Guerrero, Cristine P.

BSN IV-C2

PREMATURITY and POST-MATURITY

In humans, premature birth refers to any birth that occurs significantly before or after the
expected date of delivery.
A premature birth is defined as one that occurs less than 37 weeks after conception. A
presumptive reason (usually multiple pregnancy, maternal toxemia or hypertension,
abnormal attachment of the placenta, or congenital malformation of the infant) can be
found for 40 to 60 percent of premature births. Poor maternal health, hygiene, and
nutrition increase the likelihood of prematurity; maternal accidents and acute illness are
insignificant as causes. The chief specific causes of death among premature infants are
respiratory disturbances, infections, and spontaneous hemorrhages, especially into the
brain or lungs. With good care, about 85 percent of all live-born premature infants
should survive; those of higher weight have a better chance.
Prematurity is to be distinguished from intrauterine growth retardation, in which weight
and development are subnormal for fetal age. An estimated 1.5 to 2 percent of all
babies are significantly below a birth weight proper to their fetal age. Deficiency of
transplacental nutrition from various causes is frequently responsible. Other causes
include fetal infections and some malformations. Generally, babies under 5.5 pounds
but carried for more than 37 weeks are considered growth-retarded rather than
premature.
A postmature birth is any birth that occurs more than three weeks after the expected
date of delivery, at which time placental transfer begins to fail, and the fetus receives
decreased amounts of oxygen and nutrients. If birth does not occur naturally or is not
induced, the fetus will die. Postmature newborns are often thin, with dry, wrinkled skin
and unusually long hair and nails. If the postmature child lives through the first few days
after birth, its chances for survival are good.
SIGNS and SYMPTOMS
Premature:
A premature infant's organs are not fully developed. The infant needs special care in a
nursery until the organ systems have developed enough to sustain life without medical
support. This may take weeks to months.
A premature infant will have a lower birth weight than a full-term infant. Common
physical signs of prematurity include:
 Body hair (lanugo)
 Abnormal breathing patterns (shallow, irregular pauses in breathing called
apnea)
 Enlarged clitoris (female infant)
  Problems breathing due to immature lungs (neonatal respiratory distress
syndrome) or pneumonia
 Lower muscle tone and less activity than full-term infants
 Problems feeding due to difficulty sucking or coordinating swallowing and
breathing
 Less body fat
 Small scrotum, smooth without ridges, and undescended testicles (male infant)
 Soft, flexible ear cartilage
 Thin, smooth, shiny skin, which is often transparent (can see veins under skin)

Postmature:
 Before delivery there may be reduced fetal movement.
 A reduced volume of amniotic fluid may cause a reduction in the size of the
uterus.
 Meconium-stained amniotic fluid may be seen when the membranes have
ruptured.
 When post-mature the neonate has lower than normal amounts of subcutaneous
fat and reduced mass of soft tissue.
 The skin may be loose, flaky and dry.
 Fingernails and toenails may be longer than usual and stained yellow from
meconium.

NURSING DIAGNOSIS FOR PREMATURE AND POSTMATURE:

Premature:
 Impaired Gas Exchange related to inadequate surfactant levels
 Ineffective Thermoregulation related to prematurity and low birth weight
 Altered Nutrition less than Body Requirements related to respiratory distress

Postmature:
 Ineffective airway clearance related to meconium aspiration syndrome.
Or
Impaired gas exchange related to meconium aspiration syndrome
*The infant maintains spontaneous, unassisted regular respirations
* Arterial blood gases are within normal limits
* Transcutaneous oxygen monitor demonstrates adequate oxygenation
 Imbalanced nutrition, less than body requirement related to postmaturity
* The infant receives adequate nutritional intake for maintenance of homeostasis.
 high risk for hypothermia related to depleted stores of subcutaneous fat.
* The infant exhibits the absence of cold stress.
DIAGNOSTICS AND LABORATORIES
Premature:
 Blood gas analysis
 Blood tests to check glucose, calcium, and bilirubin levels
 Chest x-ray
 Continuous cardiorespiratory monitoring (monitoring of breathing and heart rate)
 Fetal fibronectin-  has become the most important biomarker—the presence of
this glycoprotein in the cervical or vaginal secretions indicates that the border
between the chorion and deciduas has been disrupted. A positive test indicates
an increased risk of preterm birth, and a negative test has a high predictive
value. It has been shown that only 1% of women in questionable cases of
preterm labor delivered within the next week when the test was negative.
 Ultrasonography of the cervix- Obstetric ultrasound has become useful in the
assessment of the cervix in women at risk for premature delivery. A short cervix preterm
is undesirable: At 24 weeks gestation a cervix length of less than 25 mm defines a risk
group for preterm birth. Further, the shorter the cervix the greater the risk. It also has
been helpful to use ultrasonography in women with preterm contractions, as those
whose cervix length exceeds 30 mm are unlikely to deliver within the next week.

Postmature:
Fetal movement counting - keeping track of fetal kicks and movements. A
change in the number or frequency may mean the fetus is under stress.
 Non-stress testing - a test that watches the fetal heart rate for increases with
fetal movements, a sign of fetal well-being.
 Biophysical profile - a test that combines the nonstress test with an ultrasound
to evaluate fetal well-being.
 Ultrasound - a diagnostic imaging technique which uses high-frequency sound
waves and a computer to create images of blood vessels, tissues, and organs.
Ultrasounds are used to view internal organs as they function, and to assess
blood flow through various vessels. Ultrasounds are used to follow fetal growth.
 Doppler flow studies - a type of ultrasound which uses sound waves to
measure blood flow.
If tests determine that it is no longer healthy for the fetus to stay in the mother's
uterus, labor may be induced, to deliver the baby.
The decision to induce labor for post-term pregnancy depends on many factors. During
labor, the fetal heart rate may be monitored with an electronic monitor to identify
changes in the heart rate due to low oxygenation. Changes in a baby's condition may
require a cesarean delivery.
COMPLICATIONS
Premature:
Possible complications that may occur while in the hospital include:
 Anemia
 Bleeding into the brain (intraventricular hemorrhage of the newborn) or damage
to the brain's white matter (periventricular leukomalacia)
 Infection or neonatal sepsis
 Low blood sugar (hypoglycemia)
 Neonatal respiratory distress syndrome, extra air in the tissue of the lungs
(pulmonary interstitial emphysema), bleeding in the lungs (pulmonary
hemorrhage)
 Newborn jaundice
 Patent ducturs arteriosus
 Severe intestinal inflammation (necrotizing enterocolitis)
 Possible long-time complications include:
 Bronchopulmonary dysplasia (BPD)
 Delayed growth and development
 Mental or physical disability or delay
 Retinopathy of prematurity, vision loss, or blindness

Postmature:
 Asphyxia
 Meconium aspiration:
Often, the postterm infant has expelled Meconium in utero. At birth, the
meconium may be aspirated into the lungs, obstructing the respiratory passages
and irritating the lungs, and this may lead to pneumonia. Whenever meconium-
stained amniotic fluid is detected in any delivery, oral and nasopharyngeal
suctioning often is performed as soon as the head is born. After delivery, gastric
lavage also may be performed to remove any meconium swallowed and to
prevent aspiration of vomitus.
 Poor nutrition status; depleted glycogen reserves cause hypoglycemia
In the last weeks of gestation, the infant relies on glycogen for nutrition. This
depletes the liver glycogen stores and may result in hypoglycemia.
 Polycythemia; because of intrauterine hypoxia
This puts the infant at risk for cerebral ischemia, hypoglycemia, thrombus
formation, and respiratory distress as a result of hyper viscosity of Polycythemia.
 Difficult delivery due to increased size
  Birth defects
 Seizures, due to hypoxia
 Decreased amniotic fluid volume:
Amnioinfusion is sometimes used during labor if there is very little amniotic fluid
or the fetus is compressing the umbilical cord. In amnioinfusion, a sterile fluid is
instilled with a catheter (hollow tube) into the broken amniotic sac to help replace
the low levels of fluid and cushion the fetus and cord.
RISK FACTORS
Premature:

Preterm infants usually show physical signs of prematurity in reverse proportion to

the gestational age. As a result they are at risk for numerous medical problems affecting
different organ systems.

 Neurological problems include apnea of prematurity, hypoxic-

ischemic encephalopathy (HIE), retinopathy of prematurity (ROP), developmental
disability, cerebral palsy andintraventricular hemorrhage, the latter affecting 25
percent of babies born preterm, usually before 32 weeks of pregnancy. Mild brain
bleeds usually leave no or few lasting complications, but severe bleeds often
result in brain damage or even death. Neurodevelopmental problems have been
linked to lack of maternal thyroid hormones, at a time when their own thyroid is
unable to meet postnatal needs.[
 Cardiovascular complications may arise from the failure of the ductus
arteriosus to close after birth: patent ductus arteriosus (PDA).
 Respiratory problems are common, specifically the respiratory distress
syndrome (RDS or IRDS) (previously called hyaline membrane disease). Another
problem can be chronic lung disease (previously called bronchopulmonary
dysplasia or BPD).
 Gastrointestinal and metabolic issues can arise from hypoglycemia, feeding
difficulties, rickets of prematurity, hypocalcemia, inguinal hernia, and necrotizing
enterocolitis (NEC).
 Hematologic complications include anemia of prematurity, thrombocytopenia,
and hyperbilirubinemia (jaundice) that can lead to kernicterus.
 Infection, including sepsis, pneumonia, and urinary tract infection [

 A large study on children born between 22 and 25 weeks who were currently at
school age found that 46 percent had severe or moderate disabilities such as
cerebral palsy, vision or hearing loss and learning problems. 34 percent were
 mildly disabled and 20 percent had no disabilities, while 12 percent had disabling
cerebral palsy.

Postmature:
Previous prolonged pregnancy increases risk of recurrence in subsequent
pregnancies two- to three-fold.
Few pre-natal risk factors are known. However recent work suggests an association
with:
 BMI > 35.
 Primigravidity.
 Fish consumption in first 2 trimesters.

NURSING MANAGEMENT
Premature:
Nursing interventions for the premature neonate should focus on maintaining an
environment that’s similar to the intrauterine environment. Care should be based on
knowledge of the premature neonate’s physiologic problems and the need to conserve
energy for growth and repair.
Specific Nursing Responsibilities include:
 Rapid initial evaluation
 Resuscitative measures, if needed
 Thermoregulation
 Administration of respiratory support measures
 Electronic monitoring
 Parenteral fluids, as ordered
 Medications, as ordered
 Blood specimen analysis, as ordered

Postmature:
During the ante partum period the nurse contributes to the assessment for identification
of prolonged pregnancy and often conducts non- stress test to monitor fetal well being.
Identification & management of maternal reactions are important components of the
nursing care plan. Emotional responses of the women can reflect feelings of fatigue,
frustration and anger as the pregnancy “never seems to end”. She may experience
negative feelings about her ability to cope & her “normality as a woman”. Fears for the
safety of her and the baby’s future development can arise.

Intrapartum nursing care of the fetus is the same as for all other labors. It may be similar
to that needed for fetopelvic disproportion & dystotic labor. Parental fears are
recognized & support is offered.

After birth the neonate is assessed in the same manner as all the newborns. Immediate
care is similar to that given to preterm infant.
 Prepare for possible resuscitation of asphyxiated infant at delivery.
 Perform direct visualization & suctioning when meconium is present in amniotic
fluid
 Ongoing Assessment of respiratory status of the infant
 Monitor oxygenation by invasive or non – invasive methods.
 Provide nutritional support as needed
 Monitor dextrostix until frequently
 Provide neutral thermal environment & monitor temperature continuously
 Monitor haematocrit & report abnormalities
 Observe, document & report any signs of birth injuries, limpness, abnormal
movement of extremities
 Provide information, support & resources for parents

THERAPEUTIC MANAGEMENT
Premature:
Tertiary interventions are aimed at women who are about to go into preterm labor, or
rupture the membranes or bleed preterm. The use of the fibronectin test and
ultrasonography improves the diagnostic accuracy and reduces false-positive diagnosis.
While treatments to arrest early labor where there is progressive cervical dilatation and
effacement will not be effective to gain sufficient time to allow the fetus to grow and
mature further, it may defer delivery sufficiently to allow the mother to be brought to a
specialized center that is equipped and staffed to handle preterm deliveries.
 Glucocorticosteroids- Severely premature infants may have underdeveloped
lungs, because they are not yet producing their own surfactant. This can lead
directly to respiratory distress syndrome, also called hyaline membrane disease,
in the neonate. To try to reduce the risk of this outcome, pregnant mothers with
threatened premature delivery prior to 34 weeks are often administered at least
one course of glucocorticoids, a steroid that crosses the placental barrier and
stimulates the production of surfactant in the lungs of the fetus. 
 Tocolysis- Anti-contraction medications (tocolytics), such as Beta2-agonist drugs
(ritodrine, terbutaline, fenoterol), calcium-channel blockers nifedipine and oxytocin
antagonists (atosiban) appear only to have a temporary effect in delaying delivery.
Tocolysis has not fulfilled its promise as it is rarely successful beyond 24–48 hours
because current medication do not alter the fundamentals of labor activation
Postmature:
Management of prolonged pregnancy in the absence of other complications is
controversial:
 recommended that women should be offered induction after 41 weeks.
 Women who decline induction should be offered increased antenatal monitoring
from 42 weeks, consisting of twice-weekly cardiotocography (CTG) and
ultrasound estimation of single deepest amniotic pool. A pool depth of < 8 cm
indicates increased intrapartum risk to the fetus.
 If expectant management is used, some sources recommend labor should be
induced at the beginning of the 43rd week.
 Postmature newborns that experience low oxygen levels and fetal distress may need
resuscitation at birth. If meconium is present in the amniotic fluid and the newborn is
lethargic, a tube is passed into the windpipe (trachea) to suction as much meconium as
possible from the respiratory tract. If meconium has been breathed into the lungs, a
ventilator may be needed to support breathing. Intravenous sugar (glucose) solutions or
frequent breast milk or formula feedings are given to prevent hypoglycemia.

If these problems do not occur, the major goal is to provide good nutrition so that
postmature newborns can catch up to the weight that is appropriate for them.