Submitted by:Kristine Anne Soriano

PRETERM BIRTH
Dx: LIVE PRETERM BABY DELIVERED NSD Baby Girl M

Introduction
Background of the study
Preterm birth is a major challenge in perinatal health care. Most perinatal deaths occur in preterm infants, and preterm birth is an important risk factor for neurological impairment and disability. Preterm birth not only affects infants and their families providing care for preterm infants, who may spend several months in hospital, has increasing cost implications for health services. Preterm birth -refers to the birth of a baby of less than 37 weeks gestational age. The cause for preterm birth is in many situations elusive and unknown; many factors appear to be associated with the development of preterm birth, making the reduction of preterm birth a challenging proposition. Premature birth -Commonly used as a synonym for preterm birth, refers to the birth of a baby before the developing organs are mature enough to allow normal postnatal survival. Premature infants are at greater risk for short and long term complications, including disabilities and impediments in growth and mental development. Significant progress has been made in the care of premature infants, but not in reducing the prevalence of preterm birth. Preterm birth is the major cause of neonatal mortality in developed countries. SIGNS AND SYMPTOMS: Symptoms of imminent spontaneous preterm birth are signs of premature labor; one sign is four or more uterine contractions in one hour. In contrast to false labor, true labor is accompanied by cervical dilatation and effacement. Also, vaginal bleeding in the third trimester, heavy pressure in the pelvis, or abdominal or back pain could be indicators that a preterm birth is about to occur. A watery discharge from the vagina may indicate premature rupture of the membranes that surround the baby. While the rupture of the membranes may not be followed by labor, usually delivery is indicated as infection (chorioamnionitis) is a serious threat to both fetus and mother. In some cases the cervix dilates prematurely without pain or perceived contractions, so that the mother may not have warning signs until very late in the birthing process. The shorter the term of pregnancy, the greater the risks of mortality and morbidity for the baby primarily due to the related prematurity. Causes As the cause of labor still remains elusive, the exact cause of preterm birth is also unsolved. In fact, the cause of 50% of preterm births is never determined. Labor is a complex process involving many factors. Four different pathways have been identified that can result in preterm birth and have considerable evidence: precocious fetal endocrine activation, uterine over distension, decidual bleeding, and intrauterine inflammation/infection. Activation of one or more

of these pathways may happen gradually over weeks, even months. From a practical point a number of factors have been identified that are associated with preterm birth, however, an association does not establish causality. Factors associated with preterm delivery Sociobiologic variables Maternal age (adolescence, advanced maternal age) Parity Maternal size (short stature, low weight) Low socioeconomic status Smoking, drug abuse Environmental stress Past obstetric history Prior preterm birth Prior spontaneous abortion Prior therapeutic abortion Cervical incompetence Maternal genital abnormality Preterm pre labor rupture of the membranes (PPROM) Medically assisted conception Late or no antenatal care Maternal infection A symptomatic bacteruria Pyelonephritis Genital infections Syphilis, gonorrhea, chlamydia Group B streptococcal infection Bacterial vaginosis Urea plasma urealyticum, mycoplasma hominis, trichomonas vaginalisrelationship to preterm labor or PPROM controversial Other systemic infections (e.g. pneumonia, malaria, typhoid fever) Abdominal surgery Maternal trauma Polyhydramniosis Fetal malformation Male sex

Complications of the current pregnancy Elective preterm birth (preeclampsia, eclampsia, isoimmunisation, placenta previa,abruption) Multiple gestation Antepartum hemorrhage Prevention Current medical approaches to preventing preterm labour include the use of tocolytic drugs, antibiotic treatment, andcervical cerclage.

OBJECTIVES:
At the end of the study the students will be able: To define preterm birth /premature birth To enumerate possible factors that causes risk, Signs and symptoms of preterm birth

History

DOCTORs IMPRESSION: born preterm delivered via NSD from 17 years old G1P0 29 5/7 weeks NURSING HISTORY PATIENTS NAME: BB. GIRL M PRETERM BABY GIRL DELIVERED VIA NSD TIME-OUT: 11:33AM APGAR SCORE: 9.9 BALLARDs SCORE: 29 TEMPERATURE: 36.5 C WEIGHT: 1.5 kg LENGTH: 42cm DIAGNOSIS: DATE: NOVEMBER 16, 2011

*Administered Vitamin K and Erythromycin ophthalmic ointment both eyes First Meconium: 4:00 A.M 11-17-11 First void: 11:33P.M 11-16-11

MEDICAL INTERVENTIONS:
DRUG STUDY: Doctors ordered meds Medications Dose, route Indications for use Possible side effects Nursing responsibilities

Ampicillin

75 mg IV q 12

Intra-abdominal, gynecologic, and skin-structure infections caused by susceptible betalactamase-producing strains

Check patient's Lethargy, vein temperature and irritation, watch for other thrombophlebitis, signs and heart failure symptoms. ,apnea, diaphoresis anaphylaxis, serum Monitor CBC and liver function sickness test results. Ototoxic and nephrotoxic manifestations. Check for irritation

Gentamycin

8 mg IV OD

For infection Nutritional supplement for optimum growth & development.to improve protein synthesis. Prevention and treatment of iron deficiency anemias. Dietary supplement for iron. Respiratory stimulant in CheyneStokes respiration; treatment of apnea and bradycardia in premature babies. Symptomatic relief or prevention of bronchial asthma and reversible bronchospasm associated with chronic bronchitis and emphysema

Multivitamins

0.3ml OD

No common side effects

Check color of stool

FeSO4

0.5ml OD

anaphylactic reactions,

Monitor daily pattern of bowel activity and stool consistency. Expect stools to darken in color

Aminophylline

1.2 mg IV9 12

Irritable,flushing

Assess Bowel sounds and normal output

Medications

Dose, route

Indications for use

Possible side effects

Nursing responsibilities

Dolan (ibuprofen)

100 mg/25ml Give 0.15cc per orem

fight against fever, pain and inflammation

shortness of breath, Monitor V/S stomach upset, others being vomiting, headache, indigestion, allergic rashes and diarrhea

Lanoxin Elixir

0.05 mg/ml Give 0.1cc q 12 per orem

is used to treat congestive heart failure

fast, slow, or uneven heart rate

Check laboratory data

Furosemide

1.5 mg ptab 2x a day per orem

For heart failure, kidney /liver

fast or uneven heartbeat

Monitor RR & PR Watch out for levels of potassium electrolyte level to prevent hyperkalemia. Observe 10 rightsof givingmedication Watch out for possible adversereaction of the patient

Potassium chloride

1 me 3x a day per orem

hypokalemia

Diarrhea,nausea ,stomach pain,discomfort or gas vomiting

D10W Dextrose 10% in water D5IMB Ionosol MB and Dextrose 5%

100cc/sol

used to supply water and calories to the body. infants for treatment of dehydration, acidosis, diarrhea, and burns.

Fever ,swelling

Monitor V/S

100cc

Hypervolemia,veno Monitor IV level and Vital signs us thrombosis

Laboratory Data

Prenatal Tests

Norms

Patient Results 11-16-11

Patient Results 12-02-11

Type & Rh Hematocrit & Hemoglobin

A, B, AB, O, +, F=0.37-.042 M=0.42-0.48 F=125-165g/L M=130-180g/L

AB & + 0.50 174 8.3x10+9/L 318 x10+9/L 0.44 0.53 .03 0 0 0.50 167 17.6x10+9/L 238 0.26 0.53 0.05 0 0

WBC Platelet Neutrophils Lymphocytes Monocytes Eosinophils Stab

4.5-11 x10+9/L 150-400 x10+9/L 0.36-0.66 0.22-0.40 0.04-0.08 0.01-0.04 0

XRAY IMPRESSION: Hyperaeated lungs No focal airspace disease Heart not enlarged Hemi diagraph &sulci are intact Intact bone thorax 11-17-11 No growth 5 days incubation

CONCEPT MAPPING

PATHOPHISIOLOGY Preterm birth has usually been treated as a single entity, for epidemiological and statistical purposes. This traditional empiric approach, however, presupposes a single pathologic process for which treatment could be uniform. This approach has met with only limited success in the treatment and prevention of preterm labor. It is now clear that the causes of preterm labor are multifactorial and vary according to gestational age. Important common pathways leading to preterm birth include stress, systemic or maternal genital tract infections, placental ischemia or vascular lesions, and uterine over distension. These pathways differ in their initiating factors and mediators, but ultimately, they share many common features that result in preterm uterine contractions and birth. Appropriate animal models have been very useful in describing the temporal events leading to preterm birth and the neonatal sequelae of prematurity, particularly in the setting of intrauterine infection. The use of animal models to answer specific questions related to prematurity and to describe the pathophysiological events associated with preterm birth will contribute to the development of rational and efficacious treatment and prevention strategies for preterm birth. Preterm birth pathophysiological mechanisms There are several pathophysiological factors that may trigger the events leading to preterm birth. Maternal stress/release of corticotropin releasing hormone (CRH) (1), uterine over distension (multiple pregnancy, polyhydramniosis), lack of prostaglandin dehydrogenase (2), hemorrhage (3)

infections (4) Infection seems to be the most important etiology in early gestation (4), whereas over distension and maternal stress play more important roles at later gestation These factors can act individually or in various combinations to induce uterine contractions (through production of prostaglandins, endothelin, increase the estrogen/progesterone balance increased density of oxytocin receptors or gap junctions) (5-8); by promoting cervical maturation (activation of proteolytic enzymes in the cervical tissue through interleukin-8 triggered neutrophil activation) by inducing proteolytic degradation of adhering proteins between the chorion and the decidua with subsequent release of fetal fibronectin); by rupture of the membranes (apoptosis of cells in the chorioamniotic membranes and breakdown of extracellular collagen and mucopolysacccharides). During recent years infectionrelated preterm has been recognized as an important etiology. There is a strong correlation between intra amniotic cytokine-mediated inflammation and preterm delivery both in PTL and PPROM patients (4,9). Furthermore, the risk of neonatal neurologic morbidity seems to be higher in spontaneous preterm birth (often related to infections) compared to indicated delivery related to maternal or fetal complications. Verma et al. (10) demonstrated that the occurrence of periventricular/intra ventricular hemorrhage or periventricular leukomalacia was much high subsequent to PTL (17%) or PPROM (14%) compared to after physician-initiated preterm delivery (0.5%) and the difference persisted after correction for differences in gestational age. According to some studies, there is also a strong

correlation between the degree of cytokine elevation in the amniotic fluid in women with preterm labor and the subsequent occurrence of white matter injury and cerebral palsy in the offspring (11). Therefore, it seems particularly urgent to understand more about infection-related preterm birth to develop preventive and therapeutic strategies (12).

NURSING CARE PLAN:

CUES/DATA Objective: Patient is on phototherapy Dry skin Patient in supine position Has no clothes on during phototherapy, only mittens, socks, and diapers Has eye cover during phototheraphy

NURSING DIAGNOSIS Risk for Impaired skin integrity related to exposure to high intensity light secondary to phototherapy

RATIONALE The newborn lies in one position for a long period of time that may result in skin breakdown. Due to lack of adipose tissue, the pressure exerted by bony prominences on the skin is greater thus increases the risk of skin breakdown

GOALS/EXPECTED OUTCOMES After 8 hours of nursing intervention 1. Patients skin will remain intact No signs of skin breakdown

NURSING INTERVENTION INDEPENDENT: change position every 2 hours Monitor skin for rashes and bronzing every 8 hours Inspect perianal area after each diaper change for signs of breakdown NURSING INTERVENTION INDEPENDENT: (1) assess RR and pattern (2) provide respiratory assistance as needed (oxygen hood) (3) position infant on side with a rolled blanket behind his back (4) provide tactile stimulation during periods of apnea

EVALUATION

After 8 hours of nursing intervention, goal is fully met. Patients skin remained intact as evidenced by: No signs of skin breakdown

NURSING CUES/DATA DIAGNOSIS Subjective: n/a Objective: -Preterm birth (29 5/7 weeks) -RR:58 cycles/ min -Episodes of apnea -place Oxygen hood Ineffective breathing pattern related to immature neurologic and delayed pulmonary development

RATIONALE A premature lung is structurally under developed for postnatal life. To add, the premature delivery and the inadequate pulmonary surfactant. A deficiency in surfactant, which functions to decrease the surface tension within the alveoli. Without surfactant, the infant experiences diffuse atelectasis, decreased pulmonary compliance, ventilation

GOALS/EXPECTED OUTCOMES After 30 minutes of nursing interventions, the infant will experience an effective breathing pattern as manifested by -Infants RR is between 40 and 60 -Infant will experience no apnea

EVALUATION After 30 minutes of nursing interventions, goal is partially met, the infant experienced an effective breathing pattern as manifested by -Infants RR was between 40 and 60 -Infant experienced less episodes of apnea.

DISCHARGE METHOD:
Immediate care of the preterm infant Assessment and resuscitation Dry and warm oropharyngeal suction Maintain patent airway oxygen Establish effective ventilation -facemask orendotracheal intubation Chest compression Drugs Care in the early newborn period The first week after birth is a time of major metabolic and physiological adaptation for newborn infants. Preterm infants have to cope with additional stresses because most of their organ systems are immature or because of associated illnesses, such as congenital infection. Very preterm infants (< 32 weeks gestation) or ill infants often need intensive monitoring and support during this critical period of postnatal adaptation Temperature control and fluid balance & maintaining the neutral thermal environment.

CONCLUSION:
The use of caution with the terms used and attention to their definitions is essential in efforts to understand the causes and consequences of preterm birth. It is important to recognize the limitations and variations in the data collected and entered into large administrative and research public health databases. Every effort should be made to improve the quality of national vital records, especially data on the gestational ages of newborns and the rates of preterm births. Uniform data collection and reporting procedures facilitate comparisons among states, over time, and with data from other countries. The impact of early dating of gestational age by ultrasound on clinical factors such as labor, tocolysis, administration of medicines, timing of elective induction of labor, determination of the mode of delivery, in utero transport, delivery room resuscitation, and determination of adequacy of fetal growth should be evaluated. Professional societies should encourage the routine use of early (before 20 weeks gestation) ultrasound for the establishment of gestational age. Standards of practice and recommendations for training of personnel to improve the reliability and the quality of ultrasound data should be established.