Initial Medical Therapy (Nursing)

00:01 Let's also talk about the medications that might be used to try to treat preterm labor, once the client comes to the hospital.

00:09 We may use terbutaline, magnesium sulfate, corticosteroid therapy, and antibiotics.

00:17 Terbutaline is an adrenergic agonist and it can be given P.O. or Sub Q.

00:23 The Sub Q dose is 0.25 milligrams every four hours.

00:27 P.O. dose is typically 2.5 milligrams every four hours.

00:32 There are definitely some clients who should not receive terbutaline.

00:35 Anyone who has heart disease, gestational diabetes, or severe preeclampsia would not be a candidate for this medication.

00:44 Expected effects include: tachycardia, tremors, anxiety, and transient hyperglycemia.

00:50 However, terbutaline has a "black box warning" from the FDA.

00:54 And prolonged oral exposure may lead to serious complications like hypokalemia, arrhythmias, pulmonary edema, and myocardial ischemia.

01:04 Magnesium sulfate may also be given.

01:08 Now, we give magnesium sulfate in preeclampsia because it's a CNS depressant.

01:12 In preterm labor, it does double duty because it relaxes smooth muscle, it's frequently used as primarily a tocolytic.

01:20 It also offers some neuroprotection for the preterm fetus.

01:25 It's used in preterm labor reduces the risk of neurologic problems and cerebral palsy, and babies born very premature.

01:33 An initial bolus of four grams, followed by one to two grams per hour by infusion is typical.

01:40 Therapeutic range for magnesium sulfate is somewhere between 4 and 4.7 milliequivalents per liter.

01:48 When we're giving someone magnesium sulfate for any reason, we need to monitor for signs of toxicity, and that includes pulmonary edema, absent deep tendon reflexes, hypotension, altered level of consciousness, a respiratory rate less than 12, or a heart rate that's less than 60.

02:08 Those are going to be things we absolutely need to check.

02:11 We should also be aware that these babies may need more help than usual at delivery.

02:16 The magnesium does cross the placenta, so the babies may be very sleepy or even apneic meaning they may not want to breath.

02:24 The team must be ready for that.

02:27 We can also use other medications to provide some relaxation, and one of those medications is nifedipine.

02:34 This is given orally.

02:36 Usually 30 milligrams followed by 10 to 20 milligrams every four to six hours.

02:41 Contraindications include a history of cardiac disease, hypotension, and renal disease.

02:48 How does it work? Well, we have calcium channels, and if they are activated, then we'll have a contracted myometrium.

02:55 So the uterus will contract.

02:57 If we give the nifedipine we can block the calcium channels, and that will relax the uterus.

03:03 So it's very effective in that regard.

03:07 One of the most significant complications for the newborn that's born prematurely is respiratory distress syndrome.

03:14 Fortunately, we have something that we can do to help reduce that complication, and that is to give the birthing person a corticosteroid.

03:23 Corticosteroids work by causing a stress response, which allows for the release of surfactant in the fetus.

03:30 Now, what a surfactant do? Surfactant allows for the alveoli to stay open when the newborn breeze.

03:37 Otherwise when they breathe, the alveoli stick together.

03:40 So think about surfactant like dishwashing detergent that's really oily, it allows the alveoli to stay open.

03:46 So we administer the glucose steroid to the birthing person IM.

03:52 And we do this between 24 and 34 weeks.

03:55 Now, 34 weeks is typically when the fetus will start to produce surfactant on their own, but even all the way up to 36 weeks and seven days, we may still give the corticosteroid just in case.

04:08 They're currently two corticosteroids that are used in the hospital.

04:12 Two have the most common corticosteroids that are given in hospitals in the United States are betamethadone.

04:18 And typically, this is 12 milligrams, it's given in two doses that are 24 hours apart.

04:23 And dexamethasone, which is six milligrams, it's given in four doses 12 hours apart.

04:28 This is how we're going to reduce respiratory distress syndrome in the newborn.

04:33 Remember, this is what helps with surfactant production.

04:37 Now, one big caveat I'm going to give you is that anytime we give a steroid, it causes an increase in our glucose level.

04:45 So it's important that we monitor glucose levels.

04:49 So if you have a client who has gestational diabetes or pre-existing diabetes who's at risk for delivering a preterm baby, the decision may be made to not give the corticosteroid or if given to significantly monitor blood glucose levels.

05:05 The last category I want to talk to you about in terms of medication are antibiotics.

05:09 I won't list each one because the antibiotic that's given will depend on the type of disease or bacteria that is suspected.

05:16 But antibiotics definitely will be ordered if there's a suspicion that an infection is the cause of the preterm labor, or if there's a case of rupture of the membranes, especially premature rupture of the membranes.

05:29 Now, let's try a case and see if we can put this all together.

05:33 So let's meet Lee Willis. So Lee Willis is 18.

05:37 Lee Willis is Caucasian.

05:39 Lee Willis is 27 weeks and 2 days, and this has been verified.

05:43 And Lee presents with lower abdominal cramping, a backache for the past 45 hours, and they've experienced a gush of fluid about two hours ago.

05:52 So, in thinking about Lee, what kinds of questions do you think the nurse should ask? Hopefully, you asked about their previous OB history, to give you more of a description about the abdominal pain, to talk about what the fluid looked like, and if there's any bleeding? Maybe you remember to ask about whether they felt the baby moving, or they have a support person, or what was going on right before this happened.

06:24 Those would all be excellent questions to determining kind of the background of what's going on with the symptoms that leaves experiencing.

06:32 And what items will you include in your focused assessment? See if you can come up with some.

06:44 Hopefully, you mentioned vital signs both for Lee and also for the fetus.

06:49 Hopefully, you mentioned determining whether the membranes have actually ruptured.

06:53 You may describe, putting the client on the fetal monitor to figure out what the contraction pattern might look like and to get an idea of fetal well being.

07:01 And all of those things together would definitely let us know whether Lee might or might not be in labor.

07:08 Now, maybe you weren't sure about whether or not to do a cervical exam.

07:12 And that's a really great pause to make.

07:14 Because until we know whether the membranes are ruptured, then we want to avoid doing anything that might increase the chance of infection, and a vaginal exam would absolutely do it.

07:24 So hopefully you were able to put all of that together and come up with a great story for Lee.