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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

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

  • Learning ObjectivesDefine the key terms: preterm labor, premature rupture of membranes, fetal distressUnderstand the difference in perterm birth and low birth weightIdentify risks factors of perterm laborUnderstand 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 Defination: Cervical change and uterine contractions occurring between 20 weeks an 37 weeks of pregnancyPerterm birth lead 75% of the perinatal mortalityPerterm 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 ageLow birth weight: weight at time of birth is less than or equal to 2500 grams. Intrauterine growth retadation: IUGR

  • Risk Factors of Preterm Labor Demographic Risks: young mother, low socioeconomic status, unmarried, low level of educationMedical risk: history of preterm birth, multiple abortions, uterine anomalies, low pregnancy weight, DM, Hypertentionmultiple gestation, infection, incompetent cervix, UTI, bleeding, placenta previa or abruptio plancenta, anemia, fetal anomalies

  • Behavioral and Environmental Risk for Preterm Labor Diethylstilbestrol (DES) ExposureSmokingPoor NutritionAlcohol or other substance use, expecially cocaineLate or no prenatal care Stress, uterine irritability, long working hours, inabillity to rest

  • Risk Factors for Perterm LaborBacterial Vaginosis 40 % increased riskSyphilis and gonorrhea 50% increased riskAsymptomatic bacteriuria 50% increased risk

  • Symptoms of Preterm Labor20-37 weeks of gestational agePelvic pressure feels like the baby is pushing downLow, dull backacheMenstrual-like crampsChange or increase in vaginal dischargeUterine contractions (hardness), every 10 minutes or more often with or without painIntestinal cramping with or without diarrhea

  • Supression of Uterine ActivityTocolytics TherapyRitodrineYutoparTerbutaline Magnesium Sulfate Indomethacin

  • Contraindications to TocolysisMaternal factorSevere PIH or eclampsiaActive vaginal bleedingsIntrauterine infectionCardiac distressMedical or obsteric condition that contraindicates continuation of pregnancy

  • Contraindications to TocolysisFetal Factors: Estimated gestational age > 37 weeksDilation of > 4 cmEstimated weight of birth > 2500 gramsFetal Demise Lethal fetal anomalyChorioamnionitisAcute Fetal DistressChronic IUGR

  • Nursing Diagnossi for Perterm Labor Knowledge deficit related to-recognition of preterm symptomsRisk for maternal or fetal injury related to preterm labor and birthAnxiety related to perterm birth and family consequencesImpaired mobility related to prescribed bed restAnitipatory grieving related to preterm labor and birth

  • Nursing care for women with tocolytic therapy Position on Lf side for better placenta perfusionAssess blood pressure, pulse (not > 120/min), and respiratory rateAssess signs of pulmonary edema (chest pain, shortness of breath, crackles, rhonchi)Assess urinary output q1h, monitor for ketonuriaLimit fluid intake to 2500-3000 ml/dayProvide psychosocial support and release anxietyMonitor electrolyte, blood glucose level

  • Promoting Fetal Lung MaturityAntenatal glucocorticoid therapy: betamethasone, dexamethasoneAction: stimulates fetal lung maturation by promoting release of enzymes that induce production and or release of lung surfactantNursing consideration: Assess signs of infection, pulmonary edema, blood glucse level, lung sound, takes 24 hours for drug to effective, not to give women > 35 weeks of pregnancy.

  • Health Teaching for pertem labor prevention When perterm labor occur: Lie down on your left side for 1 hourDrink 2-3 glassess of water or juicePalaate for contractions If no contraction, assume light activity, if sysmpotm come back, need to notify health care professionals. Life style modification

  • Sigsn of Perterm LoborUterine contractions every 5 minutes or lessVaginal bleedingOdorous vaginal dischargeFluid leaking from the vagina

  • Premature Rupture of Membrance (PROM )Definition: Rupture of the amniotic sac andleakage 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 PPROMChorioamnionitis: 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 poistive amniotic fluid culture May lead to sepesis, congenital pneumonia, meningitis of the newborn due to intrauterine infection casued by RPROM

  • Fetal Surviallance-counting fetal movement Teaching for fetal movements kick count: Choose a time of day for quiet momentStarting at certain time and count the babys 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.

  • Biophysical Profiles for Fetus Fetal breathing movements Gross body movementFetal toneReactive fetal heart rateQualitative amnioic fluid volumeScore: normal 8-10; equivocal 6; abnormal < 4Manning, 1995

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

  • Nursing care for women with PPROM Fetus survillance: count fetal movement at least BID, 10 fetal movements in a 12-hours period. Understand the volume of amniotic fluid remained in the amniotic sackSigns of stress on Fetal monitor Strick 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 Documented PPROM > 72 hrCervical dilaiton 3 cmNo sign of chorioamnionitis/pyelonephritisNo sign or symptoms of preterm laborClinet willingness to comply with strict pelvic restNo breech or transverse presentation (chances of proplapse cord)

  • Health Teaching for women with PPROM Take temperature Q4h when awake, Report if more than 380CRemain on modified bed restInsert nothing in the vaginaNo sexual activity, No tub bathsAssess for uterine contraction & fetal movementWatch for foul-smelling vaginal dischargeWipe front to back after urinating or having a bowel movementTake antibiotics if perscribed

  • Fetal Distress Maternal Risk Factors Pregnancy Induced HypertensionCaridac DiseasesHyperemesis gravidarumSTI, vagnial infectionPerterm laborDM, Anemia, Substance abuse Placenta previa, abruptioProlonged labor or difficulty birth Abnormal fetal presentationTraumatic labor or birth

  • Complication during labor-fetal distress Intrauterine pressure > 75 mmHgContraction > 90 secondsContraction occurring 2 min or less apartFetal bradycardia, tachycardia, or decreased variablityIrregular FHRMeconium-stained amniotic fluidArrest in progress of the labor Maternal fevelFoul-smelling vaginal dischargeVaginal Bleeding

  • Prolapse of cord during laborFetal bradycardiaMembranes rupturedCord 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 cordOxygen 8-10 L/minIV fluid Monitoring FHRDo not place cord back into cervixPrepare emergency birth (vagniaal or cesarean)

  • Ultrasonography in Third Trimester for Assessing Fetus Gestational ageViabilityDetect macrosomiaDetect congenital anomaliesDetect IUGRDetect placenta maturity Determine Fetal PositionDetect Placenta previa or abruptioVisualization for amniocentesisBiophysical profile and amniotic volume assessment

  • Fetal Distress during Labor FHR late deceleration as shown in the Fetal monitoringIndicating ultraplacenta insufficience, maternal uterine hyuperactivity, supine hypotion, epidural or spinal anesthesia, placenta previa, abruptio, hyperensive disorders, postmaturity, IRGR, DM, infection

  • Nursing Intervention for Fetal Distress as shown in FHRChange maternal positionCorrect maternal hypotension by elevating legsIncrease rate of maintenance IV Administer oxygen at 8-10L/min Fetal scalp or acoustic simulaitonAssiss with birth (CS or vaginal birth)

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

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