Introduction

Preterm delivery is defined by a birth occurring before 37 weeks of gestation (Hubinont & Debeive, 2011). The incidence of preterm births has been steadily increasing and is associated with 75% of perinatal morbidity and mortality for infants born without congenital anomalies (Iams, 2003). Preterm births have a significant societal cost as well, with each infant born before term associated with an economic burden of $51,600 in 2005 in the United States (Behrman & Butler, 2007). Although preterm labor and subsequent delivery can result from a variety of risk factors, it is impertinent to implement early detection methods in women who are at risk. With no set clinical criteria for diagnosis of preterm labor, most women at risk often are not diagnosed until delivery becomes inevitable (Iams, 2003).

Many pregnant women often confuse symptoms of preterm labor with normal discomforts of pregnancy (Simpson & Creehan, 2008). While obstetricians monitor women through their pregnancy, nursing staff should be responsible for teaching patients about risk factors of preterm labor and recognizing symptoms. Frequent reiteration of symptoms and risk factors will allow nursing staff to detect at risk patients at earlier stages where intervention methods can effectively prolong gestation (Iams, 2003). It is also advisable for nursing staff to make a detailed account of symptoms experienced by the patient at each prenatal visit. Although the one-on-one manner of teaching women about signs of preterm labor has been proven to be effective, standardized instruction to patients in clinical setting is recommended (Simpson & Creehan, 2008). The standardized instruction is more favorable because it does not impose on already stringent time constraints for the nursing staff but also allows pregnant women to discuss symptoms amongst each other and with medical staff.

Learning Contract

A learning contract can be defined as a written agreement between teacher and student which makes explicit what a learner will do to achieve specified learning outcomes (Chan & Chien). Learning contracts encourage self-motivated learning and limit the teacher’s impact and interaction with student, that is prevalent in conventional learning techniques (Chan & Chien). Learning contracts have been used as a teaching and learning strategy for both undergraduate and graduate nursing students in many countries, due to the following advantages offered by it: individualized learning, promote independence and developing strategies which could facilitate lifelong learning (Chan & Chien). Learning contracts are essential to developing the conditions for individualized instruction because they are individually developed (WPI, 2008). Students are more likely to learn, and retain learned information  because learning contracts are based on the content-specific needs, interests and wants of each, independent learner (WPI, 2008).

More specifically, for the course of this project I would like to learn about the risks associated with preterm labor and how nurse-patient interactions can be effective in early detection of onset of premature labor.  Preterm labor is the primary cause of infant morbidity and mortality and therefore has a significant economic burden as well (Hubinont & Debeive, 2011). I would like to learn which level of nurse-patient education is effective and how it can assist in detecting symptoms that would otherwise go unnoticed. An established risk factor in subsequent pregnancies is preterm labor in a woman’s first pregnancy. However, I would like to further investigate which factors put a woman at risk in the first place, i.e. in their first pregnancies.

 

Learning Objective(s) (i.e. What do I want to learn?)	Strategies and Resource(s) required to meet the objective(s) (i.e. How will I learn?)	Evidence (i.e. How will I demonstrate what I have learned)	Criteria for Evaluation & Means of Validation (How do I want to be evaluated)
Determine additional risk factors for preterm birth in mothers experiencing first pregnancies	Secondary research of latest obstetrics and medical journals   Collect primary data from local clinics and determine number of patients experiencing preterm labor in their first pregnancy	The ability to educate nurses about risk factors in first pregnancies	Discuss with instructor and peers
Effectiveness of patient-nurse interaction in early detection of preterm labor   Ability of nurses to recognize symptoms of pre-term labor without being told so explicitly by patient   Learn the level of patient education that is adequate and the scenarios in which patient receives more effective education, i.e. group setting, one-on-one, distant learning, etc.	Correlate number of women who went into preterm labor with the amount of time spent on patient education by nursing staff   Evaluation of patients in preterm labor and assess if they were educated  and how those education sessions took place	Carry out Q&A sessions with clinical patients to assess how much they know about preterm labor and how their nursing staff assisted in their patient education   Poll patients on which teaching methods and scenarios they found most effective versus those that were a waste of time and resources     Determine number of preterm labor cases reported by nurse and see if the nurse was able to recognize symptoms ahead of time	Discuss with patients and record their responses   Carry out meetings with nursing staff and ascertain if they have sufficient resources to fund this project, i.e. time, multimedia, availability of conference rooms etc.   Observe a nurse-patient education session and ascertain if it is meeting objectives or not
Fully understand the economic burden of preterm birth	Study statistics about burden preterm births on the nation as well as families, specifically	Brief peers or instructor about economic burden	Discussion with instructor

 

Literature Review

Preterm birth accounts for 85% of all perinatal mortality and morbidity in newborns (Errol R Norwitz, 2011). Preterm delivery is defined by a birth occurring before 37 weeks of gestation or before 259 days from the last menstrual period (Hubinont & Debeive, 2011). The precise mechanism of preterm labor is still unknown therefore making timely diagnosis increasingly difficult. Research shows that preterm labor could be associated either with a premature activation of the physiological contracting process or with a pathological factor responsible for uterine contractions, leading to preterm delivery (Hubinont & Debeive, 2011).

Although a variety of factors can trigger preterm labor, the established risk factors in expectant mothers are: multiple gestation, prior preterm or low birth weight, gestational bleeding and premature shortening of the cervix (NIH, 2013). Women who have delivered preterm before are at higher risk for preterm labor in subsequent pregnancies as studies show that the risk for preterm delivery increases as the number of preterm births increases (Pschirrer & Monga, 2000). Moreover, mothers with multiple gestation, i.e twins, triplets etc. are at a relatively higher risk of going into preterm labor (NIH, 2013). One study conducted in the United States showed that more than 50% of twin births occurred preterm, compared with only 10% of births of single infants (NIH, 2013). Women who have a short cervix or whose cervix shortens in the second trimester (fourth through six months) of pregnancy instead of the third trimester are also at high risk of preterm delivery (NIH, 2013).

The major causes of preterm birth are indicated in the following diagram:

 (Errol R Norwitz, 2011)

In recent years, obstetricians have become more competent in identifying women at high risk for preterm birth through the introduction of transvaginal cervical length measurements and cervicovaginal fetal fibronectin testing (Errol R Norwitz, 2011).  However, efforts to prevent preterm labor in high risk mothers have met with little success (Errol R Norwitz, 2011). In 2011, the United States Food and Drug Admistration (FDA) approved the use of progesterone supplements to mitigate the risk of recurrent preterm birth in mothers who already had a previous spontaneous preterm delivery (Errol R Norwitz, 2011).

It is important to note that after the onset of preterm labor, common methods of intervention, i.e. hydration, antibiotics, or tocolytic therapy can only delay delivery for 24-48 hours (Errol R Norwitz, 2011). Therefore, it is crucial to identify women who are at a greater risk of preterm labor and to recognize the signs or symptoms of preterm labor. Because certain symptoms of preterm labor may be common in a normal pregnancy, i.e. mild cramps, constant lower backache, it is difficult for patients to recognize and report these in a timely manner to their obstetric caregivers.  There has been little support for home monitoring of uterine activity in expecting mothers with normal pregnancies. However, in patients who are at high risk for preterm labor, home monitoring of uterine activity (HUAM) can serve as an ambulatory screening test for preterm labor ( Agency for Healthcare Research and Quality, 2012).

Unfortunately, protocols to screen for preterm birth do not fulfill the requirements of screening programs and therefore cannot be used for pregnant women who have not displayed any prior symptoms (Iams, 2003). Numerous studies have attempted to screen with numerical scoring systems, microbiologic tests, uterine contraction monitoring, digital and ultrasound examinations of the cervix, and fetal fibronectin assays of cervicovaginal secretions. Prematurity prophylaxis has been attempted with patient education, bed rest, antibiotics, tocolytics, nutritional supplements, cervical cerclage, and social support, all without consistent evidence of benefit (Iams, 2003).

Online research suggests that patient education by nursing staff did not prove effective in preventing preterm labor and therefore was abandoned in the late 1980s. The author failed to locate references which would indicate that patient education was pivotal in screening for at risk patients and those experiencing symptoms of preterm labor for the first time. However, due to the high morbidity and mortality rates associated with preterm labor and subsequent preterm birth, it is important to reinstate patient education offered by nursing staff at regular intervals during the pregnancy and up until 37 weeks gestation when the pregnancy becomes full term.