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Smoking is another major risk factor in premature birth, and even though helping women stop smoking is difficult, nurses can help, Freda says, at the least by simply asking about it and plugging women into community resources, or by actually offering smoking cessation programs.

Carrying multiple fetuses increases the risk of premature labor, says Jeanne Ruiz, RNC, PhD, WHCNP (women’s health care nurse practitioner), assistant professor at the University of Texas Health Science Center at San Antonio. A protocol Ruiz developed for advanced practice nurses to follow with multiples saved about $2 million by decreasing NICU length-of-stays. She is now working to extend the protocol to women carrying a single baby.

“Nurses need to look for the presence of stress, anxiety, and depression, which are all interrelated and all cause changes in body physiology,” Ruiz says. “We know that infections play a role in causing premature labor and stress affects the immune system.”

Down the right path

In addition to identifying stress, nurses can provide ways to alleviate it. At Banner Good Samaritan Medical Center in Phoenix, prenatal massage is offered twice a week. Patients are also given a spiritual assessment, and nurses formed a spiritual care group representing many different faiths that offers support separate from chaplain services.

“Anything that you can do to decrease stress ought to help with preterm labor symptoms,” says Terry Brisley, RN, MFN, WHNP, assistant director for antepartum, postpartum, and gyn surgery. “Nurses need a good list of resources they can refer women to.”

Stress can result from low socioeconomic status, which also affects the level of prenatal care and plays a role in other factors like nutrition and high-risk behavior. But even in these high-risk populations, nursing intervention makes a dramatic difference. LifeCycles is a multifaceted program of San Antonio’s Christus Santa Rosa Hospital, with a mobile and a freestanding clinic in a low-income area, staffed by nurses. In two years, the number of premature births among the clinics’ patients has been cut in half, says Margie Lieck, RNC, MSN, a certified childbirth educator, lactation consultant, and nurse manager for women’s services at Santa Rosa.

Stress may be one of the main culprits in the higher preterm rates for Hispanic and African-American women. Socioeconomic status explains some of these differences, but even African-American women in higher socioeconomic groups have more preterm births.

It is, therefore, especially important for nurses to assess stress in their Hispanic and African-American patients. “If screening determines that a woman is high-risk due to stress, we have to work on what is protective for them,” Ruiz says. “Find out if they are good problem-solvers or have good family support and build on that. Find resources and make sure they get plugged into those that are available.”

Nurses also must ensure — and not assume — that a patient is able to do what she is being asked, Ruiz added. If a woman is given a prescription, for example, a nurse can make sure she can read it, knows where to take it, and has transportation.

The bottom line is making sure all women are as healthy as possible, before pregnancy as well as during it. “Perhaps we should be seeing pregnant women weekly in the first or second month, the way we do in the last month,” Sinclair says. “We’ve been talking about that for a long time, but we haven’t seen the typical schedule change at all.”

“Nurses need to advocate for women to get appropriate education, to be notified and encouraged to come in for early and regular prenatal care,” Sinclair says. “I would love to see the general health care system be more receptive to educating women, and to see more nurse practitioners or midwives on the scene.”

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