PREPARED BY:

1
PREPARED BY
DIANA KATHERINE MALINAO LR/DR
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DEMOGRAPHIC DATA
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CASE NO 181
NAME MS. PTL 40/F
Dx PRETERM LABOR G2P1 Pregnancy Uterine 31 3/7
Weeks, Cephalic, PROM, Previous LSCS, GDM on
diet, Vaginal Candidiasis
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PHYSICAL ASSESSMENT
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GENERAL
?The patient is 40 y/o, FEMALE, weighs 65 kg.
She is conscious, coherent
?Vital Signs BP 120/70 mmHg PR80 bpm RR 20
/mt Temp36.9C O²Sat 98
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SKIN
? Pallor of skin and nails
? No palpable masses or lesions
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HEAD
? Maxillary, frontal, and ethmoid sinuses are not
tender.
? No palpable masses and lesions
? No areas of deformity
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LOC ORIENTATION
? Awake and alert
? Oriented to Persons, Place, Time
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EYES
? Pale conjunctivae and no dryness
? Pupils equally round and reactive to light
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EARS
? No unusual discharges noted
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NOSE
? Pink nasal mucosa
? No unusual nasal discharge
? No tenderness in sinuses
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MOUTH
? Dry mouth and lips
? Free of swelling and lesions
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NECK AND THROAT
?No palpable lymph nodes
?No masses and lesions seen
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CHEST AND LUNGS
? Equal chest expansion
? No retraction
? Clear breath sounds
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HEART
?Regular rhythm
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ABDOMEN
? Globular abdomen
? Abdominal scars from previous LSCS
? The patient complained of mild hypogastric pain
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ABDOMEN
? Leopolds Maneuver done Cephalic presentation
? FHR 152bpm
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GENITALS
? Watery discharge since 1000H 13/08/12
? Thick, yellow patchy, cheese like particles
adhere to vaginal walls
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GENITALS
? Patient claimed pain and burning on urination
? Cervix 1cm dilation, 50 Effacement, Station
-3 Cephalic, Clear AF
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EXTREMITIES
? Pulse full and equal
? No lesions noted
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PATIENT HISTORY
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PAST MEDICAL HISTORY
? On her 1st pregnancy cardiac consultation was
done all normal including 2D echo.
? Prenatal Care Previous Prenatal in Pakistan
and a clinic in Riyadh.
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PAST MEDICAL HISTORY
? Patient on Iron and Prenatal Vitamins.
? No known allergies.
? No history of Asthma, Hypertension, Renal
disease and Thyroid problem.
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PAST SURGICAL HISTORY
? 1993 Arterial Ligation (Heart) No report
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PAST SURGICAL HISTORY
? 2008 Low Segment Cesarean Section due to cord
coil under General Anesthesia without complication
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PRESENT MEDICAL HISTORY

• 12/08/12. 1 day prior to admission patient came
  to our OPD for prenatal check up. Patient claimed
  that 2 days ago
• 1. she has a reddish-brown in character and
  minimal vaginal discharge
• 2. mild hypogastric pain
• 3. dysuria.

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PRESENT MEDICAL HISTORY

• Ob/Gyne History
• Gravida 2
• Para 1
• Gestational Age 31 3/7 Weeks
• LMP not sure
• LMP by early UTZ 06-01-12
• EDD 13-10-2012

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PRESENT MEDICAL HISTORY

• On Examination
• Vital signs BP 120/70mmHg, PR 85 bpm, RR 20
  cpm, Temp. 37?C, 02 Sat 96,
• FHR 138bpm
• IE PV parous, closed.
• Cardiotocogram shows reassuring no contraction.

? Investigation Amnisure ROM test Negative
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PRESENT MEDICAL HISTORY

• 13/08/12 Patient came to ER with chief complained
  of
• watery discharged since 1000H 13/08/12
• labor pains started since 2400H 12/08/12.

? According to the patient she took Aspirin 81mg
OD 4 days ago
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PRESENT MEDICAL HISTORY
? Sugar monitoring at home are not well controlled
? No cardiac consultation on present pregnancy.

• On Examination
• IE PV 1cm dilated, 50effaced, station -3,
  clear amniotic fluid.

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INVESTIGATION
Amnisure ROM test Positive
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CTG or Cardiotocogram
CTG TRACING
NORMAL MRS. PTL
FETAL HEART RATE 110 - 160 bpm 152 bpm
CONTRACTION (PTL) NO CONTRACTION MILD TO MODERATE CONTRACTION
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AMNIOTIC FLUID NORMAL OLIGOHYDRAMNIOS POLYHYDRAMNIOS
Per milliliters 500 to 1,000 ml lt 500 ml gt 2,000 ml
Amniotic Fluid Index by Ultrasound 8 - 18 cm lt5-6 cm gt 20 24 cm
DAY 01 13.08.12
PREGNANCY UTERINE 31 WEEKS AND 1 DAY AOG BY FETAL BIOMETRY SINGLE, LIVE IN CEPHALIC PRESENTATION GOOD CARDIAC ACTIVITY POSTERIOR PLACENTA, GRADE II, NO PREVIA Total AFI ANHYDRAMNIOS BPP 6/8
DAY 03 15.08.12
AMNIOTIC FLUID VOLUME BELOW THE 3RD PERCENTILE Total AFI 7.1 cms OLIGOHYDRAMNIOS BPP 6/8 The umbilical artery pi is increased (1.71) suggestive of INCREASE UTEROPLACENTAL RESISTANCE (probably secondary to GDM) which may possibly lead to INTRAUTERINE GROWTH RESTRICTION.
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LABORATORY RESULT REFENCE RANGE
Urinalysis Leucocytes Pus cells Others 1 10-15/hpf 0-1/hpf FUNGAL HYPAE present
Cervico vaginal Swab Pus cells Ep Cells Morphology 4-6/oif 2-4/oif Lactobacilli, plenty CANDIDA PRESENT No clue cells, Negative for gonococci
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LABORATORY RESULT REFENCE RANGE
CBC HGB HCT PLT 11.3g/dl 35.4 289 11.2-15.7 g/dL 34.1-44.9 182-369/UL
Blood Group A
Rh Type Positive
PT 13.3 sec 10.9 16.3 Seconds
APTT 30.4 sec 27 39 Seconds
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LABORATORY RESULT REFENCE RANGE
Antibody Screen Negative Negative
Urine culture and sensitivity No growth seen after 48 hours of incubation at 37C
Vaginal Swab culture No growth seen after 48 hours of incubation at 37C
HBsag Negative Negative
C-Reactive Protein Negative Negative
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BLOOD GLUCOSE MONITORING
DATE BREAKFAST BREAKFAST BREAKFAST LUNCH LUNCH LUNCH DINNER DINNER DINNER
TIME OF MEAL PRE-BS POST-BS 2HRS TIME OF MEAL PRE-BS POST-BS 2HRS TIME OF MEAL PRE-BS POST-BS 2HRS
13/08/12 Upon admission 71mg/dl Upon admission 71mg/dl Upon admission 71mg/dl Upon admission 71mg/dl Upon admission 71mg/dl Upon admission 71mg/dl 1115H 93mg/dl 192mg/dl
14/08/12 116mg/dl 173mg/dl 1740H 136mg/dl 152mg/dl
15/08/12 0830H 109mg/dl 121mg/dl 1330H 110mg/dl 131mg/dl 1935H 79mg/dl 91mg/dl
16/08/12 78mg/dl 1200H 77mg/dl 112mg/dl 2000H 85mg/dl 124mg/dl
17/08/12 90mg/dl 1130H 103mg/dl 110mg/dl
18/08/12 2000H 145mg/dl
19/08/12 1200H 123mg/dl 2000H 109mg/dl
20/08/12 0400H 100mg/dl
A fasting blood glucose level below 95 to 100
mg/dL and 2 hour postprandial level below
120mg/dL Maternal Child Health Nursing
Lippincot, 2007.
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Internal Medicine CONSULTATION

• Patient has mild fluctuation in blood sugar
  level.
• Patient does not need insulin just diet
  control.
• Plan BSR x 8hourly, HBaIC, TSH

RESULT REFERENCE
Glycosylated Hemoglobin (HBa1C) 3.5 Diabetics 4.0-6.02 Good control 6.3-7.9 Satisfactory Control gt7.9 unsatisfactory control
TSH 1.35uIU/ml Euthyroid 0.25 5.0 uIU/ml Hypothyroid more than 7.0 uIU/ml Hyperthyroid less than 0.15 uIU/ml
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MEDICATION
NAME OF DRUG ACTION DOSAGE ROUTE/ FREQUENCY
Dexamethasone Corticosteroid 12mg IM x 2 doses
Ampicillin Antibiotic 500mg IV Q6 x 48
Erythromycin Antibiotic 250mg PO q6
Clotrimazole Antifungal 100mg Vaginal Supp OD HS x 6 days
Nifedipine Calcium Channel Blocker 10mg PO Stat then TID
Ferrous Sulphate Iron Supplement 100mg PO OD
Calcium Citrate Calcium Supplement 600mg PO OD
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Anesthesia CONSULTATION

• Pre-Anesthetic Visit done.
• For cardiac consultation.

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Cardiac CONSULTATION
ECG REPORT 2D ECHO REPORT NT-pro BNP
Sinus Tachycardia (after Nifedipine) otherwise WNL SWM WNL EF 70 75 All Valve WNL PASP 20 mmHg Peri cardium WNL 51 pg/mL Reference lt 75 Years lt 125 gt 75 Years lt 450

• PLAN
• No specific intervention right now from
  cardiology side.
• Low risk for cardiac arrest, no objection for
  operation if you need to do.
• If you can decrease dose of Nifedipine to
  decrease tachycardia

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COLLABORATION
Neonatologist Neonatal Intensive Care Unit
Staff for Neonatal care/resuscitation.
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TOPIC PRESENTATION
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? Preterm Labor (PTL) is defined as regular
contractions associated with cervical changes
after 20 weeks gestation and prior to 37
completed weeks of gestation.
? It is the second, only to birth defects, as the
leading cause of neonatal mortality.
? It occurs in up to 12 of all pregnancies and
is the most frustrating clinical dilemmas in
obstetrics.
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Molecular Mechanism of PTL


1. Premature activation of the maternal or fetal
HPA axis
2. Decidual and amniochorionic inflammation
3. Decidual hemorrhage
4. Pathologic uterine distention
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ANATOMY PHYSIOLOGY
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Hypothalamic-Pituitary-Adrenal Axis
Stress
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ADRENAL HORMONES
Cortisol
Aldosterone
Sex hormone DHEA
Adrenaline
Noradrenaline
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MATERNAL SYSTEMIC DISEASE Heart Gestational
Diabetes

• Current Pregnancy complications
• Fetal anomaly
• Hydramnios
• Abdominal surgery Previous LSCS
• Infection
• PROM
• UTI

DEMOGRAPHIC DATA MATERNAL AGE lt 17 gt 35
PRETERM LABOR

• OTHER
• Stress
• Occupational factors

BEHAVIORAL ENVIRONMENT Poor Nutrition Late
Prenatal care
UNKNOWN CAUSES
RISK FACTOR OF PTL
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MATERNAL STRESS (Genital infections, Maternal
factors/ Systemic Disease)
FETAL STRESS (Uteroplacental insufficiency)
Activation of maternal HPA axis
Activation of fetal HPA axis
ACTH Adrenocorticotropic hormone
?
CORTISOL
ADRENAL
DECIDUA PLACENTA MEMBRANES
?COX-2 IN ?PGDH IN
AMNION CHORION
DHEAS
?
PLACENTA MEMBRANES
CRH
ESTROGEN
?
?
?MYOMETRIAL Oxytocin Receptors, Prostaglandins,
Myosin Light Chain Kinase, calmodulin, gap
junctions
PROSTAGLANDINS
CERVICAL CHANGE
RUPTURE OF MEMBRANCES
CONTRACTIONS
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DIAGNOSTIC EVALUATION
? Vaginal Examination
? Transvaginal Cervical Ultrasound
? Clean-catch Urine For Culture, Vaginal And
Cervical Culture
? Fetal Fibronectin (Ffn)
? External Fetal Heart Monitor or Cardiotocogram
? Fetal Ultrasound
? Amniocentesis
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SIGNS AND SYMPTOMS
? UTERINE CRAMPS
? UTERINE CONTRACTIONS OCCURING AT INTERVALS OF
10 MINUTES
? LOW ABDOMINAL PAIN OR PRESSURE (PELVIC
PRESSURE)
? DULL LOW BACKACHE
? INCREASE OR CHANGE IN VAGINAL DISCHARGE
? FEELING THAT BABY IS PUSHING DOWN
? ABDOMINAL CRAMPING WITH OR WITHOUT Nausea,
Vomiting OR DIARRHEA
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NURSING INTERVENTION
1. Educate mother regarding signs and symptoms of
PTL and about steps to be taken to counteract the
process.
2. Discuss aspects of a healthy diet and adequate
maternal weight gain during pregnancy.
3. Institute bed rest with patient in side lying
position that will enhance placental perfusion.
4. Early therapy options like abstinence from
intercourse and orgasm.
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NURSING INTERVENTION
5. Obtain laboratory studies including CBC, hgb
and hct, serum electrolytes. Obtain clean-catch
urine for culture, vaginal and cervical cultures,
and fibronectin as ordered.
6. Monitoring vital signs, fetal heart rate, and
uterine activity as a baseline.
7. Initiating hydration measures and monitoring
intake and output.
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MANAGEMENT
? Early Education
? Prevention
? Limiting Neonatal Morbidity
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Preconception Care
? Baseline assessment of health and risk
? Pregnancy planning and identification of
barriers to care.
? Adjustment of prescribed and over-the-counter
medications that may pose a threat to the
developing fetus.
? Nutritional counseling as needed.
? Screen for chronic diseases.
? Genetic counseling as indicated.
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Antepartum Treatment
? Educate patient regarding signs/symptoms of PTL.
? Instruct patient and provide resources for
lifestyle modification.
a. Discuss aspects of a healthy diet and
adequate maternal weight gain during pregnancy.

• Early therapy options include bed rest,
  hydration, and abstinence from intercourse and
  orgasm

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Tocolytic Therapy
Agent Mechanism of Action Dose Side-effects Nursing Action
Nifedipine Calcium Channel Blocker Loading 20mg stat then repeat after 30minutes or until uterine activity subsides Maintenance 10mg TID HYPOTENSION TACHYCARDIA, headache, flushing BP monitoring Q15minutes for 1 hour Hold the dose For SBP lt 90 Or DBP lt 60 Hr 100 bpm
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Other Tocolytic Drugs which are not used due to
Maternal/Fetal adverse Effect
Medication Maternal/Fetal Side-effects
Terbutaline /Bricanyl B2 Adrenergic Receptor Agonist PULMONARY EDEMA is a well-documented complication, usually associated with aggressive intravenous hydration.
Indomethacin Prostaglandin Inhibitor Decrease fetal urine output resulting in Oligohydramnios Premature close of fetal ductus arteriosus which result to fetal pulmonary Hypertension.
Atosiban Oxytocin Inhibitor Nausea was significantly increased after injection administration.
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Antibiotic Therapy
Antibiotic Dose
Ampicillin Loading 2gram IV Maintenance 1 gram IV Q6 for 48hours
Erythromycin 250mg Q6 until 10 days
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General Contraindications to Tocolytic Therapy
1. Category III FHR Patterns
2. Intra-amniotic infection
3. Eclampsia or severe preeclampsia
4. Fetal demise
5. Fetal maturity
6. Maternal hemodynamic instability
7. Severe bleeding of any cause
8. Fetal anomaly incompatible with life
9. Severe IUGR
10. Cervix dilated more than 5cm
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Acceleration of Fetal Maturity
Agent Mechanism Of Action Dose Side-effects Nursing Implications
Dexamethasone Corticosteroid To hasten fetal lung maturity 12mg IM Q12 x 2 doses irritation at the injection site, tachycardia Explain the purpose of the drug Monitor v/s and fetal heart rate Postponing delivery for administration is an option because it takes about 24 hours for the Dexamethasone to have an effect. The effect last approximately 7 days.
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Acceleration of Fetal Maturity
Agent Mechanism Of Action Dose Side-effects Nursing Implications
Survanta Lung surfactant 4ml/kg intratracheally four doses in first 48 hours of life Transient bradycardia, rales Suction infant before administration. Assess RR, Rhythm, Arterial blood gas, and color before administration. Ensure proper ET tube placement before dosing. Do not suction ET tube for 1 hour after administration, to avoid removing drug.
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Complications
Prematurity and associated neonatal
complications, such as lung immaturity
? Intraventricular Hemorrhage (IVH)
? Respiratory Distress Syndrome (RDS)
? Patent ductus arteriosus (PDA)
? Necrotizing enterocolitis (NEC)
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Complications of Preterm Labor
Premature Labor cant be halt will lead to
Preterm Delivery
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PRIORITIZATION OF NURSING PROBLEMS
1. Risk for injury maternal/fetal related to
preterm labor and tocolytic therapy.
2. Deficient Knowledge Preterm labor Prevention
related to unfamiliarity with Preterm Labor
signs/symptoms and prevention)
3. Activity intolerance related to prescribed bed
rest or decreased activity secondary to threat to
preterm labor
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PRIORITIZATION OF NURSING PROBLEMS
4. Deficient Diversional activity related to
inability to engage in usual activities secondary
to attempts to avoid PTL PTB
5. Anxiety related to medication and fear of
outcome of pregnancy
6. Anticipatory grieving related to preterm labor
and birth
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PRIORITIZATION OF NURSING PROBLEMS
7. Risk for Complications secondary to tocolytic
therapy
8. Compromised Family Coping secondary to
hospitalization
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NURSING CARE PLAN
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ASSESSMENT NURSING DIAGNOSIS GOALS DESIRED OUTCOME NURSING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE I feel a sudden contraction as verbalized by the patient OBJECTIVE Continued uterine contraction Facial mask of pain Irritability V/S taken as follows BP 120/70mmHg PR 80 bpm RR 20 cpm Temp. 36.9?C FHT 152bpm Cervix 1cm dilated, 50 Effacement, Station -3 Cephalic Position Risk for Injury maternal /fetal related to preterm labor and tocolytic therapy. Within 12 hours of nursing intervention, patients contraction halt after treatment with tocolytic and fetal heart rate remains within acceptable parameters. 1. Positioned patient on left side as much as tolerated. Change to right side if client becomes uncomfortable avoid supine position. 2. Explain all procedures and equipment to patient and significant other. 3. Attached external fetal heart rate monitors for continuous evaluation of contractions and fetal response. ?Position facilitates uteroplacental perfusion. ?Client and significant other may be experiencing high anxiety and need repeated explanation. ?Uterine and fetal monitoring provides evidence of fetal well-being. After 12 hours of nursing intervention, the goal was fully met as evidenced by Cessation of uterine contraction after treatment with tocolytic. Fetal heart rate remains within acceptable parameters.
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ASSESSMENT NURSING DIAGNOSIS GOALS DESIRED OUTCOME NURSING INTERVENTION RATIONALE EVALUATION
4. Made contact with ultrasound personnel as per doctors order. 5.Extracted blood for laboratory studies such as CBC. Obtained clean-catch urine for culture, vaginal and cervical culture. 6. Inserted IV line and begin IV fluid therapy as doctors order. 7.Administered betamethasone as prescribed. ?An ultrasound can document fetal health and cervical dilation. ?Assessment provides a baseline for future comparison. ?IV fluid improves hydration, which may help to minimize contractions. ?This synthetic cortisol can accelerate fetal lung maturity by stimulating surfactant production.
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ASSESSMENT NURSING DIAGNOSIS GOALS DESIRED OUTCOME NURSING INTERVENTION RATIONALE EVALUATION
 8. Administer antibiotics, as indicated.  9. Initiate tocolytic therapy, as ordered.     10. Checked patients vital signs closely, every 15 minutes. Assessed for chest pain and dyspnea. 11. Checked fetal heart rates and pattern. ? In the event of PROM, antibiotics may be used to prevent/reduce risk of infection. ? Helps reduce myometrial activity to prevent/delay early delivery.  ? Maternal pulse over 120 beats per minute or persistent tachycardia or tachypnea, chest pain, dyspnea, or adventitious breath sounds may include impending pulmonary edema. Fetal tachycardia or late or variable decelerations indicate possible uterine bleeding or fetal distress, which requires emergency birth.
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NURSING HEALTH TEACHING
? Educate the patient about the importance of
continuing the pregnancy until the term or fetal
lung maturity.
? Encourage the need for compliance with a
decrease activity level or best rest, as
indicated.
? Teach the patient the importance of proper
nutrition and the need for adequate hydration.
? Instruct the patient not to engage in sexual
activity if diagnosed with PTL.
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NURSING HEALTH TEACHING
? Teach the patient the signs and symptoms of
infection and to report them immediately.
? When preterm labor occur
? Empty bladder to relieve pressure on the uterus
? Lie down on left side for 1 hour
? Drink 2-3 glasses of water or juice
? Palpate for contractions
? If no contractions, assume light activity, if
symptoms comes back, need to notify health care
professionals
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CONCLUSION
? Presented a case of a 40 y/o G2P1 Pregnancy
Uterine 31 3/7 weeks with 10-15 pus cells
Candida present on Cervico vaginal swab are
considered maternal infection that plays a
potential etiologic role in preterm labor
therefore an administration of antibiotic therapy
will be given to prevent perinatal transmission.
? On conservative management such as antenatal
screening and close fetal antenatal surveillance
(biophysical profile with Doppler velocimetry
every 3 days)
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CONCLUSION
? High Risk Pregnancy with Preexisting Illness
like Diabetes and Heart Disease needs a special
care provided by the Internist, Cardiologist,
Anesthesiologist, OB/Gyne Sonologist
Neonatologist.
? On tocolytic therapy such as Nifedipine,
administration of Corticosteroid Dexamethasone
for acceleration of lung maturity and provision
of neonatal care.
? Rendered close observation including fetal
status and labor progress.
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CONCLUSION
? Nurses role in providing education to the
patient about the importance of continuing the
pregnancy until term or fetal lung maturity.
? However, on Day 04 CTG shows early deceleration
and labor progresses. Patient underwent REPEAT
LSCS due to FETAL DISTRESS (persistent fetal
bradycardia) to a stillborn infant with MULTIPLE
CONGENITAL DEFECTS, AMBIGOUS GENETALIA.
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BIBLIOGRAPY
? Wolters Kluwer Lippincot Williams Wilkins.
Lippincot Manual of Nursing Practice, 9th
edition, page 1330-1333, 2010.
? Pillitteri, Adele. Maternal Child Health
Nursing, 3rd ed.Philadelphia Lippincott, 1999.
? http//en.wikipedia.org/wiki/
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THANK YOU ?