PRETERM LABOUR

Dr. Fatimah Malkawi

RMW. Areej Faeq

1

After the completion of presentation, we will be able to: Identify the definition of clinical guideline Describe the importance of the clinical

guideline Discuss the implications of the guideline in

the Jordanian women’s health Propose the appropriate modifications of

the clinical guidelines to suite the Jordanian health system

Provide the evidence based practice from the literature.

2

Clinical guideline

The IOM (Institute of Medicine) (2011) defined clinical practice guidelines as "statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options." 

3

Reliable guidelines should be based on a systematic evidence review, developed by panel of multidisciplinary experts, provide a clear explanation of the logical relationships between alternative care options and health outcomes, and provide ratings of both the quality of evidence and the strength of the recommendations .(IOM)

4

Preterm labour

Preterm labour is defined as regular contractions of the uterus resulting in changes in the cervix that start before 37 weeks of pregnancy. Changes in the cervix include effacement (the cervix thins out) and dilation (the cervix opens so that the foetus can enter the birth canal). ACOG 2012 5

Aetiology

Ascending infection from the lower genital tract up in the sterile uterus invading the decidua, chorionamniotic membranes, and amniotic fluid and in some cases; the foetus.

This is responsible for an inflammatory condition that might trigger myometrium contractions, rupture of the membranes and cervical maturation leading to PTD (Romero, et al 2014).

6

Why is preterm birth a concern ?

Preterm birth will born with serious health problems, like cerebral palsy, learning disabilities, can last a lifetime problems and may appear later in childhood or even in adulthood (ACOG).

The three most neonatal disorders in Jordan during 2013 were preterm birth complications.

7

The annual mortality rate per 100,000 people from preterm birth complications in Jordan has decreased by 61.8% since 1990, an average of 2.7% a year.

Annual mortality rate 10.2per 100,000people .

(‘Preterm-Birth-Complications’global-disease-burden.healthgrove.com).

8

Factors that increase the risk of preterm birth: Having a previous preterm birth Having a short cervix Short interval between pregnancies History of certain types of surgery on the

uterus or cervix Certain pregnancy complications, such as

multiple pregnancy and vaginal bleeding Lifestyle factors such as low pre-pregnancy

weight, smoking during pregnancy, and substance abuse during pregnancy

ACOG

signs and symptoms of preterm labour Change in type of vaginal discharge (watery, mucus,

or bloody). Increase in amount of discharge. Pelvic or lower abdominal pressure. Constant low, dull backache. Mild abdominal cramps, with or without diarrhea Regular or frequent contractions or uterine

tightening, often painless. Ruptured membranes (water breaks with a gush or a

trickle of fluid) . ACOG

10

11

Nurse/midwife Role in assessing women with

preterm labour HSS/JORDAN

History Taking

LMPHistory of PTL.History of Risk factors, e.g (multiple

pregnancy ,Smoking ,Extream age >35and <19,lowBMI…)

Warning symptoms (vaginal bleeding ,PPROM)History of vaginal infection or UTI

12

Physical Examination

Head to toe Physical examination Assess Uterine contraction

frequency and duration . Preterm labour is based on two

criteria :Uterine Contraction 4 per 20minutes or /and cervical changes

13

Laboratory Investigation

CBC ABO & Rh type UA & culture Swab of the lower vagina for culture Ultrasound to assess (fetal GA,AF,Cervical

length )

14

Nurse /Midwife Interventions in women with preterm labour

Prophylactic measures by observing and detecting the risk factors and the early signs of PLP

Assist obstetrician to identify with indication to become preterm delivery

Assist obstetrician to identify women with indications for tocolysis (GA<34w,No maternal or fetal infection , cervix dilation<4cm,No evidence of rupture membrane or placenta insufficiency ).

15

Insert IV cannula, and administer IVF according to Dr order .

Administer steroid if GA<34 weeks .

Give antibiotics according to Dr. order

Assist Obstetrician ,to monitor and administer of women on tocolysis medication.

16

Give tocolytic drugs according to physician's orders: B- sympathomimetics (Ritodrine): Dissolve

3 ampules (150 mg) of Ritodrine (Yutopar) in 500 mL D5W or Ringer's lactate Start the IV infusion at a rate of 0.05—0.1 mg/min (10-20 drops/min and increase by 0.05 mg (10 drops) each 10 minutes until:

1. Contractions stop.

2. Infusion reaches a maximum of 0.35 mg/min (70 drops/min).

3. Pulse rate reaches or exceeds 130/bpm.

4. Toxicity appears, e.g., tachycardia, nausea, vomiting and/or iritability. 17

Magnesium sulfate (MgS04): Begin MgS04 tocolysis by an

intravenous bolus of 6 gm in 100-150 mL of a standard IV solution over 20-30 minutes.

Maintain MgS04 infusion at 1—3 gm/hour to titrate cessation of contractions for approximately 24 hours.

Monitor woman for muscle weakness (absent reflexes), double vision, and respiratory insufficiency

18

Monitoring during Intravenous Tocolysis fie woman should be observed for the following:

Pulse rate should not exceed 130/bpm. The woman should be observed every 15 minutes until the maximum dose is reached, then every 30 minutes for one hour, and then every hour.

Monitor temperature to guard against pyrexia, every eight hours.

BP, every hour during IV medication; should not be < 100/60 mmHg.

Respiratory rate should not exceed 24/minute. Pulmonary edema is possible, especially if steroids are used and it is a multiple pregnancy.

19

Fetal heart rate variations: Normal is 120-160 bpm. Use continuous external fetal monitoring (EFM) when available.

Excessive vaginal discharge. Vaginal bleeding. Urinary output; every hour during IV

infusion, at least 30 cc/hour. Total fluid intake should not exceed

125 cc/hour (3000 mL/day) of mixed fluids (IV and oral).

20

If tocolysis is successful:

Transfer the woman to the antenatal ward.

Encourage bed rest to with bathroom privileges.

Allow normal diet.

Ultrasound twice weekly.

NST daily.

Monitor intake of all medications.

21

If tocolysis is not successful after six hours:

If contractions, cervical dilation, and/or effacement continue:

Stop tocolytic medication and allow the woman to progress. The obstetric specialist should attend the delivery; the pediatric specialist should be present for the delivery

22

Care of the Preterm Neonate

Preterm neonates should be referred to the neonatal unit after providing first aid management as following: First aid management Follow steps of neonatal resuscitation according to guidelines.

23

Transport the neonate immediately to the NICU in a portable incubator.

Provide an appropriate thermal environment.

Provide adequate oxygenation by oxygen mask in case of respiratory distress, cyanosis or oxygen saturation less than 88% or by ambu-bag in case of irregular gasping respirations, apnea, and persistent cyanosis, despite 100% oxygen supplementation by oxygen mask or heart rate < 100 bpm.

24

Diagnosing preterm labour for women with intact membranes(NIC, NOV2015)

clinical history taking initial assessment of a woman in labour . speculum examination (followed by a digital vaginal examinationsuspected preterm labour and she is 30+0 weeks pregnant or more, consider trans-vaginal ultrasound measurement of cervical length less than 15 mm as a diagnostic test to determine likelihood of birth within 48 hoursIf cervical length is more than 15 mm, explain to the woman that it is unlikely that she is in preterm labour and finds alternative diagnoses

25

advise her that if she does decide to go home, she should return if symptoms suggestive of preterm labour persist or recurif cervical length is 15 mm or less, view the woman as being in diagnosed preterm labour and offer treatment . fetal fibronectin testing as a diagnostic test to determine likelihood of birth within 48 hours for women who are 30+0 weeks if fetal fibronectin testing is positive (concentration more than 50 ng/ml), view the woman as being in diagnosed preterm labour and offer treatment .

26

Tocolysis factors affects a decision about whether to start tocolysis:

if woman is in suspected or diagnosed preterm labourother clinical features (for example, bleeding or infection) which may suggest that stopping labour is contraindicatedgestational age at presentationbenefit of maternal corticosteroids availability of neonatal care (need for transfer to another unit)

27

the preference of the woman.

Offer nifedipine for tocolysis to women between 24+0 and 33+6 weeks of pregnancy who have intact membranes and are in suspected or diagnosed preterm labour.

If nifedipine is contraindicated, offer oxytocin receptor antagonists for tocolysis.

Do not offer betamimetics for tocolysis

28

Maternal corticosteroids Consider maternal corticosteroids for

women between 24+0 and 35+6 weeks of pregnancy who are in suspected or established preterm labour, are having a planned preterm birth or have P PROM.‑

Do not routinely offer repeat courses of maternal corticosteroids.

29

Magnesium sulfate for neuroprotection

Offer intravenous magnesium sulfate for neuroprotection of the baby to women between 24+0 and 33+6 weeks of pregnancy who are:

in established preterm labour  or having a planned preterm birth within 24 hours.

Give a 4 g intravenous bolus of magnesium sulfate over 15 minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours (whichever is sooner).

30

care of women on magnesium sulfate

monitor for clinical signs of magnesium toxicity at least every 4 hours by recording pulse, blood pressure, respiratory rate and deep tendon .

If a woman has or develops oliguria or other signs of renal failure monitor more frequently for magnesium toxicity start reducing the dose of magnesium sulfate.

31

Fetal monitoring between 23+0 and 25+6 weeks pregnant the

external monitoring are recommended .

an abnormal trace does not necessarily indicate that fetal hypoxia or acidosis is present, although a normal cardiotocography trace is reassuring and indicates that the baby is coping well with labour.

between 34+0 and 36+6 weeks of pregnancy if it is not possible to monitor the fetal heart rate using either external cardiotocography or intermittent auscultat use of a fetal scalp electrode. 32

Mode of birth/and clamping the cords NVD are recommended more than Caesarean except

for women between 26+0 and 36+6 weeks of pregnancy with breech presentation.

If a preterm baby needs to be resuscitation, or there is significant maternal bleeding: consider milking the cord and clamp the cord as soon as possible.

Position the baby at or below the level of the placenta before clamping the cord.

if the mother and baby are stable, Wait at least 30 seconds, but no longer than 3 minutes, before clamping the cord of preterm babies

33

References 1. Steinberg, E., Greenfield, S., Wolman, D. M., Mancher, M., & Graham, R. (Eds.). (2011).

Clinical practice guidelines we can trust. National Academies Press.

2. American College of Obstetricians and Gynecologists. (2012). ACOG practice bulletin no. 127: Management of preterm labor. Obstetrics and gynecology, 119(6), 1308.

3. Fellman, V., Hellström-Westas, L., Norman, M., Westgren, M., Källén, K., Lagercrantz, H., ... & EXPRESS Group. (2010). One-year survival of extremely preterm infants after active perinatal care in Sweden. Obstetric Anesthesia Digest, 30(1), 22-23.

4. Romero, R., Dey, S. K., & Fisher, S. J. (2014). Preterm labor: one syndrome, many causes. Science, 345(6198), 760-765.

5. (http://global-disease-burden.healthgrove.com/l/20405/Preterm-Birth-Complications-in-Jordan).

6. Di Renzo, G. C., Cabero Roura, L., Facchinetti, F., Helmer, H., Hubinont, C., Jacobsson, B., ... & Radzinsky, V. (2017). Preterm Labor and Birth Management: Recommendations from the European Association of Perinatal Medicine. The Journal of Maternal-Fetal & Neonatal Medicine, (just-accepted), 1-28.

7. Midwifery Care Clinical Guidelines for Midwives .

8. American College of Obstetricians and Gynecologists. (2001). ACOG Practice Bulletin. Assessment of risk factors for preterm birth. Clinical management guidelines for obstetrician-gynecologists. Number 31, October 2001.(Replaces Technical Bulletin number 206, June 1995; Committee Opinion number 172, May 1996; Committee Opinion number 187, September 1997; Committee Opinion number 198, February 1998; and Committee Opinion number 251, January 2001). Obstetrics and gynecology, 98(4), 709.

9. https://www.nice.org.uk/guidance/ng2534