Question

Katie, a G2 P1 at 33 weeks’ gestation, presented to the Emergency room complaining of menstrual-like cramping and pelvic pressure. What do you suspect is happening? Describe the plan of care for this patient.

Answer 1

At 33 weeks pregnant, cramping like you’d have with a period could be a sign of preterm labor. So can vaginal bleeding, unusual discharge or leaking. At 33 weeks pregnant, pressure in your pelvis could be a sign too. Be on the lookout for these symptoms.

At 33 weeks gestation there may be presence of false labor pain called Braxton Hicks contractions.

Braxton Hicks aren’t painful and often happen after exercise. They’re different from regular contractions because they stop when you switch positions.

Real contractions keep going—there’d be at least five in an hour—and mean actual labor.And it’s early still, so at this point having real contractions would be considered preterm labor. Certain complications and conditions make you more likely to go into labor early, such as having excess amniotic fluid, being dehydrated or being 33 weeks pregnant with twins

Plan of Care

Tests and procedures to diagnose preterm labor include:

• Pelvic examination: Your health care provider might evaluate the firmness and tenderness of your uterus and the baby's size and position. If your water hasn't broken and there's no concern that the placenta is covering the cervix (placenta previa), he or she might also do a pelvic examination to determine whether your cervix has begun to open. Your health care provider might also check for uterine bleeding.
• Ultrasound. A transvaginal ultrasound might be used to measure the length of your cervix. An ultrasound might also be done to check for problems with the baby or placenta, confirm the baby's position, assess the volume of amniotic fluid, and estimate the baby's weight.
• Uterine monitoring. Your health care provider might use a uterine monitor to measure the duration and spacing of your contractions.
• Lab tests. Your health care provider might take a swab of your vaginal secretions to check for the presence of certain infections and fetal fibronectin — a substance that acts like a glue between the fetal sac and the lining of the uterus and is discharged during labor. These results will be reviewed in combination with other risk factors. You'll also provide a urine sample, which will be tested for the presence of certain bacteria.

Treatment

Medications

Once you're in labor, there are no medications or surgical procedures to stop labor, other than temporarily. However, your doctor might recommend the following medications:

• Corticosteroids. Corticosteroids can help promote your baby's lung maturity. If you are between 23 and 34 weeks, your doctor will likely recommend corticosteroids if you are thought to be at increased risk of delivery in the next one to seven days. Your doctor may also recommend steroids if you are at risk of delivery between 34 weeks and 37 weeks.

  You might be given a repeat course of corticosteroids if you're less than 34 weeks pregnant, at risk of delivering within seven days, and you had a prior course of corticosteroids more than 14 days previously.

• Magnesium sulfate. Your doctor might offer magnesium sulfate if you have a high risk of delivering between weeks 24 and 32 of pregnancy. May be for this patient it's not needed as she is at 33 weeks gestation.

• Tocolytics. Your health care provider might give you a medication called a tocolytic to temporarily slow your contractions. Tocolytics may be used for 48 hours to delay preterm labor to allow corticosteroids to provide the maximum benefit or, if necessary, for you to be transported to a hospital that can provide specialized care for your premature baby.

  Tocolytics don't address the underlying cause of preterm labor and overall have not been shown to improve babies' outcomes. Your health care provider won't recommend a tocolytic if you have certain conditions, such as pregnancy-induced high blood pressure (pre eclampsia)