Nursing Protocol

PROTOCOL ANALYSIS

Preterm labor is a significant health problem for many pregnant women in the United States. It is estimated that eight to ten percent of all births in the United States are the result of premature labor, which account for approximately 440,000 births annually. Preterm labor is also the leading cause of perinatal morbity and mortality and results in health care expenditures of over three billion dollars per year. (ACOG, 2001). It was thought that the incidence of preterm labor would decrease in time, but this has not been the case. Although infant morbity has decreased due to technological advances in neonatal medicine, the incidence of preterm labor has actually increased (Goldenberg, 2002). Preterm labor is defined as: "contractions occurring between 20 to 36 weeks which occur regularly, leading to progressive cervical change." (ACOG, 2003). Diagnosing preterm labor is complicated and has a high false-positive rate. The effect of false diagnoses is that many women are treated unnecessarily and possibly suffer dangerous consequences due to treatment (Freda, 2003). Therefore, as a healthcare provider, it is important to have an effective, evidenced based protocol, which can be followed to aid in the diagnosing and treatment of preterm labor.

Labor is a multifactorial physiological process, which is controlled by hormones. Why these hormones are triggered in preterm labor is not entirely known but there are many hypotheses. Some hypothesis include: preterm labor is caused by a smooth muscle reaction due to estrogen and progesterone; oxytocin sensitivity; cytokine release and prostaglandin effect on myometrial contractions and corticotropin-releasing activation due to stress (Freda, 2003). Perhaps the most easily understood hypothesis is that the fetus is able to recognize a hostile intrauterine environment and then precipitates labor. Risk factors for preterm labor have been identified and can be divided into two classifications, which include maternal factors and fetal factors. Some of the maternal risk factors include previous preterm delivery, low socioeconomic status, non-white race, maternal age less than eighteen years or greater than forty years, preterm rupture of membranes, multiple gestation, exposure to DES, maternal infections and maternal history of one or more spontaneous second-trimester abortions. Maternal lifestyle factors such as smoking, drug, alcohol use and lack of prenatal care are also significant risk factors. Fetal factors, effecting preterm labor, include intrauterine growth retardation, congenital anomalies, intrauterine fetal death and abnormal placentation.

When examining risk factors associated with preterm labor, it is clear that many of these are modifiable factors. Therefore, the advanced practice nurse could prevent many preterm labors and births by incorporating preventative care measures, health promotion aspects and facilitation of self-care into their practice. Nursing interventions for patients ideally should start before the patient conceives and continue throughout the patient's pregnancy. Unfortunately, many times patients are not seen until they are advanced into their pregnancies. A thorough history should be obtained from patients, so patients at high risk for preterm labor can be identified. APN's should counsel patients on the importance of smoking cessation, as well as eliminating the use of drugs and alcohol during pregnancy. APN's could also stress the significance of regular prenatal care, proper nutrition and ways to prevent infections during pregnancy. Patients should be educated about the signs and symptoms of preterm labor, so that they can be aware and respond speedily and appropriately. Practitioners can also counsel patients on activities to avoid that may increase chances of preterm labor, such as: stair climbing, lifting heavy objects, sexual intercourse and standing for long periods of time (Maloni, 2004). Patients should be encouraged to take responsibility and be involved in their care.

A protocol can be defined as: a particular course of action intended to achieve a result (www.atis.org). Therefore, when designing a protocol or procedure, the goal of a protocol is to aid practitioners in making decisions about appropriate care and helping the practitioners to achieve a positive outcome with their patients. In the protocol involving preterm labor the goal or expected outcome would be to stop premature labor and a preterm birth from occurring or prolonging gestation enabling lung maturity to occur. Practitioners can try to do this in several ways, which will later be discussed in the protocol analysis. The following protocol addresses management of preterm labor, and was developed in 2004. For analysis purposes, the protocol is printed in black with suggested changes or decisions to maintain the current language along with rationale printed in red.

Protocol for Preterm Labor

I. Definition. Onset of regular contractions between 20 and 37 weeks of gestation occurring at least every 10 minutes and lasting 30 seconds with cervical change. Discrimination from "false labor" is difficult. Postponement of treatment until cervical change occurs may lower the chances of success. Many protocols fail to address the definition or cause of the problem being discussed. By introducing the topic before discussing it, the practitioner acquires a better understanding and develops some common, baseline knowledge about the condition being addressed. Furthermore, this is a very good definition of preterm labor. The definition is very specific and includes specific parameters to aid the practitioner in diagnosis. This definition is also representative of what is found in the current literature and should be included in the protocol.

II. Causes. Frequently unknown. Several factors have been associated with preterm labor. According to the current literature, this statement is correct. The pathophysiology of preterm labor has been thoroughly researched and risk factors identified. By discussing causes of preterm labor in the protocol, the practitioner is made aware of the etiology resulting in better identification and prevention. Although several important causes were not included within this protocol, which should also be considered.

A. Maternal factors. Infections (systemic, vaginal, urinary tract, amnionitis), uterine anomalies, fibroids, retained IUD, cervical incompetence, overdistended uterus (polyhydramnios, multiple gestation), rupture of membranes. Other common maternal risk factors for premature labor found in the literature include: lifestyle factors such as smoking, drug/alcohol use, lack of prenatal care; previous preterm delivery, low socioeconomic status, non-white race, maternal age less than eighteen