Primary Nursing Diagnosis

Fear related to uncertainty of outcome and complexity/effects of treatments OUTCOMES. Fear control; Anxiety control; Comfort level; Coping

INTERVENTIONS. Labor suppression; High-risk pregnancy care; Security enhancement; Resuscitation: Fetus

H PLANNING AND IMPLEMENTATION Collaborative

The goals of treatment are to stop the contractions and to prevent the cervix from dilating, thereby avoiding delivery until at least 34 weeks. Once the cervix reaches 4 cm in dilation, treatment is stopped and the delivery is allowed to occur. Ideally, delivery is in a hospital with the expertise necessary to treat a preterm neonate.

Although the first strategies often employed to halt PTL, bedrest, hydration, and sedation are not supported in the literature as effective means of stopping PTL. Intravenous (IV) fluids, usually a crystalloid such as lactated Ringer's solution and a sedative if the patient is anxious, are used. Terbutaline sulfate is often given subcutaneously, along with hydration. If the contractions stop and the labor is not progressing, patients are discharged home on complete bedrest. Home monitoring of uterine contractions with transmission of data to the physician is possible. Also, patients may be discharged with a terbutaline pump, which infuses 3 to 4 mg of

774 Preterm Labor terbutaline subcutaneously each day; evidence of the effectiveness of use of the pump is being evaluated.

If labor continues, IV medications are indicated. Tocolysis (inhibition of uterine contractions) is contraindicated in cases of maternal infection, pregnancy-induced hypertension, hypovolemia, and fetal distress. During the initial period of infusion of beta-adrenergic drugs, auscultate the patient's lungs for rales and rhonchi; observe for dyspnea and chest discomfort; determine the fetal heart rate, maternal pulse, blood pressure, and respiratory rate; and monitor the status of contractions every 10 minutes. Fluid restriction, accurate monitoring of intake and output, and daily weights are indicated to monitor fluid balance.

Administer glucocorticoids concurrently with tocolytics. The incidence of respiratory distress is lower if the birth is delayed for at least 24 hours after the initiation of glucorticoids; The effect on the lung maturity persists for 1 week after the therapy is completed. If glucocorticoids are administered concurrently, monitor the patient for signs and symptoms of pulmonary edema. If magnesium sulfate is used for tocolysis, closely monitor deep tendon reflexes; hyporeflexia occurs if the patient is becoming toxic and precedes respiratory depression. If tocolysis is successful, and contractions are under control, the infusion is discontinued by gradually decreasing the rate and converting to oral administration.

Monitor the fetal heart rate variability and for the absence or presence of accelerations and decelerations. If signs of fetal stress occur, turn the patient on her left side, increase the rate of the IV hydration, administer oxygen at 10 L/min per mask, and notify the physician.

Delivery of the preterm infant can be done vaginally or by cesarean. The decision for the method of delivery is often made jointly by the physician, neonatologist, and parents. If the fetus is very premature, often the neonatologist suggests a cesarean to prevent trauma to the fetal head and an increased risk of intraventricular hemorrhage.

Pharmacologic Highlights

There are no

"first-line" drugs to treat PTL; rather, individual patient conditions and

physician preference dictate the treatment. Ritodrine, formerly the only drug approved

by the Food and Drug Administration (FDA) to treat PTL had been withdrawn from the

U.S. market by Its manufacturer.

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