PRETERM LABOR AND BIRTH

Preterm labor refers to labor that occurs after 20 weeks’ but before 37 weeks’ gestation. Preterm birth, a consequence of preterm labor, refers to delivery prior to 37 weeks’ gestation. Preterm birth is a significant contributor to infant mortality rates.

Maternal and Fetal Implications

Preterm labor and birth present a unique challenge to patients and their fetuses. Although most of the implications apply to the fetus, patients may suffer from stress due to the diagnosis of preterm labor and birth as well as from the causative agent. Specifically, patients may be experiencing preterm labor and birth due to conditions such as sepsis or stress.

The fetus is at great risk for delivering early as a result of preterm labor. The effects of preterm labor and birth depend on the gestational age of the fetus at delivery. The immaturity of fetal lungs in the presence of preterm labor and birth is a significant concern.

Signs and Symptoms

Patients presenting with preterm labor and birth often complain of feeling pressure in the pelvic area, abdominal and/or uterine cramping or contractions, painful or painless contractions, feeling as though the fetus is “balling up,” and/or constant back pain. Amniotic membranes may rupture prematurely, and a sudden gush or constant trickle of vaginal fluid may be noted.

Medical Treatment

Clinical criteria for a diagnosis of preterm labor include:

  • Persistent uterine contractions (≥4 every 20 minutes or ≥8 every 60 minutes) and
  • Cervical dilation ≥3 cm or cervical length <20 mm on transvaginal ultrasound or
  • Cervical length 20 to <30 mm on transvaginal ultrasound and positive fetal fibronectin
    (Lockwood, 2022)

Medical treatment for preterm labor and birth depends on the gestational age of the fetus. Generally, healthcare practitioners seek to avoid delivery of patients prior to 34 weeks’ gestation to allow further maturation of the fetal lungs. Glucocorticoids (betamethasone) are often prescribed to increase fetal lung maturity, tocolytics to control uterine contractions and delay birth so that glucocorticoids can take effect, antibiotics for group B streptococcal chemoprophylaxis, and magnesium sulfate for neuroprotection in offspring born preterm (Lockwood, 2022).

Nursing Care

Nursing care for patients experiencing preterm labor includes administering prescribed medications such as antibiotics, glucocorticoids, magnesium sulfate, and tocolytics, and preparing the patient for possible delivery. While hospitalized, patients are monitored for signs and symptoms of infection, which can lead to preterm labor. Fetal tachycardia indicates possible infection and should be evaluated immediately. Vital signs, contractions, and fetal status are assessed as ordered or according to institutional policy.

When patients are faced with the possibility of delivering a preterm infant, the situation may quickly become overwhelming to them. Although preterm labor and birth can occur rapidly, it is imperative that nurses address the emotional issues of the patient. Generally, this will involve answering patient questions about the status of the fetus and preparing the patient for the care required to prevent delivery or the necessary preparation for preterm delivery.

Patient Teaching

The major goal of teaching patients with preterm labor is to help them become aware of factors that may cause premature labor and delivery. If the acute episode of preterm labor has passed, patients may be discharged and taught to:

  • Continue activities of daily living, but do not lift anything >20 pounds and avoid recreational exercise.
  • Consider avoiding sexual activity if they experience an increased frequency or intensity of contractions afterward. It is possible that orgasm and prostaglandins in semen can increase myometrial activity.
  • Avoid returning to work if it involves >40 hours/week, night shifts, prolonged standing, or heavy physical work.
    (Caritis & Simhan, 2022)
POST-TERM PREGNANCY

Just as preterm delivery comes with complications, a post-term delivery can lead to complications as well. A post-term pregnancy is defined as ≥42 weeks’ gestation. Due to placental insufficiency or excessive fetal growth, maternal, fetal, and neonatal complications can occur. These include macrosomia (and possible associated surgical delivery or birth injury), intrauterine malnutrition, and perinatal mortality. It is recommended to induce at 41 weeks’ gestation in order to decrease the likelihood of complications.

CASE

Ciara phones the perinatal clinic. She is 18 years old and in the 32nd week of her second pregnancy. Ciara’s first child was born at 36 weeks’ gestation.

Ciara is sobbing over the phone and keeps repeating, “I don’t want it to happen again.” The nurse asks Ciara to take a deep breath, sit down, and explain how she is feeling. After a short time, Ciara states that she is having uterine contractions that are occurring every 10 minutes and lasting for 1–2 minutes. The contractions started about three hours ago and did not stop when she tried to walk. Asked about a gush of water from the vagina, she denies it. Ciara says, “I still feel the baby kicking. That’s a good thing, isn’t it? Did I make this happen?”

After reviewing her patient record, the nurse discovers that there is a history of social service intervention. As a result of Ciara’s impoverished circumstances, Ciara and her 3-year-old child receive nutritional support through the WIC (Women, Infants, and Children) program and live in a shelter to escape from an abusive cohabiting male.

Ciara is told to have someone bring her to the hospital as soon as possible. She states that she already called for a ride and that she should be arriving at the hospital within 30 minutes. The nurse tells Ciara to lie down on her left side, drink plenty of fluids, and wait for her ride.

Discussion

Ciara may be in preterm labor. She has several risk factors, including low socioeconomic status, significant life events (separation), anxiety, a history of preterm labor and birth, and poor nutrition. Ciara will be assessed for the condition of her cervix and amniotic membranes upon arriving at the hospital. Vital signs, contractions, and fetal status will be evaluated. She will also be observed for signs of infection and dehydration. She is very anxious, and because she has had a previous preterm birth, Ciara may have feelings of guilt that require reassurance and psychological support. The goal of her hospitalization would be to avoid delivery.
(Case study courtesy of Sharon Walker, RN, MSN.)