praevia or
abruptionabruption

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 uterushyper-irritable uterus
-Early engagement of head-Early engagement of head

17. ETIOPATHOGENESISETIOPATHOGENESIS
ACTIVATION OF FETALACTIVATION OF FETAL HPAHPA AXISAXIS
CRH,CRH,  CortisolCortisol PGEPGE22, F, F22αα
TXATXA22,,
LeukotrienesLeukotrienes
↓↓PG DehydrogenasePG Dehydrogenase
choriodecidual bacterialchoriodecidual bacterial  proteasesproteases
ColonisationColonisation  TNF,TNF,
IL-1,6,8IL-1,6,8
 myometrialmyometrial
PATHOLOGIC UTERINE ENLARGEMENTPATHOLOGIC UTERINE ENLARGEMENT contractioncontraction
(Polyhydramnios , multiple pregnancy)(Polyhydramnios , multiple pregnancy)  cervicalcervical
 Mechanical stretch,Mechanical stretch,  IL8 ripeningIL8 ripening
 Gap junction,Gap junction,  PG SynthesisPG Synthesis
preterm labour andpreterm labour and
delieverydelievery
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 duringFactors 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 moreContractions 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 withoutRegular uterine contractions with or without
painpain (at least one in every 10 mins.)(at least one in every 10 mins.)
 DilatationDilatation((≥2cm)≥2cm) & Effacement& Effacement (80%)(80%) of theof the
cervixcervix
 Length of cervixLength of cervix ≤≤2.5cm2.5cm
 Funnelling of internal OSFunnelling of internal OS
 Pelvic pressure, backache or vaginalPelvic pressure, backache or vaginal
discharge or bleding.discharge or bleding.

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

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

27. FIBRONECTINFIBRONECTIN
AA PROTEINPROTEIN that bindsthat binds
thethe FETALFETAL MEMBRANESMEMBRANES
toto DECIDUADECIDUA
Normally found inNormally found in
CERVICOVAGINALCERVICOVAGINAL
dischargedischarge beforebefore 22wks22wks &&
againagain afterafter 37wks37wks ofof
pregnancypregnancy
PRESENCE OFPRESENCE OF
FIBRONECTIN IN CVDFIBRONECTIN IN CVD
B/W 24Wks & 34 WksB/W 24Wks & 34 Wks
PREDICTSPREDICTS PRE-TERMPRE-TERM
LABOURLABOUR

29. MANAGEMENTMANAGEMENT
It includesIt includes
Prevention,if possible
Arrest of preterm
Labour, if not
contraindicated
Appropriate management
Neonatal care

30. Prevention of PretermPrevention of Preterm
LabourLabour
Primary CarePrimary Care ––
to reduce the incidence of pretermto 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 detectionincludes 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 diagnosismortality 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 assistedBe cautious when using assisted
reproductive technology (ART)reproductive technology (ART)

32. Taking preventive medications , who hasTaking 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 PRETERMARRESTING PRETERM
LABOURLABOUR
BED RESTBED REST--Left lateral positionLeft 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 THERAPYSHORT TERM THERAPY
Most successful therapyMost successful therapy
OBJECTIVES:OBJECTIVES:
-TO DELAY delivery for 48hrs for-TO DELAY delivery for 48hrs for
glucocorticoidglucocorticoid ttherapyherapy to mother toto mother to
enhanceenhance fetal lung maturationfetal 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 neonateunit more able to manage a preterm neonate

35. GLUCOCORTICOIDGLUCOCORTICOID
THERAPYTHERAPY
Advocated in pregnancy less than 34Advocated 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 doseIDDM where patients needs insulin dose
readjustmentreadjustment

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

37. GestationalGestational
diabetesdiabetes
Placenta praviea.Placenta praviea.
In case ofIn case of
placentalplacental
abnormalitiesabnormalities..

38. APPROPRIATEAPPROPRIATE
MANAGEMENTMANAGEMENT
There are basically 2 principles:There are basically 2 principles:
To prevent birth asphyxia & developmentTo prevent birth asphyxia & development
of RDSof RDS
To prevent birth traumaTo prevent birth trauma

39. FIRSTFIRST 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 intensiveLabour should be watched by intensive
clinical monitoringclinical monitoring
 In case of delay, caesarean sectionIn case of delay, caesarean section
should be performedshould be performed

40. SECONDSECOND STAGESTAGE
 TheThe birthbirth shouldshould bebe gentlegentle && slow to avoid rapidslow to avoid rapid
compression & decompression of headcompression & decompression of head
 EpisiotomyEpisiotomy may be done undermay be done under locallocal anesthesiaanesthesia toto
minimize head compression if there is perinealminimize head compression if there is perineal
resistanceresistance
 Tendency to delayTendency to delay is curtailed by low forceps. Routineis curtailed by low forceps. Routine
forceps is not indicatedforceps is not indicated
 The cord is to be clampedThe cord is to be clamped immediately at birth toimmediately at birth to
prevent HYPERVOLEMIA & HYPERBILIRUBINEMIAprevent HYPERVOLEMIA & HYPERBILIRUBINEMIA
 To shift the baby to intensive neonatal care unitTo shift the baby to intensive neonatal care unit
under care ofunder care of NEONATOLOGISTNEONATOLOGIST

41. IMMEDIATEIMMEDIATE
MANAGEMENTMANAGEMENT
 The cord is to be clamped quicklyThe cord is to be clamped quickly
 The cord length is kept long in case exchangeThe 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 toAqueous solution of vit.k 1mg given I/M to
prevent hemorrhagic manifestationsprevent hemorrhagic manifestations
 The baby should be wrapped including head inThe baby should be wrapped including head in
a sterile warm towela sterile warm towel

42. NURSING MANAGEMENTNURSING MANAGEMENT
1.1. Assess the mother’s condition to evaluateAssess 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 andDetermine the cervical dilatation and
effacement.effacement.
 Assess the status of membranes, andAssess the status of membranes, and
bloody showbloody show

43. Cont..Cont..
2.Evaluate the factors for distress, size and2.Evaluate the factors for distress, size and
maturity.maturity.
(sonography & lecithin-sphingomyelin ratio)(sonography & lecithin-sphingomyelin ratio)
3. Perform measures to manage or stop pre3. Perform measures to manage or stop pre
term labour.term labour.
Place the client on bed rest in the sidePlace the client on bed rest in the side
lying position.lying position.
Prepare for possible ultrasongraphy,Prepare for possible ultrasongraphy,
amniocentesis, tocolytic drug therapy oramniocentesis, 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 support4- 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 inResults in highhigh
-perinatal mortality-perinatal mortality
-perinatal morbidity-perinatal morbidity
• With intensive neonatal care unitWith intensive neonatal care unit,,
survival rate of the baby weighing b/wsurvival 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 aboutrate of infants born at 26wks is about
80%80%

47. CLIENTCLIENT
EDUCATIOEDUCATIO
NN
All PREGNANT womenAll PREGNANT women
should recognizeshould recognize
followingfollowing S/S ‘s:-S/S ‘s:-
-uterine contractions-uterine contractions
every 10-15 minutes orevery 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