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JJC Nursing Premature Rupture of Membranes and Preterm Labor

Terms in this set (35)

Premature Rupture of Membranes (PROM)
is defined as the Spontaneous rupture of membranes that occurs before the onset of labor.
Preterm PROM (PPROM)
is the rupture of the membranes prior to 37 weeks' gestation.
What is the cause and incidence of PROM/PPROM?
Unknown cause but often related to infection. 10-15% and represents a major source of perinatal morbidity and mortality to the risk of pre-term labor and delivery
What are risk factors for PROM/PPROM?
previous preterm birth and previous PPROM
Latent period
The time between ROM and spontaneous onset of labor.
Maternal Risks PROM/PPROM:
chorioamnionitis, endometritis and abruptio placentae
Fetal-Neonatal Risks PROM/PPROM:
Prematurity and complications associated with preterm birth, respiratory distress syndrome (RDS), necrotizing enterocolitis, and intraventricular hemorrhage, neonatal infection, fetal hypoxia.
What do we assess after PROM/PPROM?
The onset of ROM, color, consistency, amount, and odor. Assess for s/s of maternal infection.
Assess Gestational age of fetus. Assess Fetal Heart Rate (FHR) for tachycardia, decreased variability, late or variable decelerations.
What are nursing diagnoses for PROM/PPROM?
RF Infection r/t to PROM/PPROM
Fear r/t unknown, procedures, injury to baby, RF Ineffective Individual Coping r/t to unknown outcomes, RF Impaired Gas Exchange in the Fetus r/t compression of umbilical cord secondary to increased risk for cord prolapse
What are nursing interventions r/t PROM/PPROM?
Test vaginal fluid with nitrazine paper, amniotic fluid is alkaline (pH 7-7.5) and paper will turn blue, or blue green, blue gray if membranes rupture. Monitor for uterine contractions and fetal well-being (Biophysical Profile).
Promote comfort, bed rest and relaxation
Initiate IV therapy as indicated in collaboration with MD/NP (usually isotonic solution) to maintain hydration.Teach PROM/PPROM implications and treatments
How will we manage PROM/PPROM?
With no infection and if the woman is less than 37 wks. Gestation - management will be conservative: Bedrest, Monitor fetal well-being, fetal lung maturity testing if less than 34 wks. Gestation, Nonstress tests (NST's) and biophysical profiles, Maternal vital signs q four hours, Antibiotic therapy (Ampicillin or Penicillin G IV) is sometimes begun prophylactically in a woman with unknown GBBS status.
When is immediate birth indicated?
When the amniotic fluid analysis demonstrates low glucose levels, high WBC count, a positive Gram stain, or organisms in the amniotic fluid
Is Tocolysis used to manage PROM/PPROM:
Use is not indicated for management of PROM/PPROM
What is preterm labor?
is defined as regular contractions accompanied by cervical changes occurring at less than 37 weeks gestation, accounts for 90% of neonatal deaths
What are risk factors for spontaneous preterm labor?
Multiple Gestation, Inadequate prenatal care, Maternal Medical Disease, History of pyelonephritis or other maternal infection, Known cervical incompetence, Polyhydramnios, Uterine anomaly, Cervix dilated >1cm 32 weeks, Fetal abnormality, Febrile illness, Previous preterm labor, DomestincViolence/Abdominal trauma, Cigarettes >10/day, Age (less 18 more than 35), Substance abuse, STI (risk of preterm birth increases 50-400%), Anemia
What factors are associated with increasing rates of preterm labor/birth?
Increasing rise in multifetal pregnancies, Greater percentage of births to women of advanced maternal age, Increasing rates of asymptomatic infections, labor inductions, cesarean births and scheduled births
What are signs and symptoms of PTL?
Abdominal pain, Dull, low back pain, Pelvic pain/pressure, Menstrual-like cramps, Uterine contractions that occur every 10 minutes or less with or without pain and last for at least 1 hour, Change in amount and character of vaginal discharge or vaginal bleeding, Urinary frequency, Diarrhea
What is the diagnostic criteria for preterm labor?
Gestation 20-37 weeks and, Documented uterine contractions (4/20 minutes, 8/60 minutes) and, Documented cervical change or
Cervical effacement of 80% or, Cervical dilation 1 cm
What are screening tests for preterm labor?
Fetal fibronectin (fFN), Cervical length, Bishop's score
Fetal Fibronectin (fFN)
fFN, a protein, is absent from cervico-vaginal secretions from around the 20th week until near term. When fFN is present in the cervix or vagina between 20 weeks and near term, it appears to be a marker of choriodecidual disruption. The most important characteristic of fFN is it's negative predictive value, if negative, there is a decreased likelihood of labor
Cervical length
length of less than 20 mm with regular uterine contractions, or a vaginal exam that determines dilation at 3 cm or more and 80% or more effacement establishes the diagnosis of PTL
Bishop's Score
refers to a group of measurements used to determine whether a woman may have a successful vaginal delivery and whether labor ought to be induced. Bishop's Score is based on station, dilation, effacement, position and consistency
What is our goal through medical management of preterm labor?
to delay labor and/or achieve fetal maturity
How is preterm labor managed?
Primary Prevention: Early Diagnosis, Treatment of infections, Cervical cerclage, Progesterone administration. Secondary Prevention: Tocolysis-use of medications in an attempt to stop labor, Corticosteroids to assist with fetal lung maturity, Antibiotics - to address infections
What are contraindications for preterm labor management?
Fetal demise, Lethal fetal anomaly, Severe preeclampsia/eclampsia, Hemorrhage/abruptio placentae, Chorioamnionitis, Severe fetal growth restriction, Fetal maturity, Acute nonreassuring fetal status
What are the tocolytic agents?
Beta-mimetics (ritodrine, terbutaline), Magnesium Sulfate, Calcium channel blockers (nifedipine), Prostaglandin synthetase inhibitors(indomethacin)
Ritodrine hydrochloride (Yutopar)-
only drug approved by FDA for use a tocolytic but rarely used due to side effects
Action: It is a beta-receptor agonist which exerts a preferential effect on the adrenergic receptors such as those in the uterine smooth muscle. Stimulation of the receptors inhibits contractility of the uterine smooth muscle
Administration: IV, IM, Subq, PO
Dosage: Initially administered parenterally . The usual initial dose is 0.1 mg/minute (0.33 mL/minthen Oral Maintenance: 10 mg may be given approximately 30 minutes before the termination of IV therapy. The usual dosage schedule for the first 24 hours of oral administration is 10 mg every 2 hours. Thereafter the usual maintenance dose is 10 to 20 mg every 4 to 6 hours.
Terbutaline (brethine)
beta-adrenergic
Action: Stimulates beta-adrenergic receptors of sympathetic nervous system to inhibit uterine muscle activity.
Administration: Oral, Sub-q or IV
IV 0.01 to 0.05 mg/min - onset immediate - increase rate 0.01 mg/min at 10-30 min. intervals until contractions stop.
* Contraindicated before 20 weeks.
Side effects: Maternal and fetal tachycardia
Magnesium Sulfate
Action: CNS depressant, smooth muscle relaxant (decreases the frequency and intensity of uterine contractions in treatment of PTL)
Recommended loading dose: 4-6 g IV in 100mL IV fluid over 20 minutes
Maintenance dose: 1-4 g/hour titrated to
-deep tendon reflexes
-serum magnesium levels (5.5-7.5 mg/dL)
Therapy maintained 12 hours at lowest rate to diminish contractions
Maternal side effects with magnesium sulfate
flushing, feeling of warmth, headache, nausea, dry mouth, dizziness, lethargy, sluggishness
What are the nursing implications with administration of magnesium sulfate?
Monitor BP and Respirations closely during administration, Monitor serum magnesium levels (q6-8h), Deep tendon reflexes, LOC, Urinary output, Continuous monitoring of fetal heart tones
Nifedipine (procardia)
Nifedipine (procardia) used as tocolytic
Inhibits contractile activity of uterine myometrial smooth muscle cells
PO or SL administration. The recommended dose is 20 mg orally stat, followed by 20 mg orally after 30 minutes if contractions persist, followed by 20 mg orally every 3-8 hours for 48-72 hours as indicated.
Common side effects r/t arterial vasodilation -hypotension
-tachycardia
-facial flushing
-headache
May be given concomitantly with beta-mimetics
Prostaglandin synthetase inhibitors : Indomethacin, (Indocin) Sulindac (clinoril) or Celecoxib (celebrex)
Use: suppress uterine contractions/labor
Maternal side effects (few):
-Dyspepsia
-N/V
-Depression
-Dizzy spells
Contraindicated: drug-induced asthma, coagulation disorders, hepatic/renal insufficiency, peptic ulcer disease
* Indomethacin (no longer widely used)
Readily crosses placenta
Betamethasone
Indications - Acceleration of fetal lung maturity to reduce RDS severity
Action - Induces pulmonary maturation and assists with surfactant synthesis
Dosage - 12 mg IM for 2 doses 24 hours apart or 6 mg IM every 12 hours for 4 doses.
Adverse Effects on Mother - Hyperglycemia
Adverse Effects on Fetus - Hypoglycemia and Increased Risk for Infection/Sepsis
Nursing implications for betamethasone
Medical Goal with use- Fetal Lung Maturity. Medical Team attempts to delay birth 24-48 hours after Betamethasone treatment to improve lung maturity outcome. Contraindications: Greater than 34 wks gestation, Imminent birth, 2:1 LS ratio
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