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Perez, Maria
Marcha, Don
Dizon, Kaeo
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Preterm labor can be 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 fetus can enter the birth canal). In some
cases preterm labor can lead to a baby being born too soon.
Preterm labor usually results to spontaneous preterm birth or preterm rupture of fetal
membranes. Every year, an estimated 15 million babies are born preterm (before 37 completed
weeks of gestation), and this number is rising. Locally, the Philippines is ranked eighth worldwide
in terms of preterm birth and second in Southeast Asia with a total of 348 900 estimated preterm
The physiology of labor initiation has not been completely explained. However,
researchers found that labor initiation is species-specific, and the mechanisms in human labor are
unique. The first phase is quiescence and represents that time in utero before labor begins when
uterine activity is suppressed by the action of progesterone, prostacyclin, relaxin, nitric oxide,
parathyroid hormone–related peptide, and possibly other hormones. During the activation phase,
estrogen begins to facilitate expression of myometrial receptors for prostaglandins (PGs) and
oxytocin, which results in ion channel activation and increased gap junctions. This increase in the
gap junctions between myometrial cells facilitates effective contractions. In essence, the activation
phase readies the uterus for the subsequent stimulation phase, when uterotonics, particularly PGs
and oxytocin, stimulate regular contractions. In the human, this process at term may be protracted,
occurring over days to weeks. The final phase, uterine involution, occurs after delivery and is
mediated primarily by oxytocin. The first three phases of labor require endocrine, paracrine, and
IV. Pathophysiology
Three main components contribute to labor: cervical changes, persistent uterine contractions, and
activation of the decidua and membranes. The difference between labor at term and preterm is that
the former occurs via a normal physiologic process and the latter is pathological. Some processes
are acute, and can take several weeks leading up to preterm labor.
One of the key events to occur in preterm labor that is pathological is the fetal inflammatory
response syndrome (FIRS) which involves systemic inflammation and elevation of fetal plasma
fetal hypothalamus leading to secretion of CRH, stimulating the release of ACTH and therefore
cortisol production by the fetal adrenal glands, which triggers the parturition pathway to activate.
An influx of inflammatory cells into the cervical stroma leads to the release of cytokines and
prostaglandins which stimulate cervical ripening. These changes influence the structures of the
collagen and glycosaminoglycans that make up cervical tissue. Estrogen stimulates collagen
degradation whereas progesterone inhibits it. Therefore, progesterone is used to prevent or delay
ripening. Both hormones are implicated in regulating the gap-junction formation and the
secretions and is also part of the parturition process. When detected between 22 and 37 weeks
gestational age, it indicates the disruption of the decidual-chorionic interface and increased risk of
preterm labor. Evidence implicates apoptosis as a critical factor leading in the above process.
V. Assessment
A. Clinical Manifestations
Signs of a condition are things someone else can see or know about you. Symptoms are
things you feel yourself that others can’t see, like feeling dizzy. If you have any of these signs or
Change in your vaginal discharge (watery, mucus or bloody) or more vaginal discharge than
usual
If you're experiencing regular uterine contractions and your cervix has begun to soften, thin
and open (dilate) before 37 weeks of pregnancy, you'll likely be diagnosed with preterm labor.
Pelvic exam. Your health care provider might evaluate the firmness and tenderness of your
uterus and the baby's size and position. If your water hasn't broken and there's no concern
that the placenta is covering the cervix (placenta previa), he or she might also do a pelvic
exam to determine whether your cervix has begun to open. Your health care provider might
Ultrasound. A transvaginal ultrasound might be used to measure the length of your cervix.
An ultrasound might also be done to check for problems with the baby or placenta, confirm
the baby's position, assess the volume of amniotic fluid, and estimate the baby's weight.
Uterine monitoring/Tocometer. Your health care provider might use a uterine monitor to
Lab tests. Your health care provider might take a swab of your vaginal secretions to check
for the presence of certain infections and fetal fibronectin — a substance that acts like a glue
between the fetal sac and the lining of the uterus and is discharged during labor. These results
will be reviewed in combination with other risk factors. You'll also provide a urine sample,
A. Pharmacologic Therapy
Once you're in labor, there are no medications or surgical procedures to stop labor, other
than temporarily.
Corticosteroids. Corticosteroids can help promote your baby's lung maturity. If you are
between 23 and 34 weeks, your doctor will likely recommend corticosteroids if you are thought to
be at increased risk of delivery in the next one to seven days. Your doctor may also recommend
steroids if you are at risk of delivery between 34 weeks and 37 weeks.You might be given a repeat
course of corticosteroids if you're less than 34 weeks pregnant, at risk of delivering within seven
days, and you had a prior course of corticosteroids more than 14 days previously.
Magnesium sulfate. Your doctor might offer magnesium sulfate if you have a high risk of
delivering between weeks 24 and 32 of pregnancy. Some research has shown that it might reduce
the risk of a specific type of damage to the brain (cerebral palsy) for babies born before 32 weeks
of gestation.
Tocolytics. Your health care provider might give you a medication called a tocolytic to
temporarily slow your contractions. Tocolytics may be used for 48 hours to delay preterm labor to
allow corticosteroids to provide the maximum benefit or, if necessary, for you to be transported to
a hospital that can provide specialized care for your premature baby. Tocolytics don't address the
underlying cause of preterm labor and overall have not been shown to improve babies' outcomes.
Your health care provider won't recommend a tocolytic if you have certain conditions, such as
B. Surgical Procedures
Cervical cerclage
During this procedure, the cervix is stitched closed with strong sutures. Typically, the
sutures are removed after 36 completed weeks of pregnancy. If necessary, the sutures can be
removed earlier. Cervical cerclage might be recommended if you're less than 24 weeks pregnant,
you have a history of early premature birth, and an ultrasound shows your cervix is opening or
C. Prevention
Progesterone Therapy
Progesterone is a hormone known for its role in maintaining pregnancy. In the early stage
of the pregnancy, this hormone is produced by the corpus luteum. Progesterone concentrations in
peripheral blood drop before the onset of labor in most mammalian species. Nevertheless, this
antagonists to pregnant women causes cervical ripening and shortening and can lead to onset of
labor. For this reason, it has been proposed that progesterone administration can prevent preterm
cervical ripening.
Cervical pessary
The cervical pessary is a soft and flexible silicone device. It is folded and put around the
cervix by a simple vaginal examination without causing any pain. Although the exact working
mechanism is still unknown, pessaries may distribute the weight of the uterus on to the vaginal
floor and relieve pressure on the internal os. Therefore, a pessary might prevent premature
dilatation of the cervix and preterm rupture of the membranes. In addition, a pessary might support
the immunological barrier between the chorion and vaginal microbiological flora, which helps to
prevent PTB.
Seek regular prenatal care. Prenatal visits can help your health care provider monitor your
health and your baby's health. Mention any signs or symptoms that concern you. If you have
a history of preterm labor or develop signs or symptoms of preterm labor, you might need to
Eat a healthy diet. Healthy pregnancy outcomes are generally associated with good nutrition.
In addition, some research suggests that a diet high in polyunsaturated fatty acids (PUFAs)
is associated with a lower risk of premature birth. PUFAs are found in nuts, seeds, fish and
seed oils.
Avoid risky substances. If you smoke, quit. Ask your health care provider about a smoking
than six months apart, or more than 59 months apart, and an increased risk of premature birth.
Be cautious when using assisted reproductive technology (ART). If you're planning to use
ART to get pregnant, consider how many embryos will be implanted. Multiple pregnancies
Manage chronic conditions. Certain conditions, such as diabetes, high blood pressure and
obesity, increase the risk of preterm labor. Work with your health care provider to keep any
Assessment
Assess the signs and symptoms of term labor and pre-term labor
Review the obstetric history of the patient and know the patient’s risk factors
Diagnosis
When diagnosing the patient it is best to know that some signs and symptoms of pre-term
Acknowledge the patient’s feelings of confusion and doubt when should she reach for help.
Diagnosis for pre-term labor is difficult and some cases may be uncertain and may cause a
Intervention
Have the woman empty her bladder and get the urinalysis of the patient
o Do not rely solely on contraction assessment and external electronic fetal monitor
alone
Anxiety
Patient will be relieved of anxiety related to the situational crisis that is on the patient
Patient will be able to verbalize the understanding of the individual situation and outcome
Patient will appear relaxed and have the maternal vital signs within the normal limits
Patient will maintain pregnancy at least within the point of fetal maturity
Acute pain
Evaluation
Women who experience multiple episodes of preterm labor will be encouraged to seek help
Explain the procedures, nursing Information and knowledge of the reasons of these
interventions, and treatment regimen. activities can decrease fear of the unknown.
optimistic attitude.
Orient client and partner to labor suite Helps client and/or significant others feel at ease
Answer questions honestly, especially Provision of clear information can help the client or
information regarding contraction pattern couple understand what is happening and may
Encourage use of relaxation techniques. Enables the client to obtain maximum benefit from
Encourage verbalization of fears or Can help reduce anxiety and stimulate identification
Monitor maternal and fetal vital signs. Vital signs of client and fetus may be altered by
level.
Assess support systems available to the The assistance and caring of significant others,
client or couple, whether the client including caregivers, are extremely important
remains hospitalized or is to return home during this time of uncertainty and stress. If the
Administer sedative if other measures are Provides soothing and tranquilizing effect.
not successful.
References:
American College of Obstetricians and Gynecologists. (2019, January). Preterm Labor and Birth.
Blencowe H, Cousens S, Oestergaard M, Chou D, Moller AB, Narwal R, Adler A, Garcia CV,
Rohde S, Say L, Lawn JE. National, regional and worldwide estimates of preterm birth.
Gibson, J. (2011). Pharmacologic Management of Preterm Labor and Prevention of Preterm Birth.
preterm-labor-and-prevention-of-preterm-birth
Institute of Medicine. 2007. Preterm Birth: Causes, Consequences, and Prevention. Washington,
Kilpatrick, Sarah & Garrison, E.. (2007). Normal Labor and Delivery. 10.1016/B978-0-443-
06930-7.50014-1
Uy, J. R. (2015). More preterm babies surviving, but more being born too. Lifestyle.
VON DER POOL, B. Preterm Labor: Diagnosis and Treatment. Retrived from:
https://www.aafp.org/afp/1998/0515/p2457.html