PRETERM LABOUR

Presentator:
Nadia Ghaisani Qumairi 110100137
Anggia Anggraeni 110100290
Indiran Vadivalu 110100456

S u p e r v i s o r : d r. F a d j r i r, M . K e d ( O G ) , S p . O G
Mentor : dr. Ahmad Shafiq
 •Preterm labor is the presence
of contractions of sufficient
strength and frequency to
Definition effect progressive
(WHO) effacement and dilatation of
the cervix between 20 and
37 weeks’ gestation
Although it has an incidence of 10%,its
contribution to neonatal morbidity and
mortality is high ranges from 50 – 70%.
Survival by gestational age among
live-born resuscitated infants

In: Creasy, Resnik . Maternal – Fetal Medicine, 2009

Major Risks of
Preterm Delivery - Death
- Necrotising
- Respiratory enterocolitis
distress
- Jaundice
syndrome

- Infection
-Hypothermia
-Retinopathy
Hypoglycaem
of
ia
prematurity
 RISK FACTORS

Low socioeconomic state

Previous preterm delivery

Preterm premature rupture of

Maternal age <18 years or >40 years
the membranes
• Previous preterm delivery
Maternal history of one or more
spontaneous
Multiple gestation
 RISK FACTORS

Myomata (particularly
submucosal or
subplacental)

Cervical Uterine Uterine

incompetence causes septum

Bicornuate
uterus
 RISK FACTORS

Infectious causes
Chorioamnionitis
Bacterial vaginosis
Asymptomatic bacteriuria
Cervical/vaginal colonization

Fetal causes
Intrauterine fetal death
Intrauterine growth retardation
Congenital anomalies
 DIAGNOSIS

• Documented uterine contractions.

• Documented cervical changes as cervical effacement

of 80% , or cervical dilatation of 2 cm or more.
 MANAGEMENT

Bed rest
Hydrate the patient
 Assess cervical status, progress of labour and presenting part.
 Vaginal swab for bacteria vaginosis and B streptococcus and
give antibiotic
 TOCOLYTIC THERAPY

• Calcium channel blocker (nifedipine)

LD= 20mg, MD= 10-20mg 3-4x/day. Max=
60mg/day
• Magnesium sulfate
• Beta2-adrenergic receptor agonist
sympathomimetic (terbutalline)
• Tocolytic therapy may offer some short-term benefit in the
management of preterm labor.
• A delay in delivery can be used to administer
corticosteroids to enhance pulmonary maturity and reduce
the severity of fetal respiratory distress syndrome,
 CORTICOSTEROID THERAPY

Nifedipine: Inhibits the inward current of calcium iron during the 2nd phase of the
•action
Dexamethasone andmuscle
potential of uterine betamethasone
• for fetal maturation reduces mortality, respiratory distress
syndrome
Side effects: and intraventricular hemorrhage in infants between
28 and 34 weeks of gestation.
1- Headache 2- Hypotension
• benefits
3-Flushing
start at 24 hours
4- Tachycardia
and last up to seven days after
treatment
• The potential benefits or risks of repeated administration of
corticosteroids after seven days are unknown.
 ANTIBIOTIC THERAPY

• Women who received antibiotics sustained

pregnancy twice as long as those who did not
receive antibiotics had a lower incidence of
clinical amnionitis.
• Poor fetal outcome (death, respiratory distress,
sepsis, intraventricular hemorrhage or
necrotizing colitis) occurred less frequently in
women receiving antibiotics
CASE REPORT
 A. IDENTITY

• Name : Sadarhati Lase

• Age : 31st years old
• MR : 01.01.43.26
• Education : Diploma
• Occupation : Housewife
• Religion : Protestan
• Ethnic : Bataknese
• Nationality : Indonesia
• Address : Gunung Sitoli, Nias
• Admitted : 18/11/2016 at 09.30 am
CC : Mother want to strain
Review: this has been experienced since 18/11/2016 at 09.00
A.M. History of labor contraction since 18/11/2016 at 04.00
A.M. History of bleeding showed on 18/11/2016 at 04.00 A.M.
History of amniotic fluid leakage since 16/11/2016, at 18.00
A.M, colorless, odorless, water was out without control, at
beginning was little but start to increase, the volume was 1 x
changing of sarong. History of vaginal discharge in
pregnancy (+), color white yellowish, smell like salted fish, and
itching. History of fever in pregnancy (-). History of sexual
intercourse (+). History of hypertension in pregnancy (-)
Micturition and defecation were within normal limit.
:-
History of Previous illness :-
History of Medication :-

LMP : 24/04/2016
EDD : 31/01/2017
ANC : 1x Midwife

History of pregnancy :
1. Current pregnancy
Vital Signs
Cons : Fully Alert Anemic : (-)
BP : 110/70 mmHg Icteric : (-)
Pulse : 88 x/i Cyanosis : (-)
RR : 20 x/i Dypsnoe : (-)
Temp : 36,8°C Edema : (-)

Localized State :
Head : Anemic inferior Palpebra Conj (-)/(-), icteric (-)/(-)
Neck : within normal limits
Thorax : Respiratory sound : vesiculer
Additional sound : Wheezing(-)/(-), Rhales (-)/(-)
 • Abdomen : asymetrically enlarged
• Fundal Height : between umbilicus and xypoid proccess
(26 cm)
• Tension part : Left
Obtetric State • Lower part
• Fetal Movement
: head
: (+)
• Uterine contraction : 45”
• Fetal Heart Rate : 140 bpm
• EFW : 1800-2000gr

Gynecological • VT: Cervix dilatation 10cm, SRM 40 hours

State Gloves : blood slime (+), amniotic fluid (-)

• No exam
USG-TAS
LABORATORY FINDINGS ON NOVEMBER
18 TH 2016

HB : 11 N: 12-14 GR/DL
LEUKOCYTE : 9510 N:4000-11000/UL
HEMATOCRIT : 37 N: 36,0-42,0/%
PLATELET : 256.000 N: 150.000-400.000/UL
UREUM : 9 N: 10-50 MG/DL
CREATININ : 0.61 N: 0,6-1,2 MG/DL
• Diagnosis :
PG + IUP (28-30) wga+ Head Presentation + Live Fetus + second stage
of labour

• Therapy :
• IVFD RL 20gtt/I
• Spontaneuos Vaginal Delivery
• Follow the progress of Labor

• Plan : advice contraception use

consult to perinatology department

• Prognosis : good
 LABOR REPORT

• Mother laid on the gynecology table with Mc Robert position.

• During adequate HIS, baby's head move forward backward and then in
fix position. In next adequate HIS, the mother was lead to strain and the
baby born start from occiput, forehead, face, chin and head. Then there
was the outside rotary axis
• By holding biparietal, head pulled down to deliver the anterior shoulder.
Then pulled up to give birth to the posterior shoulder. With hand
guidance to baby’s back, the body was delivered. At 09:50 A.M born
baby boy, weight 1.700 gr, length 39 cm, A / S: 7/8, Ballard Score: 12,
Anus (+).
 LABOR REPORT

• The umbilical cord is clamped in two places and cut in

between.
• Then the bladder was emptied
• After the injection of oxytocin 10 IU IM, with PTT, the placenta
is born. Impression: complete.
• Evaluation of birth canal: impression: grade I lacerations
• Observation bleeding: There is no active bleeding
• The general state of the mother and baby after delivery: good
Therapy post SVD:
• IVFD RL + oksitosin 10 IU -> 20 gtt/i
• Cefadroxyl 2 × 500 mg
• Asam Mefenamat 3 × 500 mg
• Vit. B Kompleks 2 × 1 tab

Planning:
• Blood Workup 2 hours post SVD
• Monitoring vital sign, uterine contraction, and bleeding
Neonatus:
• Date of Birth : 18/ 11 /2016
• Condition : Live
• APGAR Score : 7/8
• Sex : Boy
• Body Weight : 1700 gr
• Body Height : 39 cm
 MONITORING POST SVD

Time 10.30 10.45 11.00 11.15 11.30 12.00 12.30

Pulse/minute 76 80 80 80 78 78 80

Blood Pressure 110/70 110/70 110/70 110/70 110/70 110/70 110/70

Respiratory/
24 24 24 24 24 24 24
minute

Contraction Strong Strong Strong Strong Strong Strong Strong

Bleeding (cc) 10 cc 10 cc 10 cc 10 cc 15 cc 15 cc 15 cc
FOLLOW UP
Saturday, November 19th 2016 Diagnosis Management

S:- Post SVD d/t Therapy:

O: Sens: Fully Alert Anemic : (-) preterm -IVFD RL 20 gtt/i
BP: 110/60 mmHg
Pulse: 88 bpm
Icteric : (-) labour+PD1 -Cefadroxyl 2 × 500
RR: 20 x/min Cianosis : (-) mg
T: 36.7 °C Dyspneu : (-) -Asam Mefenamat
Edema : (-) 3 × 500 mg
- Vit. B Kompleks 2 ×
Obstetric State: 1 tab
Abdomen : soepel, peristatic (+)
UFH : 1 finger below umbilicus,
contraction strong
Vaginal Bleeding : (-)
Mixturition : (+)
Defecation : (+)
Sunday, November 20th 2016 Diagnosis Management

S:- Post SVD d/t Therapy:

O: Sens: Fully Alert Anemic : (-)
Icteric : (-) preterm -Cefadroxyl 2 × 500
BP: 110/60 mmHg
Pulse: 88 bpm Cianosis : (-) labour+PD2 mg
RR: 20 x/min Dyspneu : (-) -Asam Mefenamat
T: 36.7 °C Edema : (-) 3 × 500 mg
-Vit. B Kompleks 2 ×
Obstetric State: 1 tab
Abdomen : soepel, peristatic (+)
UFH : 1 finger below umbilicus,
contraction strong
Planning: Discharge
Vaginal Bleeding : (-)
Mixturition : (+)
Defecation : (+)
DISCUSSION
 TEORY CASE
Preterm labor is defined We found out that
as regular contractions there are regular
of the uterus resulting in contractions of the
changes in the cervix uterus resulting in
that start before 37 changes in the cervix
weeks of pregnancy. before 37 weeks of
Changes in the cervix pregnancy
include effacement and
dilatation.
 THEORY CASE
The risk factors include the Risk factor in this
following: patient is premature
• Young age of mother - less than 16 years of age rupture of
• Lower socioeconomic class
• Reduced body mass index (BMI) - BMI less than membranes.
19.0
• Cigarette smoking
• Previous preterm delivery
• Multiple pregnancy
• Cervical incompetence
• Uterine abnormalities
• Premature rupture of membranes
• Obstetric complications, including hypertension in
pregnancy, antepartum haemorrhage, infection,
polyhydramnios, foetal abnormalities.
THEORY Case
When a patient with suspected preterm Obtetric State
-Abdomen : asymetrically enlarged
labour is examined, a full history must -Fundal Height : between umbilicus and
be obtained and a clinical examination xypoid proccess (26 cm)
must be performed. The clinical -Tension part : Left
-Lower part : head
examination should include a speculum -Fetal Movement : (+)
examination of the cervix to exclude -Uterine contraction : (+) 4x45”/10’
rupture of membranes, digital -Fetal Heart Rate : 140 bpm
-EFW : 1800-2000gr
examination to assess the cervical
status, assessment of foetal Gynecological State
presentation and estimated foetal VT: Cervix dilatation 10cm, SRM 40 hours
Gloves : blood slime (+), amniotic fluid (-)
weight. Vaginal and cervical
microbiological cultures and a
midstream specimen of urine culture
may be considered to exclude an
infective etiology.
THEORY
Pharmacological agents
which have been used for
uterine tocolytic:
1) Agonis reseptor β
2) Magnesium Sulfat
3) Calcium Channel Blocker
4) Inhibitor Prostaglandin
5) Antagonis Oksitosin
CASE
We did not used any
tocolytic agents as the
patient came in with Cervix
Ø 10 cm and ready to give
birth .
PROBLEMS
What is the etiology of preterm labour in
this patient?
As a general doctor in clinic, what are the
procedures must be done for this case?

What are the preventations can be done

to avoid preterm labour?
CONCLUSION
Mrs. S, 31 y.o, G1P0A0, Bataknese, Nias, Kristen, Degree 3,
Housewife, w/f Mr. J, 28 y.o, Bataknese, Senior High School,
Seller, was admitted to Dr.Pirngadi Medan Hospital on
November 18 th 2016 at 09.30 am with labour contraction.
History of bleeding show on 18/11/2016 at 04.00 am, histoy of
amniotic fluid leakage since 16/11/2016, at 18.00 am,
colorless, odorless, water was out without control , at
beginning was little but start to increase later, the volume was
1x changing of sarong.
• History of vaginal discharge in pregnancy (+) colour
white yellowish, smell was unpleasant , and itching.
History of sexual intercourse in pregnancy (+).
• Obtetric State: fundal height: between umbilicus and
xypoid proccess (26 cm), tension part: left, lower part:
head, fetal Movement: (+), uterine contraction :
4x45”/10’, fetal heart rate: 140 bpm. VT: Cervix Ø 10
cm.
• Patient was diagnosed PG + IUP (28-30) wga+ Head Presentation +
Live Fetus + second stage of labour and the plan was
spontaneuos vaginal delivery. Baby boy was born, BW: 1700 gram,
BH: 39 cm, A/S: 7/8, Anus (+). Therapy post SVD was IVFD RL +
oxytocin 10 IU 20 gtt/minute, Cefadroxil 2 x 500 mg, Asam
Mefenamat 3 x 500 mg, and Vit B-complex tab 2 x 1. Then, patient
was admitted to observe general state. Patient was discharge on 20th
november 2016
THANK YOU