26wks pregnant and in labor???

Jolie, BSN · Dec 4, 2003

I'm not sure why you dislike her doc so much, but it sounds like she is receiving appropriate care.

First of all, you are getting way ahead of yourself to assume that she is going to deliver any time soon. Her cervix is definitely thinning (effacing), which is a precursor to dilation, but is not enough itself to bring about delivery. Contractions may also contribute to further thinning and dilation of the cervix, but can be treated, usually with some success.

The first med most docs use for preterm labor is terbutaline, typically given sub-q. It is a smooth muscle relaxer, and helps to "quiet" the uterus. If effective, she will likely be put on po terbutaline, or continuous sub-q terbutaline (via mini infusion pump) and sent home for bed rest and home monitoring. If terbutaline fails to control her contractions, then IV magnesium sulfate will likely be the next drug of choice. It is a miserable medication with a multitude of uncomfortable side-effects, but isusually very effective in bringing contractions under control.

truern · Dec 4, 2003

my baby was born at 28 weeks......25 years ago :)

Jolie, BSN · Dec 4, 2003

Sorry, didn't mean to hit send.

MgSO4 can't be used forever, because of its side effects, but once contractions are under control, her doc can then try other meds, if necessary to keep things quiet. Also, it is important to understand that these meds will not completely eliminate her contractions. Her doc will set an acceptable "threshold" such as 4-6 contractions per hour. Anything over that threshold would indicate the need for further evaluation and perhaps adjustments to her meds.

She has been given 2 doses of steroids to help mature the baby's organs, especially the lungs, should delivery occur. That is good to hear. She should be kept on a weekly steroid dose, because the beneficial biochemical effects of the steriods "wear off" after about 7 days.

You don't say how far dilated (if at all) her cervix is. Since she is already having contractions, it is unlikely that a cerclage would be appropriate for her. As long as her membranes are intact, and she shows no evidence of infection or other complications, she will probably be kept on bedrest, monitoring, and meds up until 36-37 weeks gestation. That is not an uncommon scenario.

Most babies born at 26 weeks gestation survive, although often with some long-term complications such as chronic lung disease, cerebral palsy, vision and hearing impairments, and learning disabilities. Obviously, the longer delivery can be delayed, the better, as the outcomes improve with increased birthweight and gestational age.

Best of luck to your friend and her wee one.

BarbPick · Dec 4, 2003

Sounds like your friend is getting the right care. The steroid shots shows me the doctor knows what he is doing.

The steroid injections are to protect the baby's lungs untill the baby makes his or her own surfactant. This is to prevent the 2 kinds of respiratory distress syndrome in Premature infants.

If the doctor did not feel there was a good chance, they would not have gone this far. There are no percentages to give. There is a bitter medicine that needs to be swallowed by all involved. It is called "tincture of time" T I M E. Waiting is a bitter medicine to swallow.

This is where faith comes in.

BRANDY LPN · Dec 4, 2003

This is more a question for Jolie than a reply.

At my hosp.(keep in mind its a sm backward podunk place) we dont give steroids Q wk any moreafter first 2 doses. I believed that this was standard of care d/t research showing that after that its 1. not beneficial and 2. can cause SGA babies.

I also didnt think ANYONE having PTC was a candidate for cerclage

pls. fill me in if this is wrong, I'm not trying to start an arguement just educatng myself.

Mimi2RN, ASN, RN · Dec 4, 2003

I heard the same thing about the steroids, two doses is a course of tx. I don't know what the docs do on our L&D floor, though.

From my point of view, every mom that comes in in preterm labor, or PIH etc., should be given the steroids. It makes such a difference to the preterm babies that we deliver. Actually, maybe they should be given at the doctors office, just in case!

Tiki_Torch · Dec 4, 2003

As a NICU nurse I can say that from what you've told us about your friend, she is receiving care that is appropriate. I am familiar with undelivered preterm Moms receiving terbutaline and magnesium sulfate to help stop labor along with receiving steroid shots to help the babies lungs develop sooner. Actually the stress of preterm labor tends to cause unborn babies to become stronger. Nature is wonderful that way.

A good two years ago, many physicians stopped giving weekly steroid doses to undelivered Moms. One round (usually one injection given and then a second one 24 hours later) seems to be the new standard which is beneficial yet doesn't seem to cause complications associated with multiple dosing.

"Use of antenatal and postnatal steroid therapy is associated with improved survival, more rapid ventilator weaning, and decreased need for supplemental oxygen in at-risk neonates. Steroids reduce lung inflammation and improve pulmonary function in severe RDS (Respiratory Distress Syndrome). Antenatally, steroidal agents are administered to 50% of mothers and postnatally to 50% of VLBW (Very Low Birth Weight) infants. Even the choice of which glucocorticoid to use antenatally may be significant: antenatal dexamethasone increases PVL (Periverntricular Leukomalacia) compared with antenatal betamethasone. An NIH (National Institute of Health) concensus statement discourages multiple courses of antenatal steroids because of (1) impaired head growth, (2) impaired brain development and behavior, (3) increased mortality and lung disease, (4) gastroesophageal reflux, and (5) an increased severity of ROP (Retinopathy of Prematurity)." Handbook of Neonatal Intensive Care, Fifthe Edition by Gerald B. Merenstein, MD, FAAP and Sandra L. Gardner, RN, MS, CNS, PNP, Mosby, 2002.

As far as survival goes, each and every day that goes by is a success for the outcome of the baby. It's impossible to say what the chances of a good outcome are, but the older a baby is when it's born is always a move in the right direction. If her baby is born early, and it's course in the Intensive Care Nursery goes along well, she can expect to bring her baby home within two weeks of what the due date is... two weeks before to two weeks after the due date.

I don't think I've ever heard of a circlage being placed in a mother who is in active labor. There is a difference between active labor and inactive labor though... inactive is when they are not progressing. If Mom's water breaks or she gets fever, they would not try to stop labor, I believe. I'm not an L&D nurse though so maybe an L&D person can answer that question better than me.

Here's wishing the best for your friend.

sprtbikegrlsv65 · Dec 4, 2003

sorry, i didn't mean to say that i didn't think she was getting appropriate care...her doc in my and her opinion has a really CRAPPY bedside manner, and has mostly upset her with the things he's said than really educating her on what is going on. though she did get a really good nurse last night who explain a lot of what you guys told me on here. which relieved her anxiety.

they did try the stich two weeks ago but it wouldn't hold. they sent her home from the hospital, and she had to take a med every three hours to help keep the contractions from coming back. yesterday they hit her full force. she went to the hospital and they admitted her.

she's had two doses of steriods, and they are giving her more meds to stop the contractions...she did go about an hour last night without them. I haven't heard from her yet this morning but i'll let you know what i find out!

thanks for the info!

tasha

sprtbikegrlsv65 · Dec 4, 2003

oh i forgot to say that her cervix is dilated 2cm....

Jolie, BSN · Dec 4, 2003

Brandy,

Tiki Torch has provided the most current info. on steroid use in preterm labor. I'm not currently in practice, and made a reference to what was the standard about 4 years ago.

The rationale for the old practice of "renewing" steroids weekly was that steroids have 2 benefits to preemies: 1.) They accelerate development of virtually all organ systems (although the lungs are most important), so that the structures are more fully developed than they would otherwise be. 2.) They promote biochemical changes, most notably increased surfactant production. The biochemical changes are temporary, however, and begin to "wear off" about 7 days following the dose. So, if a mom received 2 doses of steroids and then delivered more than a week later, her baby would benefit from greater organ maturity, but not see much improvement in surfactant. Hence, the repeat dosing.

Apparently studies have shown serious potential complications from long term steroid use, and indicate the greatest benefit from the first 2 doses. Also, surfactant is now readily available for administration at birth, so the benefit of increased surfactant production from steroids is probably less critical than it once was.

Thanks to all for the updated info!

crankyasanoldma · Dec 4, 2003

This is my field.

The 'tilt' is not significant.

I think you mean 2.6 and 1.9 cm. That shows cervical change (along with the dilation). She has an incompetant cervix and preterm labor. She will need to be closely monitored and have a cerclage in all future pregnancies.

She is probably getting ventolin or brethine p.o.

(We have given mag for as long as 4 months- we are very aggressive. Also, some studies have shown mag helps prevent brain bleeds.)

It is correct that the steriod is given in two shots 12 to 24 hours apart and is no longer repeated q week, as it was in the past.

Viability at 26 weeks varies from institution to institution, but is generally accepted to be 60-70%.

It's important to separate the Doc from the message. It's easy to be angry with them when they are giving bad news. Most people in her position want and need to know everything in order to make the best decisions for themselves. Sometimes that information is hard to take in. It frequently needs to be repeated.

I have a perfectly healthy x 23.5 weeker who just turned six. Let me know if you have any more questions- but no pm's, please. I never check them.