Transcript Nursing Care for Women with Preterm Labor, Premature Distress

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
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
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)
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
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
Behavioral and Environmental
Risk for Preterm Labor
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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
Risk Factors for Perterm Labor
• Bacterial Vaginosis 40 % increased risk
• Syphilis and gonorrhea 50% increased risk
• Asymptomatic bacteria 50% increased risk
Symptoms of Preterm Labor
20-37 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
Suppression of Uuterine
Aactivity
Tocolytics Therapy：
1. Ritodrine（Yutopar）
2. Terbutaline
3. Magnesium Sulfate
4. Indomethacin
Contraindications to Tocolysis
Maternal factor：
1. Severe PIH or eclampsia
2. Active vaginal bleedings
3. Intrauterine infection
4. Cardiac distress
5. Medical or obstetric condition that
contraindicates continuation of pregnancy
Contraindications to Tocolysis
Fetal Factors:
1. Estimated gestational age > 37 weeks
2. Dilation of > 4 cm
3. Estimated weight of birth > 2500 grams
4. Fetal Demise
5. Lethal fetal anomaly
6. Chorioamnionitis
7. Acute Fetal Distress
8. Chronic IUGR
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
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
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.
Health Teaching for
pertem labor prevention
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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.
5. Life style modification
Signs of Perterm Labor
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Uterine contractions every 5 minutes or less
Vaginal bleeding
Odorous vaginal discharge
Fluid leaking from the vagina
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.
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.
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
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
Fetal Surveillancecounting fetal movement
Teaching for fetal movements kick count:
Choose a time of day for quiet moment
1. Starting at certain time and count the baby’s
movement until reach 10. If not count 10 in 12
hours, need to see physician.
2. 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.
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
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
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
Discharge Criteria for Women
with PPROM
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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)
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
Fetal Distress Maternal
Risk Factors
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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
Complication during laborfetal distress
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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
Prolapsed of cord during labor
• Fetal bradycardia
• Membranes ruptured
• Cord lies below the presentation part of the
fetus
• Need to do emergency delivery
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)
Ultrasonography in Third
Trimester for Aassessing Fetus
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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
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
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)
Question and Answer
Thank for your attention!
Please review the case study and be
ready for next discussion