Transcript Slide 1

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
The patient is 40 y/o,
FEMALE, weighs 65 kg.
She is conscious, coherent
Vital Signs:
BP= 120/70 mmHg
PR=80 bpm RR= 20 /mt
Temp=36.9⁰C O²Sat= 98%
 Pallor of skin and
nails
 No palpable masses
or lesions
 Maxillary, frontal,
and ethmoid sinuses
are not tender.
 No palpable masses
and lesions
 No areas of deformity
 Awake and alert
 Oriented to Persons,
Place, Time
 Pale conjunctivae
and no dryness
 Pupils equally round
and reactive to light
 No unusual
discharges noted
 Pink nasal mucosa
 No unusual nasal
discharge
 No tenderness in
sinuses
 Dry mouth and lips
 Free of swelling and
lesions
No palpable lymph
nodes
No masses and
lesions seen
ৣ Equal chest
expansion
ৣ No retraction
ৣ Clear breath sounds
Regular rhythm
৩ Globular abdomen
৩ Abdominal scars
from previous LSCS
৩ The patient
complained of mild
hypogastric pain
৩ Leopold’s Maneuver
done: Cephalic
presentation
৩ FHR: 152bpm
ে Watery discharge
since 1000H 13/08/12
ে Thick, yellow
patchy, cheese like
particles adhere to
ে Patient claimed pain
and burning on urination
ে Cervix:
1cm dilation, 50%
Effacement, Station -3
Cephalic, Clear AF
৫ Pulse full and equal
৫ No lesions noted
 1993 Arterial Ligation
(Heart) No report
 2008 Low Segment
Cesarean Section due to
cord coil under General
Anesthesia
without
complication
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.
Ob/Gyne History:
Gravida:
Para:
Gestational Age:
LMP:
LMP by early UTZ:
EDD:
2
1
31 3/7 Weeks
not sure
06-01-12
13-10-2012
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
13/08/12 Patient came to ER with
chief complained of:
1. watery discharged since 1000H
13/08/12
2. labor pains started since 2400H
12/08/12.
 According to the patient she took
Aspirin 81mg OD 4 days ago
 Sugar monitoring at home are not
well controlled
 No cardiac consultation on present
pregnancy.
On Examination:
IE: PV 1cm dilated, 50%effaced,
station -3, clear amniotic fluid.
Amnisure ROM test: Positive
CTG TRACING
NORMAL
MRS. PTL
FETAL HEART RATE
110 - 160 bpm
152 bpm
CONTRACTION (PTL)
NO CONTRACTION
MILD TO MODERATE
CONTRACTION
AMNIOTIC FLUID
NORMAL
OLIGOHYDRAMNIOS
POLYHYDRAMNIOS
Per milliliters
500 to 1,000 ml
< 500 ml
> 2,000 ml
Amniotic Fluid Index 8 - 18 cm
by Ultrasound
<5-6 cm
> 20 – 24 cm
DAY 01 13.08.12
DAY 03 15.08.12
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
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.
LABORATORY
Urinalysis
Leucocytes
Pus cells
Others
Cervico vaginal
Swab
Pus cells:
Ep Cells:
Morphology
RESULT
1+
10-15/hpf
0-1/hpf
FUNGAL HYPAE
present
4-6/oif
2-4/oif
Lactobacilli, plenty;
CANDIDA PRESENT;
No clue cells,
Negative for
gonococci
REFENCE
RANGE
LABORATORY
CBC
HGB
HCT
PLT
RESULT
11.3g/dl
35.4 %
289
REFENCE RANGE
Blood Group
A
Rh Type
Positive
PT
13.3 sec
10.9 – 16.3 Seconds
APTT
30.4 sec
27 – 39 Seconds
11.2-15.7 g/dL
34.1-44.9%
182-369/UL
LABORATORY
RESULT
REFENCE RANGE
Antibody Screen Negative
Negative
Urine culture and No growth seen
sensitivity
after 48 hours of
incubation at 37°C
Vaginal Swab
culture
No growth seen
after 48 hours of
incubation at 37°C
HBsag
Negative
Negative
C-Reactive Protein Negative
Negative
DATE
BREAKFAST
TIME PRE-BS
OF
MEAL
POST-BS
2HRS
LUNCH
TIME
OF
MEAL
PRE-BS
13/08/12
Upon admission 71mg/dl
14/08/12
116mg/dl
15/08/12 0830H 109mg/dl 121mg/dl 1330H 110mg/dl
16/08/12
78mg/dl
1200H 77mg/dl
17/08/12
90mg/dl
1130H 103mg/dl
18/08/12
19/08/12
1200H 123mg/dl
20/08/12 0400H 100mg/dl
DINNER
POST-BS TIME
2HRS
OF
MEAL
PRE-BS
POST-BS
2HRS
1115H 93mg/dl 192mg/dl
173mg/dl 1740H 136mg/dl 152mg/dl
131mg/dl 1935H 79mg/dl 91mg/dl
112mg/dl 2000H 85mg/dl 124mg/dl
110mg/dl
2000H 145mg/dl
2000H 109mg/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.
 Patient has mild fluctuation in blood sugar
level.
 Patient does not need insulin; just diet
control.
Plan: BSR x 8hourly, HBaIC, TSH
RESULT
Glycosylated
Hemoglobin (HBa1C)
3.5%
TSH
1.35uIU/ml
REFERENCE
Diabetics:
4.0-6.02 Good control
6.3-7.9 Satisfactory Control
>7.9 unsatisfactory control
Euthyroid = 0.25 – 5.0 uIU/ml
Hypothyroid more than 7.0
uIU/ml
Hyperthyroid less than 0.15
uIU/ml
NAME OF DRUG
DOSAGE
ROUTE/
FREQUENCY
Dexamethasone Corticosteroid
Ampicillin
Antibiotic
Erythromycin
Antibiotic
Clotrimazole
Antifungal
12mg
500mg
250mg
100mg
Nifedipine
10mg
IM x 2 doses
IV Q6 x 48°
PO q6
Vaginal Supp
OD HS x 6
days
PO Stat then
TID
Ferrous
Sulphate
Calcium Citrate
ACTION
Calcium
Channel
Blocker
Iron
Supplement
Calcium
Supplement
100mg
PO OD
600mg
PO OD
Pre-Anesthetic Visit done.
For cardiac consultation.
ECG REPORT
2D ECHO REPORT
NT-pro BNP
Sinus Tachycardia
SWM:
WNL
51 pg/mL
(after
Nifedipine) EF
70 – 75 % Reference:
otherwise WNL
All Valve:
WNL
< 75 Years : = < 125
PASP
20 mmHg > 75 Years : = < 450
Peri cardium: WNL
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
Nifedipine to decrease tachycardia
of
Neonatologist & Neonatal
Intensive Care Unit Staff for
Neonatal
care/resuscitation.
 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.
1. Premature activation of the
maternal or fetal HPA axis
2. Decidual and amniochorionic
inflammation
3. Decidual hemorrhage
4. Pathologic uterine distention
MATERNAL SYSTEMIC DISEASE
Heart
Gestational Diabetes
DEMOGRAPHIC
DATA:
MATERNAL
AGE
< 17 & > 35
Current
Pregnancy
complications
Fetal anomaly
Hydramnios
Abdominal
surgery
Previous LSCS
Infection
PROM
UTI
OTHER:
Stress
Occupational
factors
UNKNOWN
CAUSES
BEHAVIORAL &
ENVIRONMENT:
Poor Nutrition
Late Prenatal care
MATERNAL STRESS (Genital
FETAL STRESS
infections, Maternal factors/ Systemic Disease)
(Uteroplacental insufficiency)
Activation of maternal HPA axis

CORTISOL
COX-2 IN AMNION
PGDH IN CHORION
Activation of fetal HPA axis
ACTH Adrenocorticotropic
hormone
ADRENAL
DECIDUA
PLACENTA
MEMBRANES
CRH
DHEAS

PLACENTA
MEMBRANES
ESTROGEN

PROSTAGLANDINS
CONTRACTIONS

CERVICAL
CHANGE
MYOMETRIAL Oxytocin Receptors,
Prostaglandins, Myosin Light Chain
Kinase, calmodulin, gap junctions
RUPTURE OF
MEMBRANCES
 Vaginal
 Transvaginal
Examination
Cervical Ultrasound
 Clean-catch Urine For Culture,
Vaginal And Cervical Culture
 Fetal
Fibronectin (Ffn)
 External
Fetal Heart Monitor or
Cardiotocogram
 Fetal Ultrasound
 Amniocentesis
 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
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.
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.
MANAGEMENT
 Early Education
 Prevention
 Limiting Neonatal Morbidity
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.
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
Tocolytic Therapy
Agent
Mechanism of
Action
Nifedipine Calcium
Channel
Blocker
Dose
Side-effects
Nursing Action
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 < 90
Or DBP < 60
 Hr 100 bpm
Other Tocolytic Drugs which are not used due to
Maternal/Fetal adverse Effect
Medication
Terbutaline
/Bricanyl
B2 Adrenergic
Receptor
Agonist
Indomethacin
Prostaglandin
Inhibitor
Atosiban
Oxytocin
Inhibitor
Maternal/Fetal Side-effects
PULMONARY EDEMA is a well-documented
complication, usually associated with aggressive
intravenous hydration.
Decrease fetal urine output resulting in
Oligohydramnios & Premature close of fetal
ductus arteriosus which result to fetal pulmonary
Hypertension.
Nausea was significantly increased after injection
administration.
Antibiotic Therapy
Antibiotic
Ampicillin
Dose
Loading: 2gram IV
Maintenance: 1 gram IV Q6 for
48hours
Erythromycin 250mg Q6 until 10 days
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
Acceleration of Fetal Maturity
Agent
Mechanism
Of Action
Dose
Dexamethasone Corticosteroid 12mg
To hasten fetal IM Q12
lung maturity x 2
doses
Side-effects
irritation at
the
injection
site,
tachycardia
Nursing Implications
Explain the purpose of
the drug
Monitor v/s and fetal
heart rate
Postponing delivery for
administration
is
an
option because it takes
24 hours
about
for
the Dexamethasone to
have an effect. The effect
last approximately 7 days.
Acceleration of Fetal Maturity
Agent
Survanta
Mechanism
Of Action
Lung
surfactant
Dose
Side-effects
4ml/kg Transient
intratra bradycardia
cheally , rales
; four
doses
in first
48
hours
of life
Nursing Implications
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.
Complications
Prematurity
and
associated
neonatal
complications, such as lung immaturity:




Intraventricular Hemorrhage (IVH)
Respiratory Distress Syndrome (RDS)
Patent ductus arteriosus (PDA)
Necrotizing enterocolitis (NEC)
Complications of Preterm Labor
Premature Labor can’t be halt
will lead to Preterm Delivery
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
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
PRIORITIZATION OF NURSING PROBLEMS
7. Risk for Complications secondary to
tocolytic therapy
8. Compromised Family Coping secondary to
hospitalization
ASSESSMENT
SUBJECTIVE:
“ I feel a sudden
contraction” as
verbalized by the
patient
OBJECTIVE:
1. Continued
uterine
contraction
2. Facial mask
of pain
3. 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
NURSING
DIAGNOSIS
Risk for Injury
maternal
/fetal related
to
preterm
labor
and
tocolytic
therapy.
GOALS &
NURSING INTERVENTION
DESIRED
RATIONALE
EVALUATION
OUTCOME
Within 12 1. Positioned patient on Position
facilitates After 12 hours
hours
of
of nursing
left side as much as uteroplacental
nursing
intervention,
tolerated. Change to perfusion.
intervention
the goal was
right
side
if
client
, patient’s
fully met as
becomes
contraction
evidenced by:
uncomfortable
–
halt
after
Cessation of
avoid
supine
treatment
uterine
with
contraction
position.
tocolytic
after
and
fetal 2. Explain all procedures Client and significant treatment
heart rate
with tocolytic.
and
equipment
to
other
may
be
remains
Fetal
heart
patient
and
experiencing
high
within
rate remains
significant
other.
anxiety
and
need
acceptable
within
repeated explanation. acceptable
parameters.
parameters.
3. Attached external fetal Uterine and fetal
heart rate monitors monitoring
provides
for
continuous evidence of fetal wellevaluation
of being.
contractions
and
fetal response.
NURSING
ASSESSMENT DIAGNOSIS
GOALS &
DESIRED
OUTCOME
NURSING
INTERVENTION
RATIONALE
4. Made contact with An ultrasound can
ultrasound
document fetal health
personnel as per and cervical dilation.
doctors order.
5.Extracted blood for Assessment provides
laboratory studies a baseline for future
such
as
CBC. comparison.
Obtained
cleancatch
urine
for
culture, vaginal and
cervical culture.
6. Inserted IV line and IV fluid improves
begin
IV
fluid hydration, which may
therapy as doctors’ help
to
minimize
order.
contractions.
7.Administered
betamethasone
prescribed.
This
synthetic
as cortisol can accelerate
fetal lung maturity by
stimulating surfactant
production.
EVALUATION
NURSING
ASSESSMENT DIAGNOSIS
GOALS &
DESIRED
OUTCOME
NURSING
INTERVENTION
RATIONALE
8. Administer antibiotics, as  In the event of
indicated.
PROM, antibiotics may be
used to prevent/reduce
risk of infection.
9. Initiate tocolytic therapy,  Helps reduce
as ordered.
myometrial activity to
prevent/delay early
delivery.
10. Checked patient’s vital
signs closely, every 15
minutes. Assessed for chest
pain and dyspnea.
 Maternal pulse over
120 beats per minute or
persistent tachycardia or
tachypnea, chest pain,
dyspnea, or adventitious
breath sounds may
include impending
pulmonary edema.
11. Checked fetal heart rates Fetal tachycardia or late or
and pattern.
variable decelerations
indicate possible uterine
bleeding or fetal distress,
which requires emergency
birth.
EVALUATION
 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.
 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
 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)
 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.
 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.
 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/