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increase or change in vaginal discharge (mucus, watery, light bloody discharge).
Objective: Signs
Using Basic Tools: Palpable uterine contractions; palpable cervical dilation and effacement
Using Advanced Tools: Lab: Urinalysis and a saline wet preparation to evaluate for bacterial vaginosis. Fern
Test (amniotic fluid dries on a slide to resemble the leaves of a fern plant) to assess for PROM.
Assessment: Assess for PTL risk factors, and treat those found.
Differential Diagnosis
Low back pain/spasm - palpate for back spasm; evaluate for associated neurological symptoms (leg tingling,
radiation, etc.)
Infection - evaluate for urinary tract infection (urinalysis, fever), GI infection (diarrhea, fever) and vaginosis
(saline wet prep).
Ureter/kidney stone - evaluate flank pain, fever; perform urinalysis
True labor - verify dates of last menstrual period.
PROM - history of vaginal gush or leak, positive Fern Test
Constipation - history of infrequent bowel movements; retained fecal material
Diarrhea - infection (above), food poisoning, and others.
Plan:
Treatment
- Arrest labor:
Primary: Magnesium sulfate, 4 gm loading dose over at least 5 minutes, followed by 2 gm/hour in a steady
IV drip. Watch for magnesium toxicity with diminished reflexes and respiratory depression. Counteract with
calcium gluconate 1 gm slow IV push over 2-3 minutes if magnesium toxicity is encountered.
Alternates: Terbutaline 0.25 mg SQ, q 1-4 hours x 24 hours, total dose not to exceed 5 mg in 24 hours. May
also be given po in 2.5 - 7.5 mg doses q 1.5 - 4 hours. Target maternal pulse rate is > 100 and < 120 BPM
Indomethacin (Indocin) 50 mg po (or 100 mg PR), followed by 25 mg po q 4-6 hours for up to 48 hours. Watch
for gastric bleeding, heartburn, nausea and asthma.
NOTE: Contraindications to Tocolytic Therapy:
Maternal: Significant hypertension (see Preeclampsia section), antepartum hemorrhage, cardiac disease.
Fetal: Gestational age > 37 wks, fetal death, chorioamnionitis (intrauterine infection) - Prevent infection (PROM; PTL > 12 hours; history of UTI, vaginal infections in last 2 weeks):
Primary: Penicillin 5 million units IV initially, then 2.5 million units q 4 hrs until delivered
Alternates: Ampicillin 2 g IV q 4-6h or Rocephin may also be used, 1 gram IV q 12 hrs.
For those patients who are penicillin allergic, clindamycin 600 mg q 6 h or 900 mg q 8 h or erythromycin 1-2
g q 6 h or vancomycin 500 mg q 6 h or 1000 mg q 12 h. - Help fetus mature: After postponing delivery, many fetuses less than 34 weeks gestation will benefit from
administering steroids to the mother. The effect of the steroids on the fetus is to accelerate fetal lung maturity,
lessening the risk of respiratory distress syndrome at birth.
Dexamethasone 6 mg IM q 12 hours x 4 doses. - Evacuate the mother: Keep her rolled over on her left or right side, with a pillow between her knees, with
an IV securely in place. If IV access is lost during a bumpy truck or helicopter ride, it will be nearly impossible
to restart it without stopping or landing. Consider tocolytic therapy in all mothers being transported unless
contraindications exist or greater than 37 weeks gestation.
Patient Education
Activity: Decreased activity and bedrest may be required to avoid further PTL.
Prevention and Hygiene: Avoid emotional stress.
No Improvement/Deterioration: Report recurrent symptoms immediately. Early intervention is more effective
in stopping PTL.