OB Week 5: Ch. 7
Ch. 7 High-Risk Antepartum
- Preterm labor/birth
o Preterm labor (PTL) – regular UCs resulting in changes in the cervix before 37 wga
o Preterm birth (PTB) – birth b/t 20 wga + 36 6/7 wga
Leading cause of neonatal mortality + common reason for antenatal hospitalization
▪ Causes
¬ Individual behavioral + psychosocial factors
¬ Neighborhood characterisitics
¬ Environmental exposures
¬ Medical conditions
HTN, pre-eclampsia, hemorrhage, IUGR
¬ Infertility tx
¬ Biological factors
¬ Genetics
o Main situations where PTL/PTB may occur
Spontaneous PTL/PTB
▪ Unintentional, unplanned delivery before 37th wk of pregnancy
¬ Causes: infection or inflammation
¬ Usually unknown
¬ Hx of delivering preterm → strongest predictor for future PTB
Medically indicated PTB
▪ Healthcare provider recommended for existence of medical condition (pre-eclampsia)
Non-medically indicated (Elective)
o
Classifications of prematurity
Late Preterm infant Born 34 – 37 wga
Very Preterm infant Before 32 wga
Viability At 25 wga
Periviability 20 – 25 6/7
- Majority of neonatal deaths
Long term sequelae of preterm infants
▪ Cerebral palsy
▪ Hearing/vision impairment
▪ Chronic lung
, OB Week 5 Ch. 7
PRETERM LABOR
Causes Risk factors Assessment Findings Medical Management Contraindications Nursing Actions
- Excessive uterine - Prior PTB - Change in type of vaginal - Tocolytics (suppress UC in - Intrauterine fetal demise - Review prenatal record for
stretch/distention o Most important factor discharge PTL) - Lethal fetal anomaly risk factors
o Prostaglandins stimulate - Multiple gestation o Watery, mucus, o Nifedipine (Procardia) - Non-reassuring fetal - Assess for
the uterus to contract when - Uterine/Cervical abnormalities, bloody ▪ UCs status o Vaginal/urinary infxn
overdistended from diethylstilbestrol (DES) - amount of discharge ▪ Ca blocker - Severe preeclampsia or o ROM
multiple gestation, - Fetal anomalies - Pelvic/lover abdominal o Indomethacin eclampsia o SSE for ferning
polyhydramnios, uterine - Hx of second trimester loss pressure ▪ NSAID - Maternal bleeding w/ o Vaginal
abnormalities - Incompetent cervix/ cervical - Constant low, dull ▪ Prostaglandins hemodynamic instability bleeding/discharge
- Decidual activation insufficiency backache o Terbutaline (brethine) - Chorioamnionitis o Dehydration
o Hemorrhage - IVF pregnancy - Mild abdominal cramps, ▪ UC - PPROM absence of infxn - Assess FHR + UC
o Fetal-decidual paracrine - Hydramnios or oligohydramnios with or without diarrhea ▪ Beta 2 o Report tachycardia to
system - PROM - Regular / frequent o Ritodrine Tocolytic C/I: provider
o Upper genital tract infxn contractions or uterine o Magnesium sulfate - Active hemorrhage - Obtain vaginal + urine culture
- Short pregnancy interval
- Premature activation of normal - HTN, diabetes, vaginal tightening (painless) ▪ Neonatal - Severe maternal disease - Obtain fFN
physiological initiators of labor, - Possible ruptured neuroprophylaxis - Fetal compromise - Administer tocolytics
bleeding, clotting disorders
activation of maternal-fetal membranes - Antibiotics o Maintain strict I/O while
- Inadequate nutrition, BMI, - Chorioamnionitis
hypothalamic pituitary adrenal - Urinary frequency o For ROM, GBS (+) on tocolytics
pre-pregnancy weight, poor - Fetal death
(HPA) axis - Progesterone o May restrict total intake
weight gain - Previable gestation +
- Inflammation + infxn in the o “Keep me pregnant” PPROM to 3,000 mL/24 hr
decidua, fetal membranes, - Age Labs/diagnostics
- fFN = (+) labor within 2 - Corticoidsteroid therapy - Hypotension - Administer antenatal steroid
amniotic fluid o < 17 o Betamethasone - Position mom on side to
o > 35 wks - Dilation
- Maternal/fetal stress ▪ Lung maturity uteroplacental perfusion +
- Late/ no prenatal care - Cervical cultures - Heart problems
- Uteroplacental vascular pressure on the IVC
insufficiency - Obesity, BMI, excessive wt - CBC - Tachycardia
- Urinalysis - Assess VS
- Exaggerated inflammatory gain - Auscultate lungs
response - Working long hrs / long - U/S for cervical length
o > 30mm = No PTL - Assess cervical status
- Hormonal factors periods of standing - Emotional support
o < 20mm = PTL
- Cervical insufficiency - Ancestry/ethnicity - Monitor response to tx
- NST/BPP
- Genetic predisposition o among African - Evaluate labs
Americans o WBC count
- Maternal unmarried status o Urine + Cervical culture
- Intimate partner violence - Explain purpose + SE of meds
- Mental health issues - Bedrest
- Lack of social support - SCD’s
- Smoking, alcohol, illicit drug - Changing positions
use
- Lower education, and
socioeconomic status, poverty
, OB Week 5 Ch. 7
PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM)
Causes / Info Risk Factors Assessment Findings Medical Management Not recommended Nursing Actions
- Unknown cause - Previous preterm PROM or - Confirmed premature - IV ampicillin + erythromycin - Digital cervical examinations - Assess FHR + UCs
- PROM preterm delivery gestational age by prenatal hx for < 34 wga - Sealing techniques - Assess for signs/symptoms of
o Spontaneous ROM prior - Bleeding during pregnancy + U/S - GBS prophylaxis - Tocolytics infxn
to onset of true labor - Short cervical length - Confirmed ROM w/ SSE + - Corticosteroids for 24 – 34 - Tubs o Maternal/fetal
o > 37 wga - Hydramnios ferning test wga - tachycardia
- PPROM o AFI > 24 (1,500 mL) - Oligohydramnios seen on o Betamethasone o Maternal fever >100.4 F
o Premature spontaneous - Multiple gestation U/S - Magnesium sulfate before 32 o Uterine tenderness
ROM - STIs - Presence of clear fluid wga for fetal neuroprotective o Malodorous fluid/
o After 20 wga, before 37 - Low BMI o Ferning tx vaginal discharge
wga - Low socioeconomic status o Nitrazine - Induction - Monitor for labor + fetal
- - Cigarette smoking + illicit - AFI demise
drug use - Antenatal testing
Possible factors - Copper or Vit C deficiency o NST
- Bacterial infxns - Pulmonary/Connective tissue o BPP
- Stress + strain on the disorder - Monitor VS
membranes - Antibiotic tx
- Altered levels of hormones - Obtain cultures for GBS/
vaginal culture for GC/CT
- Urinalysis
- FKC
- Pelvic rest
- Encourage hydration
- Bed rest
o SCDs
- Anticipate delivery
CHORIOAMNIONITIS
Causes / Info Risk Factors Assessment Findings Medical Management Contraindications Nursing Actions
- Fever (100.4 +) - Fluids (PO/IV)
- WBC elevation - Acetaminophen (Tylenol)
- Foul smelling odor - Bedrest
- Abdominal tenderness - Antibiotics
o Uterus o Ampicillin/gentamycin
irritated/enflamed - Cooling blankets/Ice
- Tachycardia - FHR
- Diaphoresis - CBC
- RR - Lactic acid
- Fetal membranes are - Urinalysis
thickened, grey/tan instead - Blood culture x2
of thin/translucent - Monitor FHR + UCs
- O2
Ch. 7 High-Risk Antepartum
- Preterm labor/birth
o Preterm labor (PTL) – regular UCs resulting in changes in the cervix before 37 wga
o Preterm birth (PTB) – birth b/t 20 wga + 36 6/7 wga
Leading cause of neonatal mortality + common reason for antenatal hospitalization
▪ Causes
¬ Individual behavioral + psychosocial factors
¬ Neighborhood characterisitics
¬ Environmental exposures
¬ Medical conditions
HTN, pre-eclampsia, hemorrhage, IUGR
¬ Infertility tx
¬ Biological factors
¬ Genetics
o Main situations where PTL/PTB may occur
Spontaneous PTL/PTB
▪ Unintentional, unplanned delivery before 37th wk of pregnancy
¬ Causes: infection or inflammation
¬ Usually unknown
¬ Hx of delivering preterm → strongest predictor for future PTB
Medically indicated PTB
▪ Healthcare provider recommended for existence of medical condition (pre-eclampsia)
Non-medically indicated (Elective)
o
Classifications of prematurity
Late Preterm infant Born 34 – 37 wga
Very Preterm infant Before 32 wga
Viability At 25 wga
Periviability 20 – 25 6/7
- Majority of neonatal deaths
Long term sequelae of preterm infants
▪ Cerebral palsy
▪ Hearing/vision impairment
▪ Chronic lung
, OB Week 5 Ch. 7
PRETERM LABOR
Causes Risk factors Assessment Findings Medical Management Contraindications Nursing Actions
- Excessive uterine - Prior PTB - Change in type of vaginal - Tocolytics (suppress UC in - Intrauterine fetal demise - Review prenatal record for
stretch/distention o Most important factor discharge PTL) - Lethal fetal anomaly risk factors
o Prostaglandins stimulate - Multiple gestation o Watery, mucus, o Nifedipine (Procardia) - Non-reassuring fetal - Assess for
the uterus to contract when - Uterine/Cervical abnormalities, bloody ▪ UCs status o Vaginal/urinary infxn
overdistended from diethylstilbestrol (DES) - amount of discharge ▪ Ca blocker - Severe preeclampsia or o ROM
multiple gestation, - Fetal anomalies - Pelvic/lover abdominal o Indomethacin eclampsia o SSE for ferning
polyhydramnios, uterine - Hx of second trimester loss pressure ▪ NSAID - Maternal bleeding w/ o Vaginal
abnormalities - Incompetent cervix/ cervical - Constant low, dull ▪ Prostaglandins hemodynamic instability bleeding/discharge
- Decidual activation insufficiency backache o Terbutaline (brethine) - Chorioamnionitis o Dehydration
o Hemorrhage - IVF pregnancy - Mild abdominal cramps, ▪ UC - PPROM absence of infxn - Assess FHR + UC
o Fetal-decidual paracrine - Hydramnios or oligohydramnios with or without diarrhea ▪ Beta 2 o Report tachycardia to
system - PROM - Regular / frequent o Ritodrine Tocolytic C/I: provider
o Upper genital tract infxn contractions or uterine o Magnesium sulfate - Active hemorrhage - Obtain vaginal + urine culture
- Short pregnancy interval
- Premature activation of normal - HTN, diabetes, vaginal tightening (painless) ▪ Neonatal - Severe maternal disease - Obtain fFN
physiological initiators of labor, - Possible ruptured neuroprophylaxis - Fetal compromise - Administer tocolytics
bleeding, clotting disorders
activation of maternal-fetal membranes - Antibiotics o Maintain strict I/O while
- Inadequate nutrition, BMI, - Chorioamnionitis
hypothalamic pituitary adrenal - Urinary frequency o For ROM, GBS (+) on tocolytics
pre-pregnancy weight, poor - Fetal death
(HPA) axis - Progesterone o May restrict total intake
weight gain - Previable gestation +
- Inflammation + infxn in the o “Keep me pregnant” PPROM to 3,000 mL/24 hr
decidua, fetal membranes, - Age Labs/diagnostics
- fFN = (+) labor within 2 - Corticoidsteroid therapy - Hypotension - Administer antenatal steroid
amniotic fluid o < 17 o Betamethasone - Position mom on side to
o > 35 wks - Dilation
- Maternal/fetal stress ▪ Lung maturity uteroplacental perfusion +
- Late/ no prenatal care - Cervical cultures - Heart problems
- Uteroplacental vascular pressure on the IVC
insufficiency - Obesity, BMI, excessive wt - CBC - Tachycardia
- Urinalysis - Assess VS
- Exaggerated inflammatory gain - Auscultate lungs
response - Working long hrs / long - U/S for cervical length
o > 30mm = No PTL - Assess cervical status
- Hormonal factors periods of standing - Emotional support
o < 20mm = PTL
- Cervical insufficiency - Ancestry/ethnicity - Monitor response to tx
- NST/BPP
- Genetic predisposition o among African - Evaluate labs
Americans o WBC count
- Maternal unmarried status o Urine + Cervical culture
- Intimate partner violence - Explain purpose + SE of meds
- Mental health issues - Bedrest
- Lack of social support - SCD’s
- Smoking, alcohol, illicit drug - Changing positions
use
- Lower education, and
socioeconomic status, poverty
, OB Week 5 Ch. 7
PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM)
Causes / Info Risk Factors Assessment Findings Medical Management Not recommended Nursing Actions
- Unknown cause - Previous preterm PROM or - Confirmed premature - IV ampicillin + erythromycin - Digital cervical examinations - Assess FHR + UCs
- PROM preterm delivery gestational age by prenatal hx for < 34 wga - Sealing techniques - Assess for signs/symptoms of
o Spontaneous ROM prior - Bleeding during pregnancy + U/S - GBS prophylaxis - Tocolytics infxn
to onset of true labor - Short cervical length - Confirmed ROM w/ SSE + - Corticosteroids for 24 – 34 - Tubs o Maternal/fetal
o > 37 wga - Hydramnios ferning test wga - tachycardia
- PPROM o AFI > 24 (1,500 mL) - Oligohydramnios seen on o Betamethasone o Maternal fever >100.4 F
o Premature spontaneous - Multiple gestation U/S - Magnesium sulfate before 32 o Uterine tenderness
ROM - STIs - Presence of clear fluid wga for fetal neuroprotective o Malodorous fluid/
o After 20 wga, before 37 - Low BMI o Ferning tx vaginal discharge
wga - Low socioeconomic status o Nitrazine - Induction - Monitor for labor + fetal
- - Cigarette smoking + illicit - AFI demise
drug use - Antenatal testing
Possible factors - Copper or Vit C deficiency o NST
- Bacterial infxns - Pulmonary/Connective tissue o BPP
- Stress + strain on the disorder - Monitor VS
membranes - Antibiotic tx
- Altered levels of hormones - Obtain cultures for GBS/
vaginal culture for GC/CT
- Urinalysis
- FKC
- Pelvic rest
- Encourage hydration
- Bed rest
o SCDs
- Anticipate delivery
CHORIOAMNIONITIS
Causes / Info Risk Factors Assessment Findings Medical Management Contraindications Nursing Actions
- Fever (100.4 +) - Fluids (PO/IV)
- WBC elevation - Acetaminophen (Tylenol)
- Foul smelling odor - Bedrest
- Abdominal tenderness - Antibiotics
o Uterus o Ampicillin/gentamycin
irritated/enflamed - Cooling blankets/Ice
- Tachycardia - FHR
- Diaphoresis - CBC
- RR - Lactic acid
- Fetal membranes are - Urinalysis
thickened, grey/tan instead - Blood culture x2
of thin/translucent - Monitor FHR + UCs
- O2
