3. 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

5.  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%

6.  Pallor of skin and nails  No palpable masses or lesions

7.  Maxillary, frontal, and ethmoid sinuses are not tender.  No palpable masses and lesions  No areas of deformity

8.  Awake and alert  Oriented to Persons, Place, Time

9.  Pale conjunctivae and no dryness  Pupils equally round and reactive to light

10.  No unusual discharges noted

11.  Pink nasal mucosa  No unusual nasal discharge  No tenderness in sinuses

12.  Dry mouth and lips  Free of swelling and lesions

13.  No palpable lymph nodes  No masses and lesions seen

14. ৣ Equal chest expansion ৣ No retraction ৣ Clear breath sounds

15. Regular rhythm

16. ৩ Globular abdomen ৩ Abdominal scars from previous LSCS ৩ The patient complained of mild hypogastric pain

17. ৩ Leopold’s Maneuver done: Cephalic presentation ৩ FHR: 152bpm

18. ে Watery discharge since 1000H 13/08/12 ে Thick, yellow patchy, cheese like particles adhere to vaginal walls

19. ে Patient claimed pain and burning on urination ে Cervix: 1cm dilation, 50% Effacement, Station -3 Cephalic, Clear AF

20. ৫ Pulse full and equal ৫ No lesions noted

24.  1993 Arterial Ligation (Heart) No report

25.  2008 Low Segment Cesarean Section due to cord coil under General Anesthesia without complication

26.  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.

27.  Ob/Gyne History: Gravida:2 Para:1 Gestational Age:31 3/7 Weeks LMP:not sure LMP by early UTZ:06-01-12 EDD: 13-10-2012

28.  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

29.  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

30.  On Examination: IE:PV 1cm dilated, 50%effaced, station -3, clear amniotic fluid.  No cardiac consultation on present pregnancy.  Sugar monitoring at home are not well controlled

31. Amnisure ROM test: Positive

32. CTG TRACING NORMALMRS. PTL FETAL HEART RATE110 - 160 bpm152 bpm CONTRACTION (PTL)NO CONTRACTIONMILD TO MODERATE CONTRACTION

33. AMNIOTIC FLUIDNORMALOLIGOHYDRAMNIOSPOLYHYDRAMNIOS Per milliliters500 to 1,000 ml< 500 ml> 2,000 ml Amniotic Fluid Index by Ultrasound 8 - 18 cm<5-6 cm > 20 – 24 cm DAY 01 13.08.12 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 DAY 03 15.08.12 AMNIOTIC FLUID VOLUME BELOW THE 3 RD 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.

34. LABORATORYRESULTREFENCE RANGE Urinalysis Leucocytes Pus cells Others 1+ 10-15/hpf 0-1/hpf FUNGAL HYPAE present Cervico vaginal Swab Pus cells: Ep Cells: Morphology 4-6/oif 2-4/oif Lactobacilli, plenty; CANDIDA PRESENT; No clue cells, Negative for gonococci

35. LABORATORYRESULTREFENCE RANGE CBC HGB HCT PLT 11.3g/dl 35.4 % 289 11.2-15.7 g/dL 34.1-44.9% 182-369/UL Blood GroupA Rh TypePositive PT13.3 sec10.9 – 16.3 Seconds APTT30.4 sec27 – 39 Seconds

36. LABORATORYRESULTREFENCE RANGE Antibody ScreenNegative Urine culture and sensitivity No growth seen after 48 hours of incubation at 37°C Vaginal Swab culture No growth seen after 48 hours of incubation at 37°C HBsagNegative C-Reactive ProteinNegative

37. DATEBREAKFASTLUNCHDINNER TIME OF MEAL PRE-BSPOST-BS 2HRS TIME OF MEAL PRE-BSPOST-BS 2HRS TIME OF MEAL PRE-BSPOST-BS 2HRS 13/08/12Upon admission 71mg/dl1115H93mg/dl192mg/dl 14/08/12116mg/dl173mg/dl1740H136mg/dl152mg/dl 15/08/120830H109mg/dl121mg/dl1330H110mg/dl131mg/dl1935H79mg/dl91mg/dl 16/08/1278mg/dl1200H77mg/dl112mg/dl2000H85mg/dl124mg/dl 17/08/1290mg/dl1130H103mg/dl110mg/dl 18/08/122000H145mg/dl 19/08/121200H123mg/dl2000H109mg/dl 20/08/120400H100mg/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.

38.  Patient has mild fluctuation in blood sugar level.  Patient does not need insulin; just diet control. Plan: BSR x 8hourly, HBaIC, TSH RESULTREFERENCE Glycosylated Hemoglobin (HBa1C) 3.5%Diabetics: 4.0-6.02 Good control 6.3-7.9 Satisfactory Control >7.9 unsatisfactory control TSH1.35uIU/mlEuthyroid = 0.25 – 5.0 uIU/ml Hypothyroid more than 7.0 uIU/ml Hyperthyroid less than 0.15 uIU/ml

40.  Pre-Anesthetic Visit done.  For cardiac consultation.

41. ECG REPORT2D ECHO REPORTNT-pro BNP Sinus Tachycardia (after Nifedipine) otherwise WNL SWM: WNL EF 70 – 75 % All Valve: WNL PASP 20 mmHg Peri cardium: WNL 51 pg/mL Reference: < 75 Years : = < 125 > 75 Years : = < 450 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 of Nifedipine to decrease tachycardia

42. Neonatologist & Neonatal Intensive Care Unit Staff for Neonatal care/resuscitation.

44.  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.

45. 1. Premature activation of the maternal or fetal HPA axis 2. Decidual and amniochorionic inflammation 3. Decidual hemorrhage 4. Pathologic uterine distention

49. Current Pregnancy complications Fetal anomaly Hydramnios Abdominal surgery Previous LSCS Infection PROM UTI UNKNOWN CAUSES OTHER: Stress Occupational factors MATERNAL SYSTEMIC DISEASE Heart Gestational Diabetes BEHAVIORAL & ENVIRONMENT: Poor Nutrition Late Prenatal care DEMOGRAPHIC DATA: MATERNAL AGE 35

50. MATERNAL STRESS (Genital infections, Maternal factors/ Systemic Disease) FETAL STRESS (Uteroplacental insufficiency) FETAL STRESS (Uteroplacental insufficiency) Activation of maternal HPA axis Activation of fetal HPA axis ACTH Adrenocorticotropic hormone CORTISOL ADRENAL DHEAS PLACENTA MEMBRANES ESTROGEN  MYOMETRIAL Oxytocin Receptors, Prostaglandins, Myosin Light Chain Kinase, calmodulin, gap junctions RUPTURE OF MEMBRANCES CRH PROSTAGLANDINS CERVICAL CHANGE CONTRACTIONS DECIDUA PLACENTA MEMBRANES  COX-2 IN  PGDH IN    AMNION CHORION 

51.  Vaginal Examination  Transvaginal Cervical Ultrasound  Clean-catch Urine For Culture, Vaginal And Cervical Culture  Fetal Fibronectin (Ffn)  External Fetal Heart Monitor or Cardiotocogram  Fetal Ultrasound  Amniocentesis

52.  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

53. 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.

54. 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.

55. MANAGEMENT  Early Education  Prevention  Limiting Neonatal Morbidity

56. 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.

57. 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

58. Tocolytic Therapy AgentMechanism of Action DoseSide-effectsNursing Action NifedipineCalcium Channel Blocker 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

59. Other Tocolytic Drugs which are not used due to Maternal/Fetal adverse Effect MedicationMaternal/Fetal Side-effects Terbutaline /Bricanyl B2 Adrenergic Receptor Agonist PULMONARY EDEMA is a well-documented complication, usually associated with aggressive intravenous hydration. Indomethacin Prostaglandin Inhibitor Decrease fetal urine output resulting in Oligohydramnios & Premature close of fetal ductus arteriosus which result to fetal pulmonary Hypertension. Atosiban Oxytocin Inhibitor Nausea was significantly increased after injection administration.

60. Antibiotic Therapy AntibioticDose AmpicillinLoading: 2gram IV Maintenance: 1 gram IV Q6 for 48hours Erythromycin250mg Q6 until 10 days

61. 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

62. Acceleration of Fetal Maturity AgentMechanism Of Action DoseSide-effectsNursing Implications DexamethasoneCorticosteroid To hasten fetal lung maturity 12mg IM Q12 x 2 doses irritation at the injection site, tachycardia  Explain the purpose of the drug  Monitor v/s and fetal heart rate Postponing delivery for administration is an option because it takes about 24 hours for the Dexamethasone to have an effect. The effect last approximately 7 days.

63. Acceleration of Fetal Maturity

64. Complications Prematurity and associated neonatal complications, such as lung immaturity:  Intraventricular Hemorrhage (IVH)  Respiratory Distress Syndrome (RDS)  Patent ductus arteriosus (PDA)  Necrotizing enterocolitis (NEC)

65. Complications of Preterm Labor Premature Labor can’t be halt will lead to Preterm Delivery

66. PRIORITIZATION OF NURSING PROBLEMS 1. Risk for injury maternal/fetal related to preterm labor and tocolytic therapy. 3. Activity intolerance related to prescribed bed rest or decreased activity secondary to threat to preterm labor 2. Deficient Knowledge: Preterm labor Prevention related to unfamiliarity with Preterm Labor signs/symptoms and prevention)

67. PRIORITIZATION OF NURSING PROBLEMS 4. Deficient Diversional activity related to inability to engage in usual activities secondary to attempts to avoid PTL & PTB 6. Anticipatory grieving related to preterm labor and birth 5. Anxiety related to medication and fear of outcome of pregnancy

68. PRIORITIZATION OF NURSING PROBLEMS 7. Risk for Complications secondary to tocolytic therapy 8. Compromised Family Coping secondary to hospitalization

70. ASSESSMENT NURSING DIAGNOSIS GOALS & DESIRED OUTCOME NURSING INTERVENTION RATIONALEEVALUATION 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 Risk for Injury maternal /fetal related to preterm labor and tocolytic therapy. Within 12 hours of nursing intervention, patient’s contraction halt after treatment with tocolytic and fetal heart rate remains within acceptable parameters. 1. Positioned patient on left side as much as tolerated. Change to right side if client becomes uncomfortable – avoid supine position. 2. Explain all procedures and equipment to patient and significant other. 3. Attached external fetal heart rate monitors for continuous evaluation of contractions and fetal response. Position facilitates uteroplacental perfusion. Client and significant other may be experiencing high anxiety and need repeated explanation. Uterine and fetal monitoring provides evidence of fetal well- being. After 12 hours of nursing intervention, the goal was fully met as evidenced by: Cessation of uterine contraction after treatment with tocolytic. Fetal heart rate remains within acceptable parameters.

71. ASSESSMENT NURSING DIAGNOSIS GOALS & DESIRED OUTCOME NURSING INTERVENTIONRATIONALE EVALUATION 4. Made contact with ultrasound personnel as per doctors order. 5.Extracted blood for laboratory studies such as CBC. Obtained clean-catch urine for culture, vaginal and cervical culture. 6. Inserted IV line and begin IV fluid therapy as doctors’ order. 7.Administered betamethasone as prescribed. An ultrasound can document fetal health and cervical dilation. Assessment provides a baseline for future comparison. IV fluid improves hydration, which may help to minimize contractions. This synthetic cortisol can accelerate fetal lung maturity by stimulating surfactant production.

72. ASSESSMENT NURSING DIAGNOSIS GOALS & DESIRED OUTCOME NURSING INTERVENTIONRATIONALE EVALUATION 8. Administer antibiotics, as indicated. 9. Initiate tocolytic therapy, as ordered. 10. Checked patient’s vital signs closely, every 15 minutes. Assessed for chest pain and dyspnea. 11. Checked fetal heart rates and pattern. In the event of PROM, antibiotics may be used to prevent/reduce risk of infection. Helps reduce myometrial activity to prevent/delay early delivery. Maternal pulse over 120 beats per minute or persistent tachycardia or tachypnea, chest pain, dyspnea, or adventitious breath sounds may include impending pulmonary edema. Fetal tachycardia or late or variable decelerations indicate possible uterine bleeding or fetal distress, which requires emergency birth.

73.  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.

74.  Teach the patient the signs and symptoms of infection and to report them immediately.  When preterm labor occur:  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  Empty bladder to relieve pressure on the uterus

75.  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)

76.  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.

77.  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.

78.  Wolters Kluwer & Lippincot Williams & Wilkins. Lippincot Manual of Nursing Practice, 9 th edition, page 1330-1333, 2010.  Pillitteri, Adele. Maternal & Child Health Nursing, 3rd ed.Philadelphia: Lippincott, 1999.  http://en.wikipedia.org/wiki/