How accurate is a woman's diagnosis of threatened preterm delivery?

Symptoms described by African American women evaluated for preterm labor

OBJECTIVE

To describe symptoms, self-care for symptoms, and lay consultations of African American women later diagnosed with a likelihood of preterm labor (PTL).

DESIGN

Qualitative descriptive study.

SETTING

Two sites within the United States, one urban and one suburban high-risk maternity referral center.

PARTICIPANTS

Twenty-five African American women presenting for emergent care and subsequently diagnosed as "rule out PTL." Five of the women later delivered before 37 weeks gestation, of whom 4 had a preterm low-birthweight infant (<or=2,500 g).

MAIN OUTCOME MEASURE

Women's symptoms, self-care for symptoms, and lay consultations prior to seeking care for PTL.

RESULTS

The most common reason for seeking care was due to "pains," and the second most common was "cramping," with most women (n = 17) seeking care within 4 to 24 hours of first experiencing symptoms. Importantly, 15 of the women first contacted friends/family members before seeking care.

CONCLUSIONS

In African American women, implications about PTL teaching include adding the word "pain" as another teaching descriptor and targeting education to individuals whom the patient considers to be significant such as a close friend or family member.

Rofecoxib Versus Magnesium Sulfate to Arrest Preterm Labor: A Randomized Trial

OBJECTIVE

To compare oral rofecoxib with intravenous magnesium sulfate as a tocolytic.

METHODS

This was a randomized study of patients who were between 22 and 34 weeks of gestation with preterm labor. Patients were randomly assigned to receive either daily oral rofecoxib (50 mg) or intravenous magnesium sulfate for a maximum of 48 hours. Outcome variables included delay of delivery for 48 hours and the incidence of side effects. Data were analyzed by using the Student t test, Mann-Whitney U test, chi(2) test, and repeated-measures analysis of variance. Sample size calculations were based on previous studies of tocolytic efficacy.

RESULTS

Two hundred fourteen patients were randomly assigned (105 received rofecoxib and 109 received magnesium sulfate). Delivery was delayed for 48 hours in 95 (90.4%) and 96 (88%) of the patients in the rofecoxib and magnesium sulfate groups, respectively (relative risk 0.97; 95% confidence interval 0.89, 1.06). To show a statistically significant benefit in delay of delivery past 48 hours, a total of 2,686 patients would be required in each group. There was no difference between the groups over the course of the study in cervical dilatation, amniotic fluid index, or cervical length by vaginal ultrasonography. The median hospital days on the original admission were also similar at 2 for both groups (P =.10). There was a higher reported incidence of maternal side effects in the magnesium sulfate group (relative risk 1.81; 95% confidence interval 1.07, 3.06). There was no difference in the incidence of neonatal side effects.

CONCLUSION

There was no difference between oral rofecoxib and intravenous magnesium sulfate in arresting preterm labor.

Women's recognition of the spontaneous onset of labor

BACKGROUND

Despite extensive research on the onset of labor, almost no data are available on women's perception of labor onset. We undertook a study to assess how women experience spontaneous onset of term labor.

METHODS

A semistructured questionnaire was given to 235 women admitted in spontaneous labor at term. Women noted when labor had started, whether and when membranes had ruptured, and answered an open question about how labor had announced itself. Two investigators independently subdivided women's experiences on how labor had started into 369 sampling units corresponding to 8 predefined categories.

RESULTS

Nearly two-thirds of the sampling units (63.4%) related to recurrent and nonrecurrent pain, and the ratio between the two types was higher for multiparas than for nulliparas. The number of women and sampling units were identical for each of the following categories: watery fluid (n = 47), blood-stained loss (n = 33), gastrointestinal symptoms (n = 10) and altered sleep patterns (n = 11); 22 sampling units relating to emotional upheaval were mentioned by 16 women. Although 33.6 percent of women experienced rupture of membranes before admission, only 21.6 percent associated it with their onset of labor, either alone (11.5%) or in association with other categories (10.1%).

CONCLUSIONS

Although women experience onset of labor in a variety of ways, for most it is a concrete event. Studies on duration of labor should take women's perception of onset of labor as a starting point rather than rely on surrogate measures.

Impact of participation in the Halifax County Preterm Birth Prevention Project

OBJECTIVES

(1). To determine if participation in the Halifax County Preterm Birth Prevention Project (HCPBPP) reduced the risk of preterm birth; (2). to evaluate the degree to which specific components of the HCPBPP contributed to preterm-birth risk reduction.

METHODS

A nested case-control study was conducted among women residing in Halifax County who gave birth at the IWK Grace Health Centre during the final year of the HCPBPP. Cases, defined as women who delivered preterm (<37 weeks), and controls, defined as women who delivered at full term, were recruited to complete interviewer-administered questionnaires. Three controls per case were sequentially selected. The exposures of interest were overall participation and compliance with specific components of the program. Univariate and multivariate statistical methods were employed to evaluate the effect of exposure to the preterm-birth prevention program.

RESULTS

Seventy cases and 210 controls were enrolled in the study. Although 82% of subjects participated in some aspect of the HCPBPP, only 8% of high-risk and 6% of low-risk women complied fully with program recommendations. Exposure to project educational strategies or pelvic examinations provided no protective benefit for preterm birth in low-risk or high-risk women. However, compliance with prenatal care providers recommendations to restrict activity or monitor for uterine contractions by self-palpation was associated with a marked reduction in the risk of preterm birth among low-risk women (odds ratio, 0.20; 95% confidence interval, 0.08 0.50).

CONCLUSION

Although full participation in the HCPBPP protocol was limited, the findings of this case-control study suggest that activity restriction and uterine activity monitoring by self-palpation may reduce the likelihood of preterm birth in women with no identifiable risk factors for prematurity.

Resolving the uncertainty of preterm symptoms: women's experiences with the onset of preterm labor

OBJECTIVE

To describe expectant women's experiences with the onset of preterm labor.

DESIGN

Qualitative, using grounded theory methods.

SETTING

Southwestern tertiary women's hospital.

PARTICIPANTS

Thirty pregnant women who were less than 35 weeks gestation, had experienced preterm labor within the past 7 days, and had no previous experience with preterm labor.

DATA SOURCE

Taped and transcribed interviews.

RESULTS

Themes that emerged from the interview data included the following: recognition and naming of sensations, a consistent pattern of attribution of symptoms, the threat or risk inferred by the attributed cause of the symptom pattern, the associated certainty or uncertainty about these attributions, the process of interpreting and verifying symptom meaning, and the decision to self-manage the symptoms or engage health care assistance. The core process of women experiencing the onset of preterm labor symptoms was identified as "resolving the uncertainty of preterm labor symptoms: recognizing and responding to the possibilities."

CONCLUSIONS

Preterm labor often is not within expectant women's consciousness. They may attribute the symptoms to nonthreatening causes, which results in delays in seeking care for preterm labor. Education about symptom patterns at the onset of preterm labor will increase the probability that women and their health care providers will recognize and interpret the early, subtle symptoms that herald the onset of preterm labor. Uncertainty in illness theory and attribution theory offer frameworks for understanding women's experiences with the onset of preterm labor.

External four channel tocography in preterm labor. First results

In order to known more about preterm labor the objective of our investigation was to look for a correlation between the spatial and temporal pattern of uterine contractions and the duration of pregnancy. 50 patients with preterm labor between 21 and 35 weeks of gestation underwent repeated measurements using four-channel tocography in which the pressure of contractions was registered simultaneously on the left and right sides at the fundus and the lower segment of the uterus. Half of all recorded signals were locally restricted (typical labor pattern in only one or two registration tracks). The following two phenomena were significantly associated with a shorter duration of pregnancy: 1. the reproducibility of a center of dominance (defined as the locus of registration with the highest sum of amplitudes), and 2. a predominant origin of labor in the right fundal region of the uterus. Four-channel tocography indicates whether preterm labor is likely to lead to preterm delivery. It may therefore help the obstetrician in deciding whether to use tocolytic therapy.

New perspectives for the effective treatment of preterm labor

Preterm birth (before 37 completed weeks of gestation) continues to account for the vast majority of neonatal morbidity and mortality. The incidence of preterm birth can be reduced by appropriate social interventions and antenatal care. Currently available tocolytic agents suffer from low uterospecificity and prolong pregnancy only marginally, although postponement of birth by a few days may be of some value. Further progress is needed in at least four areas: prevention of preterm labor; identification of preterm labor; selection of candidates for tocolysis, and treatment of preterm labor. Effective, early treatment of vaginosis offers particular promise for the prevention of preterm labor and identification of specific biochemical markers will facilitate early detection of this process. Oxytocin antagonists offer greater specificity than current tocolytics and can be expected to show improved efficacy and risk profiles. Such compounds will allow more effective treatment of preterm labor with a lower risk of side effects.

A nursing model for a community hospital preterm birth prevention program

Newer interventions for the treatment of preterm labor led to the development of a nursing program for preterm birth prevention. The Roy adaptation model was used as a framework for patient and community education. Quality improvement activities provided the impetus for nursing practice changes. Tools were developed to produce a comprehensive, consistent approach for patient care from assessment to discharge.

Nursing assessment and responsibilities in monitoring the preterm pregnancy

Evaluating women for pregnancy-related problems that may result in preterm birth frequently requires electronic fetal monitoring at early gestational ages. Caution is needed to interpret information correctly from the preterm fetal heart rate and uterine activity tracings. Interpreting fetal heart rate tracings from preterm fetuses requires knowledge of fetal physiologic development. Obtaining clear tracings of preterm uterine activity remains a challenge and heightens the importance of thorough nursing assessment, including inquiry about risk factors for pregnancy complications.