Mrs. Carolyn L.

Bote
Clinical Instructor
Angelie M. Elvambuena
Aiza Capiral
Angelo Garcia
Marie Rose Villeza
Jaizel Bernardino
Wilson Tobias
Introduction:

Pregnancy is normally a time of happiness and anticipation,

but it can also be a time of unknowns. Many women have
concerns about what is happening with their baby. Premature labor
occurs in about 12% of all pregnancies. However, knowing the
symptoms and avoiding particular risk factors can lower a
woman’s chance of premature labor.

Preterm labor is defined as the presence of uterine

contractions of sufficient frequency and intensity to affect
progressive effacement and dilatation of the cervix prior to term
gestation (between 20 and 37 weeks). Preterm labor precedes
almost half of preterm births and is the leading cause of neonatal
mortality. Preterm babies at are higher risk of needing
hospitalization, having neurological, breathing, digestive, or other
long-term health problems and of dying than babies born after the
37th week. They are also at risk of delayed development and
learning disabilities.
 
Causes
• Certain genital tract infections, such as
chlamydia, bacterial vaginosis (BV), and
trichomoniasis, are associated with
preterm delivery.

Substances produced by bacteria can

weaken the membranes around the
amniotic sac and cause it to rupture early.
Even when the membranes remain intact,
bacteria can cause preterm labor if they
get into the amniotic fluid or sac.
• Having a problem with the
placenta, such as placenta
previa or placental abruption.
• Having structural abnormalities of
the uterus or cervix, such as a cervix
that's shorter than 25 millimeters and
that effaces or dilates without
contractions (cervical insufficiency).
• Having an excessively large uterus,
which is often the case when you're
pregnant with multiples or have
too much amniotic fluid.
• Certain chronic maternal illnesses
may be related to preterm labor,
such as diabetes, sickle cell anemia,
severe asthma, lupus, inflammatory
bowel disease, and chronic active
hepatitis. Other conditions to watch
for include non-uterine infections,
such as a kidney infection or
pneumonia; abdominal surgery, such
as having your appendix taken out;
and trauma to the abdomen.
Definition of terms:

• Low birth weight infant – infant with a birth weight of less

than 2500 grams.
• Very low birth weight infant – infant with a birth weight of
less than 1500 grams.
• Extremely low birth weight infant – infant with a birth
weight of less than 1000 grams.
• Large for Gestational Age – birth weight above the 90th
percentile rank.
• Appropriate for Gestational Age – birth weight between
the 10th and 90th percentile rank.
• Small for Gestational Age – birth weight below the 10th
percentile rank.
Genaral Objective:

After this case presentation, the student nurse will be able to

present a summary of the different aspects of the client’s case, in
order to promote further consciousness and awareness of the
condition, Preterm Labor. It is for the promotion of health and
prevention of further complications as equally significant to the
client’s wellness.
Specific Objectives:

After this case presentation, the students will be able to:

* understand the anatomy and physiology

* discuss the pathophysiology of the client’s disease condition
* create a plan of care appropriate for the client’s condition
>Epidemiology:
In most cases, the cause of preterm labor is not diagnosed,
and the etiology is likely to be multifactorial. In 25 percent of
preterm births, labor is induced for various maternal and fetal
medical indications; approximately 30 percent of preterm births
are associated with premature rupture of the membranes
(PROM). Preterm birth can potentially be prevented in less than
one half of the mothers who present in labor earlier than 37
weeks of gestation.

About 12 percent of babies in the

Philippines are born prematurely.
 Baseline Data
Name: Mrs. G. D.L

Address: Daang Sarile, Cabanatuan City

Age: 20 y/o

Gender: Female

Religion: Roman Catholic

Nationality: Filipino

Date of Admission: Nov 18, 2010

Time of Admission: 8:10 AM

Chief Complaint: lumbo sacral pain for two days

Admitting Diagnosis: PU 29 wks AOG CIL

Admitting Physician: Dr. Maducdoc

Health History:

>Present:

2 days PTA, the patient experienced intestinal cramps

associated with low back pain. Patient rested every now and
then which gave relief to patient’s condition. Few hours PTA,
still with persistence of above signs and symptoms, patient
experienced uterine contractions and bloody discharge.
Condition prompted; consult here in our institution hence
admission.

>Past:

G3P1, patient had history of abortion on first pregnancy.

>Familial History:

DM HPN Cancer Asthma

Maternal - - - -
Paternal - - - -

The parents of the client both manifest (-) history of the

following diseases: DM, Hypertension, Cancer, Asthma as
interviewed.
Assessment:
Body Parts Techniques Actual Findings Normal Findings Analysis
Skin Inspection, with facial Ranges from pinkish Pt’s skin
Palption chloasma, linea white to shades of discoloration is
nigra and striae brown normally seen in
gravidarum pregnant women
Free from breaks due to certain
factors that
contribute to
pregnancy

Nail Inspection, Nail is convex & Convex & follow the

Palpation follows curve of natural curve of the
finger finger

Blanch test normal Angle below on the nail

bed is normally 160
degrees

Blanch test normal

Head Inspection, Head & face is Head & face proportion

Palpation, proportion
Auscultation Rounded
(normocephalic,
symmetrical, smooth
skull contour)
Eyes Inspection Visual acuity,
Eyelashes present ocular movements,
curving outward. visual fields,
external structures
No lesions noted and
on the eyelid. accommodation

Pupil equal, round,

reactive to light and
accommodation.

Ears Inspection, Pt doesn’t have a Color the same as

Palpation hearing problem facial skin

No discharges Symmetrical size &

shape
Symmetrical
Aligned with outer
No swelling and canthus of the eye
tenderness.
Pinna recoils after
Can respond to it is folded
normal voice tone.
No discharges; no
Intact with no lesions.
lesions.
Not tender; no
swelling
Nose & Sinuses Inspection, Pt. doesn’t have a Nose
Palpation nasal problem Air moves freely as
the pt. breathes
No discharges through nares

No swelling and Symmetric &

tenderness noted straight
upon inspection.
No discharge or
flaring

Uniform color;
mucosa pink

Not tender; no
lesions

Nasal septum intact

& in midline

Facial sinuses
Not tender
Mouth Inspection The patient had Lips uniform pink
pallor lips. color

Reddened gums, Soft, moist, smooth

without teeth. texture

Thin whitish coating Symmetry of

noted in the tongue; contour
it moves freely
without lesions. Pink gums

Tongue in central
Neck Inspection, Neck is Muscles equal in
Palpation symmetrical with size; head centered
head
Lymph nodes not
Can turn head from palpable
right to left
gradually, but with Trachea in central
resistance. placement

Palpable lymph
nodes
Chest & Back Inspection, Pt has normal Chest symmetrical Enlargement of the
Palpation, chest symmetry & intact breast is due to
Auscultation milk production and
Presence of No tenderness; no increased estrogen
wheezing sound masses level
noted upon
auscultation Full & symmetric
chest expansion
Breasts are enlarge
Abdomen & Back Inspection, Globularly enlarged Symmetrical with flat Enlarged abdomen
Palpation, abdomen and rounded is due to the
Percussion contours presence of fetus in
(+) linea nigra the mother’s womb
Abdominal
movement
associated with
respiration

Normal presence of
air or gas in the
stomach and
intestine that
produces drum-like
sound upon
percussion

No tenderness; no
lesions

Musculoskeletal Inspection, Increased weight, Symmetrical

Palpation pelvis tilt, increase contours and curves
spinal curve,
softening connective Normal range of
tissue and motion and strength
separation of
symphysis pubis Normal mobility,
size, skin color
Neurologic Inspection Normal Normal
sensorimotor sensorimotor and
functions and reflexes
reflexes
Anatomy and
Physiology
 The female reproductive system contains two main parts: the
uterus, which hosts the developing fetus, produces vaginal and
uterine secretions, and passes the male’s sperm through the
fallopian tubes; the vagina meets the external organs at the vulva,
which includes the labia, clitoris and urethra. The vagina is
attached to the uterus through the cervix, while the uterus is
attached to the ovaries via the fallopian tubes. At certain intervals,
the ovaries release an ovum, which passes through the fallopian
tube into the uterus.
If, in this transit, it meets with the sperm, the sperm
penetrates and merge with the egg, fertilizing it. The fertilization
usually occurs in the oviducts, but can happen in the uterus itself.
The zygote then implants itself in the wall of the uterus, where it
begins the processes embryogenesis and morphogenesis. When
developed enough to survive outside the womb, the cervix dilates
and contractions of the uterus propel the fetus through the birth
canal, which is the vagina.
The ova are larger than sperm and are generally all created
by birth. Approximately every month, a process of oogenesis
matures one ovum to be sent down the fallopian tube attached to
its ovary in anticipation of fertilization. If nit fertilized, this egg is
flushed out of the system through menstruation.
VAGINA and CLITORIS
The vagina is the opening located directly below the urethral opening. Directly
outside the vaginal opening are the labia minora, the smooth inner lips of the vulva.
Outside of the inner lips are the labia majora, the fleshier outer lips that are typically
covered in hair after puberty.
The clitoris is a sensitive organ. Its function is to provide sexual pleasure. It is a
hard round “button” at the top of the vulva. The clitoral structure surrounds and
extends into the vagina. It contains erectile tissue, very similar to the male penis.
When a woman gets sexually aroused, it engorges with blood. The clitoris is densely
packed with nerve endings and, while similar in number to the penis, they are much
more concentrated and closer together.

UTERUS
The uterus provides structural integrity and support to the bladder, bowel, pelvic
bones and organs. The uterus helps separate and keep the bladder in its natural
position above the pubic bone and the bowel in its natural configuration behind the
uterus. The uterus is continuous with the cervix, which is continuous with the vagina,
much in the way that the head is continuous with the neck, which is cintinuous with the
shoulders.
 The reproductive function of the uterus is to accept a fertilized ovum which
passes through the utero-tubal junction from the fallopian tube. It then becomes
implanted into the endometrium, and derives nourishment from blood vessels which
develop exclusively for this purpose. The fertilized ovum becomes an embryo,
develops into a fetus and gestates until childbirth. Due to anatomical barriers such as
the pelvis, the uterus is pushed partially into the abdomen due to its expansion during
pregnancy.

CERVIX
The cervix (or the neck of the uterus) is the lower, narrow portion of the uterus
where it joins with the top end of the vagina. It is cylindrical or conical in shape and
protrudes through the upper anterior vaginal wall.
During menstruation the cervix stretches open slightly to allow the endometrium
to be shed. This stretching is believed to be part of the cramping pain that many
woman experience. Evidence for this is given by the fact that some women’s cramps
subside or disappear after their first vaginal birth because the cervical opening has
widened. During childbirth, contractions of the uterus will dilate the cervix up to 10 cm
in diameter to allow the child to pass through. Stimulation of the cervix leads to
orgasm for some women. During orgasm, the cervix convulses and the external os
dilates.
FALLOPIAN TUBE
The fallopian tubes, named after Gabriel Fallopius (Gabriele Fallopio), also known
as oviducts, uterine tubes, and salphinges are two very fine tubes lined with ciliated
epithelia, leading from the ovaries of the female mammals into the uterus, via the
utero-tubal junction.
When the ovum is developing in an ovary, it is encapsulated in a sac known as an
ovarian follicle. On maturity of the ovum, the follicle and the ovary’s wall rupture,
allowing the ovum to escape and enter the fallopian tube. There it travels toward the
uterus, pushed along by movements of cilia on the inner lining of the tubes. This trip
takes hours or days. If the ovum is fertilized while in the fallopian tube, then it normally
implants in the endometrium when it reaches the uterus, which signals the beginning
of pregnancy.

OVARY
The ovaries are the main source of female hormones (estrogen and
progesterone) these hormones control the development of female body
characteristics, such as the breasts, body shape, and body hair. The ovaries also
regulate the menstrual cycle and pregnancy.
Pathophysiology:
Labor that occurs before the week 37 of gestation

Risk factors:
PROM Predisposing factors:
Preeclampsia Lifestyle

Chronic medical illness Smoking

Drug abuse stress

Abnormal structure of
uterus
Cervical incompetence
Previous preterm birth
Decrease function of
placenta
Placenta previa
Abruptio placenta
Polyhydramnios
Erythroblastosis fetalis
Dehydration
 Fetal fibronectin leak

Trued uterine contraction

Cervical dilatation

Rupture of membrane

Fetal presentation

Delivery of the fetus

Delivery of placenta
 Signs and symptoms:
Dull, persistent low back ache
Vaginal spotting
Pelvic pressure or abdominal tightening
Menstrual-like cramping
Increase vaginal discharge
Uterine contraction
Intestinal cramping

Complications:
Immature infant
Respiratory distress syndrome
Bleeding in the brain
Infant death
Diagnostic Tests:
• transvaginal ultrasonography (TVU) of the cervix

• fetal fibronectin (fFN) testing

Health care providers give the fFN test to women between 24 and 34 weeks of
pregnancy. The presence of fFN during these weeks, along with symptoms of labor,
suggests that the “glue” may be disintegrating ahead of schedule and alerts health
care providers to a possibility of premature labor and delivery.
Providers use a cotton swab to collect samples of cervico-vaginal secretions
during a speculum examination (similar to a Pap smear). Results usually are
available within 24 hours. The result is either positive (fFN is present) or negative
(fFN is not present).
Management:
Medical Management
• Maternal stabilization and fetal monitoring
• Control of blood loss, blood replacement
• Delivery of viable neonate
• Drug Administration

Pharmacologic Management

Generic Brand Class. Mech. Of Side Effects Nursing

Name Name Action Interventions
Terbutaline Brethine Adrenergic It is a direct Dizziness, • Asses respiratory
Inhalant acting anxiety, flushes, function
sympathomim sweating, • Teach client use
etic which nausea, vomiting, of inhaler
relaxes lethargy, tinnitus, • Teaach client to
bronchial muscle cramps, avoid getting
smooth headache. aerosol in eyes;
muscle by burning, stinging
selective will occur.
action on β2
receptor. It
also
decreases
uterine
contractility.
Generic Brand Class. Mech. Of Side Effects Nursing
Name Name Action Interventions
Ritodrine Yutopar Sympathomi- A selective β2 Tachycardia, • Assess maternal
metics adrenoceptor palpitation, V/S, fetal heart
agonist with headache, tone during
its main nervousness, infusion
action on the anxiety, nausea, • Assess for
uterus, vomiting, intensity & length
causing anaphylaxis, of uterine
relaxation. It arrhythmia, contraction
reduces the pulmonary
intensity and edema,
frequency of hypokalemia
contractions.
Nursing Management
Assessment Diagnosis Planning Intervention Rationale Evaluation
SUBJECTIVE Anxiety Within 1 hour of Independent Within 1 hour
DATA: related to nursing 1. Monitor Vital >To obtain baseline of nursing
“natatakot ako, hospitalizati intervention, Signs data. intervention,
hindi ko pa on client will manage 2. Assess level of >Identify areas of client managed
naman and anxiety with anxiety through concern that might anxiety with
kabwanan” upcoming positive coping verbal and nonverbal interfere with the positive coping
As verbalized delivery mechanisms as cues. normal progress of mechanisms as
by the patient. process evidenced by: labor. evidenced by:
OBJECTIVE V/S within normal 3. Employ a calm, >Enhances nurseclient V/S within
DATA: range caring, confident, relationship. normal
>Exhibit poor >Verbalizes and non-judgmental range
eye control of approach. >Provides a healthy >Verbalizes
contact the situation 4. Allow client to outlet of emotions control of
>Facial tension >Verbalizes desire express fears and and relieves the situation
observed to feelings of anxiety anxiety. >Verbalizes
>Impaired participate in appropriately. desire to
attention labor >Adequate participate in
Noted process 5. Acknowledge explanation helps labor
>Appears normalcy of fear reduce anxiety, process
preoccupied; and provide soothe fears, and
decreased opportunity for provides assurance.
perceptual questions and
field. answer honestly
within client’s level
of understanding.
Assessment Diagnosis Planning Intervention Rationale Evaluation
6. Offer support >Provides feeling
by or
staying with the sense of security
patient, pating and trust
her between
arms, and the nurse and the
brushing patient.
a whisp of hair off
her forehead, and
provide a cool
cloth
on her forehead
as
needed. Mechanism of
Dependent action is to
1. Administer relieve
antianxiety anxiety.
medication .
as ordered by the
physician.
Assessment Diagnosis Planning Intervention Rationale Evaluation
SUBJECTIVE Altered comfort: Within 20 mins. Of Independent: Within 20 mins.
DATA: Pain related to nusing intervention 1. Assess the Provide baseline Of nursing
“Aray ko ang bearing down client shall actively degree of pain and data for future intervention the
sakit sakit efforts and participate in labor its characteristics, interventions client was able to
ayoko na!!!” as distention of the and cope with the location, severity, Gives pt a sense of actively
verbalized by perineum discomfort duration, and trust and Improves participate in
the patient as evidenced by: effectively as frequency. nurse-client labor
OBJECTIVE by: 2. Employ a calm, relationship. and cope with the
DATA: >sighing and >Verbalize desire to caring, confident, Pain is a subjective discomfort
>sighing and moaning continue with the and non-judgmental experience and effectively as
moaning observed labor process. approach. cannot be felt by evidenced by:
observed >Facial tension >comply with the 3. Accept patient’s . others. > Verbalize desire
>Facial tension and instructions of the description of pain Provides feeling or to
and grimacing noted physician 4. Support pt. sense of security continue with the
grimacing >Restlessness effectively paincoping and trust between labor process.
noted observed >Demonstrated activities: the nurse and the >comply with the
>Restlessness >Profuse proper breathing Offer support by patient. instructions of the
observed sweating techniques staying with the physician
>Profuse noted patient, pating her effectively
sweating arms, and brushing >Demonstrated
noted a whisp of hair off proper breathing
her forehead, and techniques
provide a cool cloth
on her forehead as
needed.
Assessment Diagnosis Planning Intervention Rationale Evaluation

5. Instruct patient Proper breathing

to do proper technique can
breathing prevent
technique exhaustion,
therefore
preventing
prolonged
delivery
of the fetus and
Collaborative: prolonged pain.
6. Participate in To minimize
the workload,
delivery process therefore
with other health saving time and
care team making the
members delivery
of the fetus faster