Premature or preterm labor is described as early labor occurring before 37 weeks gestation. While preterm labor does not necessarily result in a preterm birth, immediate medical attention is needed to prevent complications.
If preterm labor results in preterm delivery, the baby will be born premature and may have serious health problems like underdeveloped lungs, vision or hearing loss, cerebral palsy, behavioral issues, and learning disabilities.
Preterm labor can be diagnosed through a cervical examination. If the cervix has become effaced and dilated, the pregnant patient is in preterm labor. Early intervention can help stop and prevent premature birth.
In this article:
Nursing Process
Preterm labor does not necessarily lead to preterm birth. To prevent this, immediate interventions must be initiated. Nurses play a vital part in administering medications, monitoring the status of the mother and fetus, and providing emotional support.
Medications like tocolytics and magnesium sulfate are prescribed to stop the contractions and delay delivery. If the labor has progressed and is imminent, corticosteroids are given to help improve fetal lung maturity.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to preterm labor.
Review of Health History
1. Assess for warning signs of preterm labor.
Warning signs of preterm labor include:
- Constant lower backache
- Persistent and severe contractions occurring every 10 minutes or more
- Vaginal spotting
- Pelvic pressure
- Premature rupture of membranes
- Change in vaginal discharge
2. Determine the patient’s risk.
Several factors can cause preterm labor:
- High-risk pregnancy
- Chronic health conditions (hypertension, diabetes)
- Previous preterm labor or birth
- Smoking
- Obesity
- Maternal age (younger or older)
- Inconsistent prenatal care
- Polyhydramnios
- Stressful life events
3. Collect a detailed obstetric history.
Obstetric history that may trigger preterm labor includes:
- History of preterm deliveries
- Placental abruption
- Stretching of the uterus from multiple babies (twins, triplets, or more)
- Excessive amniotic fluid (polyhydramnios)
- Cervical incompetence
- Uterine abnormality
- Hormonal changes
- Sexually transmitted diseases or bacterial vaginosis
4. Review the patient’s medical history.
Check for conditions that may cause uteroplacental insufficiency, such as:
- Hypertension
- Insulin-dependent diabetes
- Drug abuse
- Smoking
- Alcohol consumption
5. Determine psychosocial factors causing maternal stress.
Chronic maternal stress alters the body’s blood circulation, hormone levels, and capacity to fight illness over the long term and has the potential to cause labor to begin prematurely. Assess for social stressors like unstable housing or food insecurity, social support from family, financial concerns, partner violence, and drug use.
6. Note for any infection during pregnancy.
The cause of at least 40% of premature deliveries is intrauterine infection. A significant number of premature births are caused primarily by infection and inflammation.
7. Monitor contractions.
The nurse must recognize true contractions from Bracton-Hicks contractions. Braxton-Hicks contractions are irregular and frequently stop upon movement and change in position.
Physical Assessment
1. Monitor the maternal vital signs and fetal heart rate.
Close monitoring of maternal vital signs and fetal heart rate is essential to monitor the status of mom and baby. Fetal distress or unstable maternal vital signs may warrant preterm delivery.
2. Assess for uterine contractions.
Assessment of a patient in labor measures the duration, intensity, and frequency of uterine contractions.
3. Palpate the abdomen.
Evaluate abdominal pain and tenderness, fetal size, and position through palpation.
4. Perform a cervical exam.
A cervical exam assesses asymptomatic cervical dilatation and effacement.
Diagnostic Procedures
1. Visualize the cervix.
The range for cervical length is 35 to 48 mm. A short cervix is less than 25 mm in length between 16 and 24 weeks of pregnancy. A transvaginal ultrasound can assist in differentiating between cervical effacement brought on by cervical insufficiency and preterm active labor.
2. Monitor lab studies.
Laboratory testing for risk assessment in patients with a history of midterm loss includes the following:
- Rapid plasma reagin test
- Anticardiolipin antibody
- Lupus anticoagulant antibody
- Activated partial thromboplastin time
- One-hour glucose challenge test
- Vaginal pH/wet smear/whiff test
- Gonorrheal and chlamydial screening
- TORCH (toxoplasmosis, other infections, rubella, cytomegalovirus infection, herpes simplex)
- Immunoglobulin G and immunoglobulin M screening
3. Send a fFN sample.
Before performing a pelvic cervical examination, collecting a vaginal fetal fibronectin (fFN) sample may be recommended if preterm labor is suspected but not yet confirmed. Fetal fibronectin is not found between 22 to 35 weeks gestation, so its presence is a sign that the amniotic sac is disturbed.
4. Assess for PPROM.
Preterm premature rupture of membranes (PPROM) can be assessed by testing the pH of vaginal secretions. PPROM increases the risk of infection.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions related to preterm labor.
Manage the Labor
1. Manage according to the age of gestation.
The gestational age at which the mother arrives at the hospital determines the management strategy.
- If a mother exhibits premature labor at > 34 weeks gestation, she is admitted for observation. If cervical dilation and effacement do not progress after several hours and the fetus is not in distress, she can be sent home with instructions to follow up in 1-2 weeks.
- Hospitalization is recommended for mothers with premature labor symptoms and signs at 34 weeks gestation or less.
2. Administer tocolytics as ordered.
Tocolytic medications (magnesium sulfate, indomethacin, nifedipine) may be used for up to 48 hours to delay labor so corticosteroids can be administered.
3. Administer magnesium sulfate cautiously.
Magnesium sulfate is typically given to prevent seizures in patients with preeclampsia but is used off-label for preterm labor for neuroprotection. The nurse should monitor the mother for signs of toxicity, including:
- Respiratory depression
- Loss of deep tendon reflexes
- Hypotension
- Hypothermia
- Oliguria
- Confusion
4. Anticipate emergency delivery.
Pregnancy cannot be continued long enough to allow for additional intrauterine growth and maturation once membranes rupture. Hospital admission, administration of medications, and possible emergency childbirth are necessary to save the mother and the baby.
5. Administer corticosteroids.
Antenatal corticosteroids like betamethasone are administered between 23-34 weeks of gestation to support fetal lung maturity when delivery is imminent.
6. Anticipate cervical cerclage for patients with cervical concerns.
Cervical cerclage is when the cervix is sutured closed to prevent preterm labor and is not recommended for all patients but may prove beneficial when a woman has been diagnosed with cervical insufficiency or has a history of recurrent mid-trimester losses.
7. Create a birth plan with the patient.
There may or may not be delivery after preterm labor. Involving the patient in the planning process and offering options (if appropriate) can assist the patient in preparing for delivery.
Prevent Preterm Labor
1. Avoid illegal or harmful substances.
Advise the patient to avoid using recreational drugs, alcohol, tobacco, or unprescribed medications.
2. Gain or lose weight as indicated.
Before pregnancy, the patient may need to lose weight to decrease the risk of maternal complications. Some patients may need to be advised on appropriate weight gain while pregnant. Instruct on dietary intake while pregnant.
3. Manage stress.
Encourage the patient to seek strategies to lessen or control their stress during pregnancy. Engage in daily exercise, relaxing hobbies, and self-care. Encourage therapy or support groups if struggling with emotional or psychosocial issues.
4. Recommend prenatal and dental care.
It is crucial to attend every prenatal appointment to monitor the progress of the pregnancy and look for any factors that may trigger preterm labor. Patients should also be advised on dental hygiene and completing dental check-ups, as studies show that gum disease is linked to preterm labor.
5. Treat the underlying conditions.
Underlying conditions may cause preterm labor by interrupting the circulation of blood between the mother and the baby. Address and manage any medical comorbidities, such as:
- High blood pressure
- Gestational diabetes
- Vaginal infections
6. Advise on progesterone supplements as ordered.
Progesterone, administered vaginally or parenterally, has been shown to reduce the incidence of preterm birth in patients who are at high risk for preterm delivery.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for preterm labor, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for preterm labor.
Acute Pain
Premature labor causes cramping in the abdomen and low, dull backache that may be constant.
Nursing Diagnosis: Acute Pain
Related to:
- Uterine contractions
As evidenced by:
- Reports of pain
- Expressive behavior
- Guarding behavior
- Facial grimacing
- Protective behavior
- Reports pain intensity
- Distraction behavior
- Positioning to reduce discomfort
- Muscle tension
Expected outcomes:
- Patient will report relief from contractions.
- Patient will demonstrate interventions to help reduce contractions and discomfort.
Assessment:
1. Conduct a comprehensive pain assessment.
Lower back pain is common in pregnancy, but pain that becomes severe and constant may be a sign of preterm labor. Abdominal contractions that are strong and persistent are also a concern.
2. Assess and monitor uterine contractions.
The nurse must assess if the contractions are Braxton Hicks contractions or true labor pains. Braxton Hicks contractions are irregular, mild, and localized to the lower abdomen. True labor pains are intense, regular, and become more painful over time.
Interventions:
1. Place the patient in a lateral recumbent position.
A lateral recumbent position promotes patient comfort and placental blood circulation by increasing venous return.
2. Encourage relaxation techniques.
Anxiety from preterm labor can aggravate the patient’s discomfort. Relaxation techniques like deep breathing and meditation can calm the patient and significantly reduce pain.
3. Encourage comfort measures.
A patient in pain due to premature uterine contractions can greatly benefit from comfort measures like a heating pad or massage to reduce pain.
4. Reduce strenuous activity.
While strict bedrest is not recommended, reducing strenuous activities can reduce premature uterine contractions, promote comfort, and further delay the early delivery of the baby.
Anxiety
Anxiety in pregnancy is common and expected when experiencing preterm labor.
Nursing Diagnosis: Anxiety
Related to:
- Disease process
- Situational crisis
- A perceived threat to the fetus and self
- Conflict about life goals
- Unfamiliar situation
As evidenced by:
- Altered attention
- Preoccupation
- Confusion
- Expresses tension
- Increased blood pressure
- Increased heart rate
- Crying
- Inability to concentrate
- Expresses insecurity
- Expresses distress
- Fidgeting
- Helplessness
Expected outcomes:
- Patient will demonstrate interventions that can reduce anxiety.
- Patient will verbalize understanding of the current situation and adhere to the plan of care.
Assessment:
1. Assess the patient’s level of anxiety and outward expression.
Stress and anxiety cause changes in the body’s vascular system and hormone levels, potentially influencing early labor and delivery. Ask the patient how they are feeling regarding their current status. Monitor for signs of increasing distress, such as vital sign changes, restlessness, or shaking.
2. Assess for a history of mental health problems.
Stressful events can cause preterm labor. Assess for a history of anxiety, depression, or other possible psychiatric illnesses that could exacerbate the patient’s current status.
Interventions:
1. Educate the patient about the management of preterm labor.
A better understanding of what is happening and interventions performed can reduce the patient’s anxiety and promote adherence to the treatment regimen.
2. Build a therapeutic relationship.
The nurse is often a source of emotional support for the mother and can create a healthy and safe environment. Remain calm and professional to keep the patient’s anxiety low.
3. Encourage the patient to use relaxation techniques.
Relaxation can significantly reduce anxiety levels, especially for those experiencing preterm labor. Instruct on breathing techniques, and create a calming environment through soothing music, back rubs, and dim lighting.
4. Provide honest and accurate answers about the situation.
This will help the patient and family understand what is happening and significantly reduce stress and anxiety.
5. Assist the patient in planning for delivery.
Preterm labor may or may not result in delivery. Allowing the patient to be a part of the planning and providing choices (if applicable) can help prepare the patient in case delivery is imminent.
Risk for Decreased Cardiac Output
During preterm labor, the patient’s heart rate and blood pressure can drastically change, which places additional strain on the heart. Possible bleeding during early childbirth can further decrease cardiac output.
Nursing Diagnosis: Risk for Decreased Cardiac Output
Related to:
- Disease process
- Alterations in blood pressure
- Bleeding
- Altered contractility
- Altered heart rate
- Altered heart rhythm
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will maintain vital signs within normal parameters.
- Patient will not experience dysrhythmias.
Assessment:
1. Assess the patient’s vital signs.
Preterm labor and its associated symptoms can cause alterations in the patient’s vital signs. Assessing and monitoring vital signs can help identify complications and develop prompt interventions.
2. Assess fetal status and fetal heart rate.
The baby’s status must be assessed and monitored to determine appropriate interventions and the need for an emergency delivery. Fetal distress may be caused by compromised maternal cardiac output, circulatory problems, and insufficient uteroplacental perfusion.
3. Obtain the patient’s medical history.
A detailed medical history must be obtained to determine patients in preterm labor who are at risk for developing compromised cardiac output. Patients with a history of cardiac problems are at higher risk of developing decreased cardiac output during preterm labor.
Interventions:
1. Monitor the patient for any signs of bleeding.
Preterm labor can cause bleeding, significantly decreasing central venous pressure and cardiac filling, reducing cardiac output.
2. Place the patient in a side-lying lateral position.
The left side-lying lateral position promotes uteroplacental perfusion and optimal cardiac output in patients who are in preterm labor.
3. Administer supplemental oxygen as indicated.
An alteration in oxygen saturation can indicate decreased cardiac output. Administering supplemental oxygen to a patient who is in preterm labor ensures organ and placental perfusion.
4. Administer tocolytics with caution.
Tocolytics are administered to delay contractions and delivery but carry side effects of tachycardia, myocardial ischemia, and arrhythmias. Use caution and monitor vital signs and EKG closely.
Risk for Injury
Preterm labor can increase the risk of injury to the patient and baby. If delivery cannot be stopped, the preterm infant can have health complications and birth injuries. Premature babies will require special care in the neonatal intensive care unit.
Nursing Diagnosis: Risk for Injury
Related to:
- Disease process
- Early labor and delivery
- Delivery of premature infant
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will adhere to the treatment regimen and reach at least 37 weeks gestation.
- Patient will deliver a preterm infant without any complications.
Assessment:
1. Assess the progression of preterm labor.
Assessing cervical opening and uterine contractions can determine if interventions to prevent early delivery are possible.
2. Assess fetal heart rate and any notable changes in fetal movement.
This will help determine the fetus’s condition inside the uterus. An increase or decrease in fetal heart rate can indicate fetal distress and may require an emergency cesarean delivery.
Interventions:
1. Educate the patient about interventions that can help prevent the progression of preterm labor and early delivery.
When the patient knows and understands what is happening, she will be more likely to adhere to the interventions and treatment regimen.
2. Administer tocolytics as indicated.
Medications like magnesium sulfate and other tocolytics can help reduce uterine contractions.
3. Encourage bed rest.
If hospitalized, bed rest may be prescribed to reduce pressure on the cervix and slow preterm delivery. The mother should only get up to go to the bathroom. Blood clots are a concern with bed rest so ensure sequential compression devices are on the lower legs while in bed.
4. Administer steroid therapy as needed.
Steroids may be provided to help reduce respiratory distress syndrome, necrotizing enterocolitis, and neonatal death in premature infants, as this drug can enhance the formation of surfactant in the fetal lungs.
Situational Low Self-Esteem
Low self-esteem may occur in response to preterm labor. The process can be a traumatic experience for the patient, with notable feelings of helplessness, fear, and guilt.
Nursing Diagnosis: Situational Low Self-Esteem
Related to:
- Decrease in environmental control
- Difficulty accepting alteration in the perceived role
- Powerlessness
- Unrealistic self-expectations
- Feeling responsible for preterm labor
As evidenced by:
- Depressive symptoms
- Helplessness
- Expresses loneliness
- Indecisive behavior
- Self-negating verbalizations
Expected outcomes:
- Patient will openly discuss any feelings of guilt or poor self-worth.
- Patient will express a positive outlook and self-appraisal by discharge.
Assessment:
1. Assess for a history of preterm labor.
A history of preterm labor, especially with the most recent pregnancy, increases the risk of future preterm labor. If the patient is unaware of this, they may feel immense responsibility for causing their preterm labor.
2. Assess the patient’s self-esteem and coping skills.
Proper assessment of the patient’s self-esteem and past coping skills can help the nurse develop interventions to support the mother’s mental and emotional well-being.
Interventions:
1. Encourage the patient to verbalize feelings about the current situation.
In preterm labor, patients may blame themselves for what is happening, causing severe distress and anxiety. Encouraging the patient to verbalize feelings allows the nurse to intercept misunderstandings and discuss fact vs. emotion.
2. Provide accurate information about the condition and its management.
There are causes of preterm labor related to lifestyle factors (smoking, poor prenatal care), but many are out of one’s control, and there is no way to know the exact cause. The nurse can provide accurate information and focus on the management and delaying delivery in an attempt to guide the mother away from guilt or blame.
3. Provide reassurance during preterm labor.
Providing reassurance can help decrease stress and anxiety, promote self-esteem, and encourage coping with the current status.
4. Encourage family members to participate in the plan of care.
Having a reliable support system can strengthen and promote confidence in the patient.
References
- Agrawal, V., & Hirsch, E. (2012). Intrauterine infection and preterm labor. Seminars in Fetal and Neonatal Medicine, 17(1), 12-19. https://doi.org/10.1016/j.siny.2011.09.001
- Cleveland Clinic. (2022, November 7). Premature (pre-term) labor: Signs & treatment. Retrieved May 2023, from https://my.clevelandclinic.org/health/diseases/4498-premature-labor
- Preterm Labor. Mayo Clinic. Reviewed: February 08, 2022. From: https://www.mayoclinic.org/diseases-conditions/preterm-labor/symptoms-causes/syc-20376842
- Preterm Labor. Standford Medicine Children’s Health. 2021. From: https://www.stanfordchildrens.org/en/topic/default?id=preterm-labor-90-P02497
- Preterm Labor. Suman V, Luther EE. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536939/
- Premature Labor. Traci C. Johnson, MD. WebMD. Reviewed: August 8, 2022. From: https://www.webmd.com/guide/premature-labor
- Preterm Labor and Birth. ACOG The American College of Obstetricians and Gynecologists. Updated January 2022. From: https://www.acog.org/womens-health/faqs/preterm-labor-and-birth
- Ross, M. G. (2023, April 5). Preterm labor: Practice essentials, overview, risk of preterm labor. Diseases & Conditions – Medscape Reference. Retrieved May 2023, from https://emedicine.medscape.com/article/260998-overview#a7
- Suman, V., & Luther, E. E. (2022, August 8). Preterm labor – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved May 2023, from https://www.ncbi.nlm.nih.gov/books/NBK536939/
