Preterm / Premature Labor: Etiology

PRETERM / PREMATURE LABOR
 Labor that occurs before the end of week 37 of gestation

 Characterized by regular uterine contractions that are strong enough to cause
significant cervical dilatation and effacement
 It occurs in approximately 9% to 11% of all pregnancies
 Associated with dehydration, urinary tract infection and chorioamnionitis
(infection of fetal membranes and fluid)
 Women who continue to work at strenuous jobs or perform shift work that leads
to extreme fatigue may have a higher incidence than the others
Etiology
 History of previous PTL
 One or more spontaneous second-trimester abortions are considered a major
risk factor
 Epidemiological factors:
 low socio-economic status
 low prepregnancy weight
 pregnancy age of less than
18 years or more than 40
 maternal smoking
 use of cocaine
 stressful living condition
 job that requires physical
labor
 teenage primigravida
 multiparity
 overdistention of uterus caused by
multiple pregnancy and hydramnios
 uterine abnormalities
 maternal infections
 PROM
 Infection of amniotic fluid
 Congenital malformation of fetus and placenta
 Fetal death
Signs and Symptoms

 Persistent, dull, low back pain
 Watery or bloody vaginal spotting
 Feeling of pelvic pressure or abdominal tightening due to descent of fetus
 Menstrual-like cramping
 Uterine contractions
 Intestinal cramping
 Increased vaginal discharge
Pathophysiology of Preterm Birth
Spontaneous preterm birth is a physiologically heterogeneous syndrome. The

cascade of events that culminate in spontaneous preterm birth has several possible
underlying pathways. Four of these pathways are supported by a considerable body of
clinical and experimental evidence: excessive myometrial and fetal
membrane overdistention, decidual hemorrhage, precocious fetal endocrineactivation,
and intrauterine infection or inflammation.These pathways may be initiated weeks to
months before clinically apparent preterm labor. The processes leading to preterm
parturition may originate from one or more of these pathways; for example, intrauterine
infection or inflammation and placental abruption often coexist in preterm births.
Decidual hemorrhage and intrauterine infection share several inflammatory
molecular mechanisms that contribute to parturition. Our understanding of the nature of
the molecular cross-talk among these pathways is in its infancy. The etiologic
heterogeneity of preterm birth adds complexity to therapeutic approaches. Although the
ultimateclinical presentation of women with preterm labor may appear to be
homogeneous, the antecedent contributing factors probably differ considerably from
woman to woman.
Certain clinical presentations and risk factors preferentially predispose the

maternal–fetal unit to preterm birth in a pathway-specific fashion. For example, women
with multifetal pregnancies are at particular risk for preterm birth, presumably owing to
pathologic uterine overdistention. Women with preterm rupture of membranes or
preterm labor at a very early gestational age (e.g., 24 to 28 weeks) are at increased risk
for having underlying intrauterine infection; the precise nature of such predispositions is
not known at this time.
Therapeutic Management
 Diagnostics
1. Analyzing changes in the vaginal mucus, such as the presence of fetal
fibronectin, a protein produced by the trophoblast cells. If this is present in the
vaginal mucus, it predicts that preterm contractions are ready to occur.
2. Shortened cervix revealed by sonography/ultrasound
3. Vaginal and cervical cultures and clean-catch urine sample are obtained to rule
out infection
 Hospital Management
1. Place on bed rest to relieve the pressure of the fetus on the cervix.
2. Intravenous fluid therapy to keep a woman well hydrated is initiated because
hydration may help stop contractions. If a woman is dehydrated, the pituitary
gland is activated to secrete antidiuretic hormone, and this may cause the rlease
of oxytocin which strengthens uterine contractions. By keeping a woman well
hydrated, therefore the release of oxytocin may be minimized.
 Tocolytics – medications given to patient to prevent and stop uterine
contractions when:
 Cervix is dilated less than 4 centimeters
 Membranes are intact with no bulging on the internal os
 Fetus has an estimated weight of less than 2500 grams
 Used for 48-hour period in patients at 24-34 weeks gestation, who are dilated
more than 4 cm and at risk for preterm labor; allows time for corticosteroids
therapy to stimulate surfactant production in fetal lungs reducing the severity
and incidence of respiratory distress
syndrome in premature neonate
 Contraindicated in:
 Abruptio placenta
 Acute fetal distress or death
 Eclampsia or severe preeclampsia
 Chorioamnionitis
 Maternal dynamic instability
 Drugs used:
1. Ritodrine HCl (Yutopar)
Side effects: maternal hypotension, tachycardia, arrhythmia
Antidote: Propanolol
2. Magnesium Sulfate (MgSO4)
Drug of choice for IV tocolytic therapy
Effective in delaying delivery for 48 hours
3. Terbutaline (Brethine)
Highly effective tocolytic that causes active transport of calcium
out of uterine muscle cells, resulting in relaxation or reduction in
muscle activation
Side effects: tachycardia, hypotension, dysrhythmias, chest pain, nervousness,
nausea, headache, vomiting
Contraindicated to patients with DM or cardiac disease
4. Indomethacin (Indocin)
Prostaglandin inhibitor; reduces the concentration of calcium within the cells and
smooth muscle contractility
5. Nifedipine (Procardia)
Inhibits the flow of calcium into the muscle cells, causing muscle relaxation
 Drugs that hasten fetal lung maturity:

1. Glucocorticoid therapy – if labor cannot be delayed for 48 hours to accelerate
fetal lung maturity and prevent respiratory distress and hyaline membrane
disease
2. Phenobarbital/Vitamin K – reduces incidence of intraventricular hemorrhage in
preterm neonates
3. Inositol supplementation – administered to preterm infants with respiratory
distress to lessen severity
4. Thyrotropin releasing hormone – helps reduce incidence of bronchopulmonary
dysplasia
 If delivery cannot be prevented:

1. Sedatives and analgesics are kept to minimum to prevent respiratory distress
syndrome as the infant is premature.
2. Amniotomy is performed only if fetal head is firmly engaged to prevent cord
prolapsed.
3. Cord is cut immediately without waiting for pulsations to stop because
premature infants have difficulty excreting the extra bilirubin that will be
formed from the additional blood transfused from the placenta.
PREMATURE RUPTURE OF MEMBRANES (PROM)
 Rupture of fetal membranes with loss of amniotic fluid during pregnancy
 Rupture of membranes before 38 weeks gestation and is an important cause of
maternal and perinatal morbidity and mortality
 Associated with infection of the membranes (chorioamnionitis), vaginal infection,
multifetal gestation, breech presentation and intrapartum fetal distress
 Occurs in 5% to 10% of pregnancies
 If rupture occurs early in pregnancy, it poses a major threat:
 after rupture, the seal to the fetus is lost and uterine and fetal infection
may occur
 a second complication that can result is increased pressure on the
umbilical cord from the loss of amniotic fluid, inhibiting the fetal nutrient
supply, or cord prolapsed
Pathophysiology
Numerous risk factors are associated with preterm PROM. Black patients are at
increased risk of preterm PROM compared with white patients. Other patients at higher
risk include those who have lower socioeconomic status, are smokers, have a history of
sexually transmitted infections, have had a previous preterm delivery, have vaginal
bleeding, or have uterine distension (e.g., polyhydramnios, multifetal pregnancy).
Procedures that may result in preterm PROM include cerclage and amniocentesis.
There appears to be no single etiology of preterm PROM. Choriodecidual infection or
inflammation may cause preterm PROM. A decrease in the collagen content of the
membranes has been suggested to predispose patients to preterm PROM. It is likely
that multiple factors predispose certain patients to preterm PROM.
Assessment
 Suggested by the history: a woman usually describes sudden gush of clear fluid
from the vagina, with continued minimal leakage
Diagnosis
1. Sterile vaginal speculum examination –
done to observe for vaginal pooling of
liquid
2. Nitrazine paper test – amniotic fluid
causes an alkaline reaction on the
paper (appears blue)
3. Ferning – typical appearance of high
estrogen fluid on microscopic
examination
4. Sonogram – to assess amniotic fluid
index
5. Cultures for Neisseria gonorrhoeae, streptococcus B and Chlamydia
Therapeutic Management
 Attempts to avoid delivery are of two primary forms:

1. Nonintervention or expectant management – nothing is done and spontaneous
labor is simply awaited
2. Intervention that may include corticosteroids, given with or without tocolytic
ageants to arrest preterm labor in order that the corticosteroids have sufficient
time to induce pulmonary maturation
 Hospital / Home Management

1. Place on bed rest and administer
corticosteroids to hasten fetal lung
maturity
2. Prophylactic administration of broad spectrum antibiotics may delay onset of
labor and reduce risk for infection in newborn to allow the corticosteroid to have
its effect
3. Women positive for streptococcus B need an intravenous administration of
penicillin or ampicillin to reduce the possibility of this infection in the newborn
4. Following endoscopic intrauterine procedures, membranes can be resealed by
use of a fibrin-based commercial sealant so they are again intact
Sia, Maria Loreto J. “Outline in Obstetrics: Textbook and Reviewer for Nurses and
Midwives”. 3rd edition. 2006.
Cunningham, F. Gary. Williams Obstetrics (22th Edition). United States: McGraw-Hill

Companies Inc. 2005
Pillitteri, Adele. Maternal and Child Health Nursing: Care of the Childbearing and
Childrearing Family (5th Edition). Philippines: Lippincott Williams and
Wilkins. 2007

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PRETERM / PREMATURE LABOR

 Labor that occurs before the end of week 37 of gestation

Signs and Symptoms

Pathophysiology of Preterm Birth

Spontaneous preterm birth is a physiologically heterogeneous syndrome. The

Certain clinical presentations and risk factors preferentially predispose the

 Drugs that hasten fetal lung maturity:

 If delivery cannot be prevented:

 Attempts to avoid delivery are of two primary forms:

 Hospital / Home Management

Cunningham, F. Gary. Williams Obstetrics (22th Edition). United States: McGraw-Hill

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