Definition

preterm labour

onset of labour after 22weeks gestation and before 37 completed

weeks (pregnancy.)
• extremely preterm ( <28/52 )
• very preterm (28 to <32/52 )
• moderate to late preterm (32 to <37/52)
Predisposing factor
Maternal causes
1. extreme emotional illness
2. drug abuse
3. antepartum hamorrhage
-placenta previa
- placenta abruptio
4. Uterine anormalies
-septate uterus
-incompetent servix
-fibroid uterus
 CONT
• history of preterm labour
• genital tract infection
✓GBS
✓bacteria vaginosis

• medical disorder
✓preeclampsia
✓chronic nephritis
✓anemia and malnutrition.
Uterine abnormality
 Fetal causes:
1.Congenital 2.Intrauterine 3.Polyhydramnios
anomalies fetal death

6.Premature
4.Multiple 5.Rh- rupture of
pregnancy isoimmunization
membranes

7.Idiopathic
DIAGNOSIS of preterm labour

Uterine contraction
•frequency every 10 minutes or less
•duration at least 30 seconds
•continue for at least 1 hour
cont
❑Ruptured of membrane – after 22/52 until 37/52
completed week
❑ Duration of pregnancy – after 22/52 until 37/52
completed week
 • Uterine activity
• uterine contraction occurring more frequently than every
10 minutes persisting for 1 hour or more uterine
contraction may be painful or painless

Sign and • Discomfort

symptom • lower abnormal cramping similar to gas pains,may be
accompanied by diarrhea dull,intermittent low baxk
preterm pin(below the waist painful menstrual –like
cramps,suprapubic pain or pressure or heaviness,feeling
the “baby is pushing down”,urinary frequency.
labour
• Vagina discharge
• change is character or amount of usual discharge ,thicker
(mucus) or thinner (watery,bloody,brown or colourless,or
increased amount ruptured of amniotic membranes.
 • EXPLAINATION
Giving proper explanation

OBSERVATION
Management General condition
of mother asses the general condition of the mother e.g pain or
anxiety so that an appropriate nursing intervention can
with be done to minimize the problem.
prematured
labour with Monitor vital sign

tocolytic BP, pulse rate, respiration

Monitor progress of labor

- Timing contraction every 30 minute
- VE – show/ amniotic fluid (ROM)
 OBSERVATION
Observation pad chart
- amount, colour and odour

Physical assessment
cont ✓ palpation – engagement,presentation

Fetus wellbeing
- CTG – monitor FHR, present of deceleration
- FKC
Management Psychological support
of mother • provide explanation and answer all the
mother’s question so that the mother can
with understand, reduce the anxiety and can
prematured give cooperation
labour with • Give emotional support to the mother
tocolytic • Encourage husband friendly care
 PHARMACOLOGICAL
PAIN NON-PHARMACOLOGICAL
MANAGEMENT - back rub
- hot water bag
cont

Investigation

➢ FBC and FBP (TRO anemia)

➢Renal Profile (TRO chronic nephritis)
➢High vagina swab for C&S (TRO infection)
➢Ultrasound : AFI (TRO
polyhydramnios/oligohydramnios)
➢Urinalysis ( to detect proteinurea)
➢ECG,CXR ( TRO cardiac disease)
 NIFIDIPINE(Adalat) (Calcium
channel blocker)

TERBUTALINE- Beta-adrenergic
UBATAN – argonist (beta-nimetic)
TOCOLYTIC
MAGNESIUM SULPHATE
 NIFIDIPINE
Initial oral dose tab nifedipine 20mg STAT
20mg for 30 minute if contraction persist,
3rd dose of 20 mg given is contraction still persist. Max dose:
Action- relaxes smooth muscle If indicated – cont maintenance dose 20 mg TDS for 48 hours. 120mg/day)
including the uterus by blocking
calcium entry.

Is a tocolytic medication used for preterm labour to slow uterine contraction.

Tab nifedipine 20mg (calcium
channel blocker)

Nifedipine blocks the passage of calcium into certain tissues, relaxing the uterine muscles and
smooth muscles of blood vessels throughout the body.

Treatment with other tocolytic medications was stopped because of the side effects.
 hypotension

headache

Side effect flushing

dizziness

nausea

tachycardia
contraindication

1. in women with cardiac 2. co-incident use of

disease and should be calcium channel blocker
used with caution in with magnesium sulfate
women with hypotension could resilt in
or renal disease. neuromuscular blockade
 • vital sign prior to loading dose
• vital sign every 15minutes for 1 hour
Nursing after loading dose
consideration • vital sign prior to and 30 minutes
after each dose until stabilized then
blood pressure every 4-6 hours
• continue fetal uterine activity
monitoring until stable
• inform doctor stat if any
abnormalities detected
 Terbutaline / bricanyl 0.5mg/ml

it can be given IV or S/C

Beta –adrenergic
For IV : Dissolve 2.5mg(5mls) of terbutaline in
agonist 500mls N/S
(beta -mimetic) start with 10dpm (30mls/hr) and increase the
dose every 10-20min till the uterine
terbutaline contraction stops.

maximum dose 20mcg/min

maximum infusion rate 80dpm(240mls/hr)

for S/C dose : 0.25mg every 3-4hrs for 12hrs

Regime terbutaline at HSB
Tarbutaline dosage Infusion syringe pump 2.5mg (5ml)+ 45 Dropmat
(mcg/min) ml Dextrose 5% or Normal Saline 2.5mg (5ml)+ 500ml Dextrose 5% or
Normal Saline
Drop per minute Ml/hr Drop per minute Ml/hr
(dpm) (dpm)
2.5 1 3 10 30
5 2 6 20 60
7.5 3 9 30 30
10 4 12 40 120
12.5 5 15 50 150
15 6 18 60 180
17.5 7 21 70 210
20 8 24 80 240
Cont

At the rate of 10-40mcg/min increased at the intervals of 10

minutes until evidence of patient response as shown by
reduction of strength,frequency or duration of
contractions,maintain rate for 1 hour after contractions
stopped,the gradually reduce by 50% every 6 hours.
Contraindication
• Cardiac arrhytmias and cardiac disease
• poor controlled diabetes

Nursing consideration

Terbutaline for tocolysis acceptable vital sign should assess prior to monitor vital sign and
for < 48h to 72hours each dose every 15 minutes for symptom pulmonary
the first hour after initial dose edema,tachycardia and
cardiac arrythmias.
SIDE EFFECT
MATERNAL FETAL
Nasal congestion Tachycardia
tachycardia Hyperinsulinemia
Cheast discomfort Hyperglycemia
Palpitation Myocardial ischemia
Myocardial ischemia
Tremor,dizziness ,nervousness
Headache
Nousea and vomiting
Hypokalemia
Hyperglysemia
Hypotension pulmonary edema
 1. Bed rest for 24 – 48 hours,
infusion and discharged after
72 hours if no
Management contraindication.
after 2. Vital sign / FHR and uterine
infusion activity are done hourly for 6-
12 hours.
3. Steroids may be repeated
weekly till 36 weeks.
 Treatment is discontinued if

a. Maternal pulse rate > 140/mins

b. Systolic BP < 90mmhg or Diastolic decreases by 20 mmHg
c. Fetal Heart Rate > 180/mins
d. Maternal side effect – palpation, chest tightness or pain.
e. Uterine contraction continue despite maximum infusion rate
for of 6-8 hours
f. Hypokalaemia.
 ATOSIBAN

INDICATION
is indicated to delay immenent pre term birth in pregnant women with:
• Regular uterine contractions of at least 30 second duration at a rate of> 1 per 10 minute
• A cervical dilation of 1 to 3cm ( 0-3 for multiparas) and effacement of >50%
• Age > 18 years
• A gestational age from until 33 completed weeks.
• A normal fetal heart rate.
• To be used as a second line,and only if nifedine cannot be used due to unwanted side effects (e.g.
tachycardia,hypotension ), or if failed suppression with nifedipine.
• Women with cardiovascular disease in which nifedipine and beta- agonist (salbutamol) are
contraindicated.
• Usage allowed only after specialist/consultant input.
STRENGTH

7.5MG/ML,5 Monitoring - continuos -monitor bp

ML /VIAL fetal heart and heart
(one vial of rate rate and
5ml contains contractions
37.5mg of ½ hourly
atosiban)
 Hyperglycaemia
Headache /dizziness
Tachycardia
Hypotension
SIDE Nausae/vomiting

EFFECT Fever(rare)
Rashes(rare)
Contraindication
- use with caution in women with liver disease
- no need for dose adjustment in renal impairment.
 1 vial=5ml=37.5mg(7.5mg/ml)

a minimun of 4 vials of atosiban Is

PREPARATION required for one course of treatment.

to be given in 3 steps
 STEP 1

dose 6.75mg
Concentration 1 amp = 7.5mg/ml

preparation Withdraw 0.9 ml of

undiluted atosiban
administration To give slow bolus over 1
min
STEP 2

dose 54mg
Concentration 0.75mg /ml

preparation Withdraw 4ml (balance from 1st vial )+ 5ml (2nd vial)=9ml
Add 9ml of atosiban to 81 ml of normal saline in a
microchamber
Withdraw 18ml of the solution and put aside for later use

administration To give the remaining 72 ml at 24ml/H (18mg/H)

Duration- 3 hours.
 STEP 3
dose 88.5mg
concentration 0.98mg/ml
preparation Add 18ml of the solution from step 2 to 10ml of undiluted
atosiban(3rd and 4th vial) =28ml of solution
Add 28 ml of the solution to 62 ml of normal saline in a
microchamber = 90ml of solution

administration To give at 6 ml/h (6mg/H)

duration 15 Hours (can be continued up to 45 hours).
 Magnesium Sulphate for
Neuroprotection in Preterm Delivery
• Magnesium sulphate has been proven to reduce the
incidence of cystic periventricular leukomalacia and
cerebral palsy

• Gestation of administration
• - although this remains controversial,it shoul be
given to fetuses between 24 to 31th weeks of
gestation.
DOSSAGE AND
TIMING
• Most studies were conducted in the context
of eclampsia prophylaxis,therefore we
recommend –iv magnesium sulphate 4g
slow bolus followed by an infusion of
1g/hour until delivery
• aim to complete at least 4 hours of
magnesium sulphate infusion prior to
delivery. If the woman does not go into
labour as expected,the infusion can be
discontinued.
• If magnesium sulphate was given solely for
neuroprotection in prematurity, then the
infusion can be discontinued after delivery
1.Facial flushing

2.Hypotension

3.Tachycardia

4. Nausea and vomiting

5. Muscle weakness and paralysis (in

SIDE EFFECT
women with neuromuscular disorderes-
rare)

( Sarawak general hospital edition 2020)

 Antenatal streroid therapy in preterm labour-
DEXAMETHASONE
• Antenatal corticosteroids have been proven to reduce rates of
neonatal death,respiratory distress syndrome and intraventricular
haemorrhage while being safe for the mother.

Gestation of administration
1. 24 - to 25weeks- consider in women with established preterm
labour
2. 26-30 weeks- offer to all women at risk of preterm labour
3. 34- 35 weeks- consider in women with SGA/IUGR/GDM/DM
4. below 24 weeks – consultant decision.
 • IM Dexamethasone 12mg bd x 2
Dosage and doses
• IM Dexamethasone 6mg bd x 4
timing doses can be used in women with
diabetes in whom delivery is not
imminent.
• Maximun benefit – 24 hours after
and up to 7 days after
administration of the second dose
of steroids. Some benefit is still
seen even within 4 hours of
administration.
CIRI-CIRI BAYI PRAMATANG
- Bayi yang di lahirkan kurang dari 37 minggu lengkap kehamilan

ANTROPOMETRI
- berat, 2.5kg
- Lilitan kepala< 32cm-33cm
- ukuran Panjang <45cm

- KEPALA
- Lebih besar di bandingkan dengan badan
- suture dan fontanelle luas da lembut
- skull bone masih lembut.
 CONT
MATA
• Bola mata terjojol ( the eyes bulge) kerana belum terbentuk dengan sempurna dan
orbital ridges prominent
• telinga
• pinnae telinga kurang cartilage

Nipple
• aerola and nipple not prominent

Abdomen
• prominent kerana hepar dan spleen besar dan otot-otot abdomen sangat lemah.