Preterm Labour and Birth

Clinical Description

Onset of contractions that cause progressive cervical dilation at < 37 weeks gestation. It’s associated with significant neonatal morbidity and mortality, especially between 28-34 weeks gestation.

Signs and Symptoms

• Lower abdominal pain, lower back pain, may have rupture of the membranes or not, contractions, cervical dilatation, and effacement on VE.

Investigations

• FBC, Urine dipsticks and urine microscopy
• Check MPs and MRDT

Prevention

• Screen and treat asymptomatic UTI / bacteriuria.
• If previous preterm birth and current singleton gestation, then treat with Hydroxyprogesterone Acetate 250mg.
• Offer a choice of either prophylactic vaginal progesterone or prophylactic cervical cerclage to women with:
• A history of spontaneous preterm birth or mid-trimester loss between 16+0 and 34+0 weeks of pregnancy and in whom a transvaginal ultrasound scan has been carried out between 16+0 and 24+0 weeks of pregnancy that reveals a cervical length of < 25 mm.
• Consider prophylactic cervical cerclage for women in whom a transvaginal ultrasound scan has been carried out between 16+0 and 24+0 weeks of pregnancy that reveals a cervical length of < 25 mm and who have either:
• Had PPROM in a previous pregnancy or a history of cervical trauma
• Established preterm labor
• Refer to district hospital if at health Centre
• At the district or tertiary hospital:
• Monitor fetal heart rate and contractions
• IV line with NS at maintenance rate
• Send investigations if available: FBC, urinalysis / urine dipsticks, speculum exam to check for abnormal discharge.
• Do a wet prep/mount for trichomonas and bacterial vaginosis
• USS for presentation, AFI, placental location, EFW, EGA and anatomy
• Give Steroids if gestation age is <34 weeks
• Betamethasone 12 mg IM every 24 hours, 2 doses; or
• Dexamethasone 6 mg 12 hourly, 4 doses
• Tocolytic medications to delay delivery for 48 hours (for steroids) if contractions are present:
• Nifedipine (immediate release) 20 mg load then 10 mg PO if still contracting after 30 minutes and 10mg 2 hourly (hold if maternal BP < 90/50 mm Hg)

Or

• Indomethacin 50-100 mg load then 25- 50mg PO 6 hourly for 48 hours (Only if <32 weeks)

Or

• Salbutamol 250 ug IV slow push over 5 minutes
• Delivery and neonatal care: Refer to district hospital or tertiary hospital if at health centre.
• Inform NICU so that neonatologist or pediatrician may attend delivery
• Deliver with intact membranes if possible
• Minimize trauma by easing out the head in second stage of labour
• Forceps may be used to assist delivery; avoid vacuum extraction
• Clear airway immediately, if necessary, avoid hypothermia and transfer neonate to NICU as soon as possible
• Consider Caesarean delivery if breech presentation
• Consider using Magnesium sulfate for neuroprotection if viable, EGA <32 weeks, and concern for imminent preterm birth (dosage as per preeclampsia protocol; or if IV infusion available, give 4g IV loading dose over 30 minutes, followed by 1 g per hour maintenance).
• If antenatal magnesium sulfate has been started for fetal neuroprotection, tocolysis should be discontinued.
• For planned preterm birth for fetal or maternal indications, magnesium sulfate should be started ideally within 4 hours before birth.
• Magnesium sulfate should be discontinued at delivery, if delivery is no longer imminent, or when a maximum of 24 hours of therapy has been administered.