Preterm Labor

Preterm labor: Clinical findings, diagnostic evaluation, and initial treatment - UpToDate 10/13/20, 12:13 PM
Author: Charles J Lockwood, MD, MHCM

Section Editor: Vincenzo Berghella, MD
Deputy Editor: Vanessa A Barss, MD, FACOG
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2020. | This topic last updated: Jun 12, 2020.
INTRODUCTION
Identifying women with preterm contractions who will go on to deliver preterm is an inexact process, even
though preterm labor is one of the most common reasons for hospitalization of pregnant women. Accurate
identification of women in true preterm labor allows appropriate application of interventions that can improve
neonatal outcome: antenatal corticosteroid therapy, group B streptococcal infection prophylaxis, magnesium
sulfate for neuroprotection, and transfer to a facility with an appropriate level of newborn care (if necessary).
Just as important, accurate identification of women not actually in preterm labor avoids unnecessary and
sometimes costly interventions in the approximately 50 percent of patients with suspected preterm labor who
subsequently deliver at term without tocolytic therapy [1].
This topic will describe the clinical findings and diagnostic evaluation of women who present with signs and
symptoms of preterm labor, and initial treatment of women in whom a diagnosis of preterm labor is made. Risk
factors, prevention, and tocolytic therapy for preterm labor are discussed separately. (See "Preterm birth: Risk
factors, interventions for risk reduction, and maternal prognosis" and "Inhibition of acute preterm labor".)
PATHOGENESIS OF PRETERM LABOR

The pathophysiology of preterm labor involves at least four primary pathogenic processes that result in a final
common pathway ending in spontaneous preterm labor and delivery:
● Premature activation of the maternal or fetal hypothalamic-pituitary-adrenal axis

● Inflammation and infection
● Decidual hemorrhage
● Pathological uterine distention
These processes and the pathophysiology of normal labor are discussed in detail separately. (See
"Pathogenesis of spontaneous preterm birth" and "Physiology of parturition".)
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CLINICAL FINDINGS
The clinical findings that define true labor (ie, regular contractions plus cervical change) are the same whether
labor occurs preterm or at term. The following prodromal signs and symptoms may be present for several hours
before diagnostic criteria for labor are met:
● Menstrual-like cramping
● Mild, irregular contractions
● Low back ache
● Pressure sensation in the vagina or pelvis
● Vaginal discharge of mucus, which may be clear, pink, or slightly bloody (ie, mucus plug, bloody show)
● Spotting, light bleeding
Uterine contractions are the sine qua non of labor, but mild irregular contractions are a normal finding at all
stages of pregnancy, thereby adding to the challenge of distinguishing true labor (contractions that result in
cervical change) from false labor (contractions that do not result in cervical change [ie, Braxton Hicks
contractions]). True labor is more likely when an increasing frequency of contractions is accompanied by
increasing intensity and duration of the contractions since an increase in the frequency alone may occur
transiently, especially at night and with increasing gestational age. Although many investigators have tried, no
one has been able to identify a threshold contraction frequency that effectively identifies women who will
progress to true labor. Only 13 percent of women presenting at <34 weeks of gestation who meet explicit
contraction criteria for preterm labor deliver within one week [2].
Cervical changes on physical examination that precede or accompany true labor include dilation, effacement,
softening, and movement to a more anterior position. The rate of cervical change distinguishes cervical
ripening, which occurs over days to weeks, from true labor, in which cervical change occurs over minutes to
hours. A short or a dilated cervix may be the first clinical manifestation of impending preterm labor triggered by
subclinical inflammation [3].
COMPONENTS OF THE DIAGNOSTIC EVALUATION

In most women, the diagnostic evaluation is performed on the labor unit or a labor triage unit. However, the
clinician may elect to evaluate women with very mild, nonspecific symptoms in the office.
History and initial examinations — Our initial evaluation of women with suspected preterm labor includes:
● Review of the patient's past and present obstetric and medical history, including risk factors for preterm
birth (table 1). Although many cases appear to be idiopathic, clinicians should consider possible causes of
the preterm contractions based on the history and physical examination.
Preterm labor may be triggered by an underlying obstetric complication (eg, abruption) or medical/surgical
disorder (eg, appendicitis, bowel obstruction or strangulation, pyelonephritis, acute cholecystitis,

pneumonia [4]) that requires specific intervention. These cases may present with additional symptoms
and/or symptoms atypical for preterm labor. Sometimes, this requires a high index of suspicion since
laboring women have abdominal pain and may have back pain, nausea, vomiting, or diarrhea.
● Assessment of gestational age, based on the best estimate from the first ultrasound examination [5]. If prior
ultrasound estimation of gestational age is not available, an ultrasound examination for fetal biometry to
assist in estimation of gestational age should be performed. (See "Prenatal assessment of gestational age,
date of delivery, and fetal weight".)
● Evaluation of signs and symptoms of preterm labor. (See 'Clinical findings' above.)
● Maternal vital signs (temperature, blood pressure, heart rate, respiratory rate).
● Review of the fetal heart rate pattern. (See "Intrapartum fetal heart rate monitoring: Overview".)
● Assessment of contraction frequency, duration, and intensity. (See "Management of normal labor and
delivery", section on 'Uterine contractions'.)
● Examination of the uterus to assess firmness, tenderness, fetal size, and fetal position.
Speculum examination — We perform a speculum examination using a wet non-lubricated speculum

(lubricants may interfere with tests performed on vaginal specimens). The goals of this examination are to:
● Estimate cervical dilation. Cervical dilation ≥3 cm supports the diagnosis of preterm labor.
● Assess the presence and amount of uterine bleeding. Bleeding from abruptio placentae or placenta previa
can trigger preterm labor. (See "Placental abruption: Pathophysiology, clinical features, diagnosis, and
consequences" and "Placenta previa: Epidemiology, clinical features, diagnosis, morbidity and mortality".)
● Evaluate fetal membrane status (intact or ruptured) by standard methods. Preterm prelabor rupture of
membranes (PPROM) often precedes or occurs during preterm labor. Diagnosis and management of
PPROM are reviewed separately. (See "Preterm prelabor rupture of membranes: Clinical manifestations
and diagnosis".)
● Use a swab to obtain a cervicovaginal fluid specimen in case fetal fibronectin (fFN) testing is desired after
transabdominal ultrasound examination. The swab is rotated in the posterior fornix for 10 seconds.
"Blind" sampling without a speculum is also acceptable. In one method, the posterior vaginal wall is
depressed with an unlubricated, gloved finger and then the polyester swab is slowly passed along the
finger toward the posterior fornix until resistance is felt [6]. In another method, the labia are held apart and
then the swab is blindly inserted into the vagina and directed slowly toward the posterior fornix until
meeting resistance [7]. In both methods, it is important to stop at the first sign of resistance to avoid
rupturing exposed membranes, if present. (See 'Fetal fibronectin for selected patients' below.)
Digital cervical examination — In most patients, cervical dilation and effacement are assessed by digital
examination after placenta previa and rupture of membranes have been excluded by history and physical,
laboratory, and ultrasound examinations, as appropriate. A digital examination should be performed before
speculum examination if the information is urgently needed to care for the patient (eg, abnormal fetal heart rate,
probable advanced phase of active labor) and placenta previa is unlikely. As discussed above, cervical dilation
>3 cm in the presence of uterine contractions at 20+0 to 36+6 weeks supports the diagnosis of preterm labor;
inhibition of acute preterm labor is less likely to be successful as the cervix dilates beyond 3 cm.
When assessing cervical dilation and effacement in the second trimester, it is important to distinguish between
patients whose membranes have hour-glassed (prolapsed) through a mildly dilated and effaced cervix
(suggestive of cervical insufficiency) and those who are in active labor with advanced cervical dilation and
effacement. Transvaginal ultrasound (TVUS) assessment of the cervix can help distinguish between the two
entities when the diagnosis is uncertain. (See "Cervical insufficiency", section on 'Physical examination-based
cervical insufficiency' and "Transvaginal cervical cerclage", section on 'Replacement of prolapsed membranes'.)
Transvaginal ultrasound examination — TVUS measurement of cervical length is useful for supporting or
excluding the diagnosis of preterm labor when the diagnosis is unclear. A short cervix before 34 weeks of
gestation (<30 mm) is predictive of an increased risk for preterm birth in all populations, while a long cervix (≥30
mm) has a high negative predictive value for preterm birth. Knowledge of cervical length in women with
threatened preterm labor may improve outcome, particularly avoidance of unnecessary hospitalization and
interventions when the cervix is long, but data are limited [8].
The procedure for measurement of cervical length is described separately. (See "Short cervix before 24 weeks:
Screening and management in singleton pregnancies".)
Obstetric ultrasound examination — Obstetric ultrasound examination provides other useful information,
including presence/absence of fetal, placental, and maternal anatomic abnormalities; confirmation of fetal
presentation; assessment of amniotic fluid volume; and estimated fetal weight. This information may be used for
counseling the patient about the potential causes and outcomes of preterm birth and determining the best route
of delivery.
Laboratory evaluation
Overview — We order the following laboratory tests:
● Rectovaginal group B streptococcal culture, if not done within the previous five weeks; antibiotic
prophylaxis depends on the results. (See "Neonatal group B streptococcal disease: Prevention", section on
'Special populations'.)
● Urine culture since asymptomatic bacteriuria is associated with an increased risk of preterm labor and birth.
(See "Urinary tract infections and asymptomatic bacteriuria in pregnancy".)
● Drug testing in patients with risk factors for substance abuse, given the link between cocaine and
methamphetamine use and placental abruption. (See "Substance use during pregnancy: Screening and
prenatal care" and "Testing for drugs of abuse (DOA)".)
● fFN in women <34 weeks of gestation with cervical dilation <3 cm and cervical length 20 to 30 mm on
TVUS examination. (See 'Cervical length 20 to <30 mm' below.)
● Testing for sexually transmitted infections (eg, chlamydia, gonorrhea) depends on the patient’s risk factors
for these infections and, if indicated, whether antepartum testing was recently performed. (See "Prenatal
care: Second and third trimesters", section on 'Screen for sexually transmitted infections'.)
Fetal fibronectin for selected patients — fFN is an extracellular matrix protein present at the decidual-
chorionic interface. Disruption of this interface due to subclinical infection or inflammation, abruption, or uterine
contractions releases fFN into cervicovaginal secretions, which is the basis for its use as a marker for predicting
spontaneous preterm birth [9].
Measurement of fFN is performed to distinguish women in true preterm labor from those with false labor.
Theoretically, accurate identification of women in true preterm labor provides an opportunity for interventions
that can improve neonatal outcome (eg, antenatal corticosteroid therapy, group B streptococcal infection
prophylaxis, magnesium sulfate for neuroprotection, transfer to a facility with an appropriate level nursery, if
necessary). It should also avoid unnecessary and sometimes costly intervention for the approximately 50
percent of patients who will subsequently deliver at term without tocolytic therapy [1].
However, fFN results alone are not useful [10,11]. In a systematic review of six randomized trials in which a total
of 546 women with threatened preterm labor were randomly assigned to management with reported or
concealed fFN results, clinician knowledge of fFN results did not reduce rates of maternal hospitalization (risk
ratio [RR] 1.06, 95% CI 0.79-1.43) or preterm birth <34 weeks (RR 1.09, 95% CI 0.54-2.18) [12]. Use of
tocolytics and betamethasone, gestational age at delivery, rate of respiratory distress syndrome, and number of
days in a neonatal intensive care unit were similar for both groups. Costs were increased in the reported group
[10]. It is possible that physicians place greater significance on positive test results than on negative results,
resulting in an overall increase in health care utilization [13].
The review excluded studies in which management involved use of both fFN and sonographic cervical length,
which is our approach. We obtain fFN selectively, limiting its use to women with cervical length 20 to 30 mm.
(See 'Cervical length 20 to <30 mm' below.)
Qualitative fFN — Qualitative fFN results are reported as positive or negative. A positive fFN test refers
to a fFN concentration ≥50 ng/mL in cervicovaginal fluid between 22+0 and 34+6 weeks of gestation in women
with intact membranes, cervical dilation <3 cm, and no gross vaginal bleeding. A positive fFN result correlates
with an increased risk of preterm delivery within seven days.
In women with signs and symptoms of preterm labor, a systematic review of five randomized trials and 15
diagnostic test accuracy studies evaluating cervicovaginal fFN for predicting preterm birth reported the following
pooled estimates [14]:
● Delivery within 7 to 10 days of testing – Sensitivity and specificity 76.7 and 82.7 percent, respectively
● Delivery <34 weeks of gestation – Sensitivity and specificity 69.1 and 84.4 percent, respectively
● Delivery <37 weeks of gestation – Sensitivity and specificity 60.8 and 82.3 percent, respectively
Positive and negative predictive values depend on the prevalence of preterm birth in the population. In a
systematic review in which the prevalence of preterm birth within seven days of sampling varied from 2 to 30
percent among the included studies, the overall pretest probability of delivery within seven days of testing was
7.7 percent, and based on positive or negative fFN results, the posttest probabilities were 25.9 and 2.4 percent,
respectively [15].
False-positive results can occur due to ejaculate from coitus within the previous 24 hours, a grossly bloody
specimen, or digital cervical examination [16-18]. Theoretically, TVUS examination may cause a false positive
result, but in one study all 25 women with a negative baseline fFN test had a second negative fFN test post-
ultrasound [19]. Administration of intravaginal substances, such as lubricants, medications, or douching may
interfere with the assay [20].
Quantitative fFN — Quantitative measurement of fFN appears to improve predictive value compared
with use of the qualitative test using a 50 ng/mL threshold [21-23]. In symptomatic women, the positive
predictive values of fFN thresholds of 10, 50, 200, and 500 ng/mL for preterm birth within 14 days were 11, 20,
37, and 46 percent, respectively, in one prospective blinded study [21]. For preterm birth <34 weeks of
gestation, positive predictive values for the same thresholds were 19, 32, 61, and 75 percent, respectively.
Instrumentation for quantitative measurement of fFN is not commercially available in the United States.
The combination of quantitative fFN testing and cervical length measurement in symptomatic women increases
predictive value [24]. An algorithm combining quantitative fFN and cervical length, demographic information,
and obstetric history (previous spontaneous preterm birth/preterm prelabor rupture of membranes or suspected
preterm labor) has been incorporated into an App (QUiPP) for prediction of spontaneous preterm birth in
Europe [25-27].
Other laboratory tests — Like fFN, placental alpha-microglobulin-1 (PAMG-1) [28-30] or phosphorylated
insulin-like growth factor binding protein-1 (pIGFBP-1) [31] in vaginal or cervical secretions suggests disruption
of the fetal membranes (ROM or labor) and are potential markers of an increased risk of preterm birth.
However, the utility of these tests has not been validated in either large or randomized clinical trials.
In the largest study, which included 796 women with signs and symptoms of preterm labor, the sensitivities of
PAMG-1 and fFN for spontaneous preterm birth within seven days were 50 percent (3/6) and 67 percent (4/6),
respectively, and specificities were 98.4 percent (619/629) and 85.7 percent (539/629), respectively [30]. In a
prospective study that compared PAMG-1 with pIGFBP-1 in women in preterm labor with intact membranes,
dilation ≤3 cm, and cervical length 15 to 30 mm, both tests had similar sensitivity (75 to 85 percent) for delivery
within seven days, but PAMG-1 was more specific (95 versus 77 percent) [32].
DIAGNOSIS
We make the diagnosis of preterm labor based upon clinical criteria of regular painful uterine contractions
accompanied by cervical change (dilation and/or effacement). Vaginal bleeding and/or ruptured membranes in
this setting increase diagnostic certainty [33]. Because the clinical findings of early labor are poorly predictive of
the diagnosis, over-diagnosis is common until labor is well established.
We use the following specific criteria: Uterine contractions (≥4 every 20 minutes or ≥8 in 60 minutes) plus
● Cervical dilation ≥3 cm or
● Cervical length <20 mm on transvaginal ultrasound or
● Cervical length 20 to <30 mm on transvaginal ultrasound and positive fetal fibronectin
The contraction criteria are those used for selecting subjects in research settings. Before the use of ultrasound
for measuring cervical length, research studies also required documented cervical change or cervical
effacement ≥80 percent or cervical dilation >2 cm. These criteria were chosen because women who did not
meet them were often ultimately diagnosed with false labor and went on to have a late preterm or term delivery
[34].
APPROACH TO TRIAGE: SINGLETON PREGNANCIES
≥34 weeks of gestation — Women in preterm labor at ≥34 weeks are admitted for delivery. After an
observation period of four to six hours, women without progressive cervical dilation and effacement are
discharged to home, as long as fetal well-being is confirmed (eg, reactive nonstress test) and obstetric
complications associated with preterm labor, such as abruptio placentae, chorioamnionitis, and preterm rupture
of membranes, have been excluded. We arrange follow-up in one to two weeks and give the patient instructions
to call if she experiences additional signs or symptoms of preterm labor, or has other pregnancy concerns (eg,
bleeding, rupture of membranes, decreased fetal activity). (See "Patient education: Preterm labor (Beyond the
Basics)".)
The 34th week of gestation is the threshold at which perinatal morbidity and mortality are too low to justify the
potential maternal and fetal complications and costs associated with inhibition of preterm labor, which only
results in short term delay in delivery (see "Inhibition of acute preterm labor", section on 'Lower and upper
gestational age limits'). Furthermore, we generally do not administer antenatal corticosteroids after 34 weeks of
gestation because of the low risk of severe respiratory morbidity at this gestational age and the theoretic
potential for long-term harm following late exposure. The risks, benefits, and controversies regarding steroid
use after 34 weeks are discussed in detail separately. (See "Antenatal corticosteroid therapy for reduction of
neonatal respiratory morbidity and mortality from preterm delivery".)
<34 weeks of gestation — In women <34 weeks with uterine contractions, cervical dilation ≥3 cm supports the
diagnosis of preterm labor. We initiate treatment of preterm labor in these women to reduce the morbidity and
mortality of preterm birth. Further diagnostic evaluation with sonographic measurement of cervical length or
laboratory assessment of fetal fibronectin (fFN) is not performed because these tests do not enhance diagnostic
accuracy in this setting. (See 'Initial treatment of women with preterm labor <34 weeks' below.)
The diagnosis of preterm labor is less clear in women with contractions, cervical dilation <3 cm, and intact
membranes. Our approach to diagnosis and treatment in these cases is shown in the algorithm and discussed
below (algorithm 1). The use of cervical length measurement, with fFN in selected cases, is based upon clinical
experience and accumulating data on risk of preterm birth according to cervical length on transvaginal
ultrasound, in the absence of abruption [2,33,35-39].
Cervical length 20 to <30 mm — Symptomatic women with cervical dilation <3 cm and cervical length 20 to
<30 mm are at increased risk of preterm birth compared with women with longer cervical lengths, but most of
these women do not deliver preterm. Therefore, for this subgroup of women, we send a cervicovaginal sample
for fFN testing (see 'Fetal fibronectin for selected patients' above). We believe that selective testing helps
reduce diagnostic uncertainty and, in turn, unnecessary intervention, by identifying the significant proportion of
patients in this group who are at low (<5 percent) risk of preterm delivery within seven days [40]. Since the test
is expensive, reducing the number of women tested by one-third is advantageous [41-43].
If the fFN test is positive, we begin interventions to reduce morbidity associated with preterm birth (see 'Initial
treatment of women with preterm labor <34 weeks' below). If the fFN test is negative, we discharge the patient
after 6 to 12 hours of observation, given its high negative predictive value (98 to 100 percent for delivery within
7 or 14 days [44]) [14].
Use of sonographic cervical length and fFN determinations to differentiate true labor from false labor in preterm
symptomatic women are supported by the American College of Obstetricians and Gynecologists [45] and
Society for Maternal-Fetal Medicine [46], although high quality evidence of efficacy is not available.
Cervical length <20 mm — Symptomatic women with cervical length <20 mm are at high risk (>25 percent)
of delivery within seven days; the addition of fFN testing does not significantly improve the predictive value of
cervical length measurement alone [40-42,47,48]. Therefore, we do not send their cervicovaginal samples to
the laboratory for fFN testing and we begin interventions to reduce morbidity associated with preterm birth. (See
'Initial treatment of women with preterm labor <34 weeks' below.)
Cervical length ≥30 mm — Approximately 50 percent of women with symptoms of preterm labor have a
transvaginal ultrasound cervical length ≥30 mm [36]. Symptomatic women with cervical length ≥30 mm are at
low risk (<5 percent) of delivery within seven days, regardless of fFN result; the addition of fFN testing does not
significantly improve the predictive value of cervical length measurement alone [40,41,47,48]. Therefore, we do
not send their cervicovaginal samples to the laboratory for fFN testing.
After an observation period of four to six hours, women without progressive cervical dilation and effacement are
discharged to home, as long as fetal well-being is confirmed (eg, reactive nonstress test) and obstetric
complications associated with preterm labor, such as abruptio placenta, chorioamnionitis, and preterm rupture
of membranes, have been excluded. We arrange follow-up in one to two weeks and give the patient instructions
to call if she experiences additional signs or symptoms of preterm labor, or has other pregnancy concerns (eg,
bleeding, rupture of membranes, decreased fetal activity). (See "Patient education: Preterm labor (Beyond the
Basics)".)
APPROACH TO TRIAGE: TWIN PREGNANCIES

The prediction of preterm birth based on cervical length measurement is somewhat different for twin
pregnancies, which necessitates some changes in triage criteria. The optimal cervical length threshold appears
to be higher due to the higher baseline risk for preterm birth in twins compared with singletons; however, less
data are available for establishing appropriate thresholds [49,50].
≥34 weeks of gestation — Triage is the same as for singletons. (See '≥34 weeks of gestation' above.)
<34 weeks of gestation — For women with twin pregnancies <34 weeks with uterine contractions, cervical
dilation ≥3 cm supports the diagnosis of preterm labor; further diagnostic evaluation with sonographic
measurement of cervical length or laboratory assessment of fetal fibronectin (fFN) does not enhance diagnostic
accuracy. Treatment of preterm labor is initiated. (See 'Initial treatment of women with preterm labor <34 weeks'
below.)
The diagnosis of preterm labor is less clear in women with contractions, cervical dilation <3 cm, and intact
membranes, so a transvaginal ultrasound measurement of cervical length is obtained.
● Women with cervical length >35 mm and no cervical change on digital examination after a four- to six-hour
period of observation are at low risk for preterm delivery, and can be discharged home, as long as fetal
well-being is confirmed, maternal status is stable, and there are no additional maternal concerns.
● Women with cervical length <25 mm are at high risk of preterm delivery; therefore, we begin interventions
to reduce morbidity associated with preterm birth. (See 'Initial treatment of women with preterm labor <34
weeks' below.)
● Women with cervical length 25 to 35 mm on transvaginal ultrasound examination undergo fFN testing. If
the test is positive, we begin interventions to reduce morbidity associated with preterm birth (see 'Initial
treatment of women with preterm labor <34 weeks' below). If the test is negative, we discharge the patient
after a 6- to 12-hour period of observation.
INITIAL TREATMENT OF WOMEN WITH PRETERM LABOR <34 WEEKS

We hospitalize women diagnosed with preterm labor <34 weeks of gestation and initiate the following
treatments, in general agreement with recommendations from the American College of Obstetricians and
Gynecologists [51]:
● A course of betamethasone to reduce neonatal morbidity and mortality associated with preterm birth. A
single rescue course of antenatal steroids is indicated for pregnancies <34 weeks of gestation that are at
risk of preterm delivery within the next seven days and had a course of antenatal corticosteroids at least 14
days previously [51] and at ≤28 weeks of gestation [52]. (See "Antenatal corticosteroid therapy for
reduction of neonatal respiratory morbidity and mortality from preterm delivery".)
● Tocolytic drugs for up to 48 hours to delay delivery so that betamethasone given to the mother can achieve
its maximum fetal effect. Inhibition of acute preterm labor and management of pregnancies after successful
inhibition are reviewed separately. (See "Inhibition of acute preterm labor" and "Management of pregnant
women after resolution of an episode of acute idiopathic preterm labor".)
● Antibiotics for GBS chemoprophylaxis. (See "Neonatal group B streptococcal disease: Prevention", section
on 'Special populations'.)
● Magnesium sulfate for pregnancies at 24 to 32 weeks of gestation. In utero exposure to magnesium sulfate
provides neuroprotection against cerebral palsy and other types of severe motor dysfunction in offspring
born preterm. (See "Neuroprotective effects of in utero exposure to magnesium sulfate".)
Antibiotic therapy has no role in the treatment of acute preterm labor in the absence of a documented infection
or GBS prophylaxis [53]. (See "Inhibition of acute preterm labor", section on 'Antibiotic therapy'.)
Progesterone supplementation has no role in the treatment of acute preterm labor. (See "Progesterone
supplementation to reduce the risk of spontaneous preterm birth", section on 'Treatment or cotreatment of
threatened or established preterm labor'.)
OUTCOME
Tocolytic therapy is more effective than placebo for delaying delivery for 48 hours in randomized trials; however,
even when tocolytic therapy is not administered, approximately 50 percent of women diagnosed with preterm
labor deliver at term [54]. (See "Inhibition of acute preterm labor", section on 'Efficacy'.)
Whether a history of suspected preterm labor is associated with adverse neonatal outcome in women who go
on to deliver at term is controversial. These women may have underlying pathology, such as subclinical intra-
amniotic inflammation, that may adversely affect fetal growth or development even though they go on to have a
term birth [55-59].
SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around the world
are provided separately. (See "Society guideline links: Preterm labor and birth".)
INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics
patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the
four or five key questions a patient might have about a given condition. These articles are best for patients who
want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education
pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade
reading level and are best for patients who want in-depth information and are comfortable with some medical
jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
"patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Preterm labor (The Basics)" and "Patient education: How to tell
when labor starts (The Basics)")
● Beyond the Basics topics (see "Patient education: Preterm labor (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● Early signs and symptoms of labor are nonspecific and include: menstrual-like cramping; mild, irregular
contractions; low back ache; pressure sensation in the vagina; vaginal discharge of mucus, which may be
clear, pink, or slightly bloody (ie, mucus plug, bloody show). (See 'Clinical findings' above.)
● The diagnosis of preterm labor is based on clinical criteria of regular painful uterine contractions
accompanied by cervical dilation and/or effacement. (See 'Diagnosis' above.)
Singleton pregnancies
● We use the following specific criteria for diagnosis of preterm labor: Uterine contractions (≥4 every 20
minutes or ≥8 in 60 minutes) and
• Cervical dilation ≥3 cm or
• Cervical length <20 mm on transvaginal ultrasound or
• Cervical length 20 to <30 mm on transvaginal ultrasound and positive fetal fibronectin (fFN)
th
● The 34th week of gestation is the threshold at which perinatal morbidity and mortality are too low to justify
the potential maternal and fetal complications and costs associated with inhibition of preterm labor, which
only results in short-term delay in delivery. (See '≥34 weeks of gestation' above.)
● For pregnancies ≥34 weeks of gestation, women without progressive cervical dilation and effacement after
an observation period of four to six hours can be discharged to home, as long as fetal well-being is
confirmed (eg, reactive nonstress test) and obstetric complications associated with preterm labor, such as
abruptio placenta, chorioamnionitis, and preterm rupture of membranes, have been excluded. Women in
preterm labor are admitted for delivery. (See '≥34 weeks of gestation' above.)
● For pregnancies <34 weeks and cervical dilation ≥3 cm, we administer tocolytic drugs for up to 48 hours,
antibiotics for group B streptococcal chemoprophylaxis (when appropriate), and antenatal betamethasone.
Magnesium sulfate is administered for neuroprotection to pregnancies at 24 to 32 weeks of gestation. (See
'Initial treatment of women with preterm labor <34 weeks' above.)
● For pregnancies <34 weeks of gestation and cervical dilation <3 cm, transvaginal ultrasound measurement
of cervical length and laboratory analysis of cervicovaginal fFN level help to support or exclude the
diagnosis of preterm labor, as described in the algorithm (algorithm 1). For women diagnosed in preterm
labor, we administer tocolytic drugs for up to 48 hours, antibiotics for group B streptococcal
chemoprophylaxis (when appropriate), and antenatal betamethasone. Magnesium sulfate is administered
for neuroprotection to pregnancies at 24 to 32 weeks of gestation. (See '<34 weeks of gestation' above.)
Twin pregnancies
● The diagnosis of preterm labor in twin pregnancies is based on the same uterine contraction criteria as for
singleton pregnancies, and management of preterm labor in twin gestations ≥34 weeks of gestation or <34
weeks with cervical dilation ≥3 cm is also similar to that for singletons, but cervical length criteria for triage
of twin pregnancies <34 weeks with cervical dilation <3 cm is different. (See 'Approach to triage: Twin
pregnancies' above.)
For twin pregnancies <34 weeks and cervical dilation <3 cm, transvaginal ultrasound measurement of
cervical length and laboratory analysis of cervicovaginal fFN level help to support or exclude the diagnosis
of preterm labor:
• Cervical length >35 mm and no cervical change on digital examination after a four- to six-hour period
of observation – Low risk for preterm delivery: discharge.
• Cervical length <25 mm – High risk of preterm delivery: initiate interventions to reduce morbidity
associated with preterm birth.
• Cervical length 25 to 35 mm – fFN testing. If positive, initiate interventions to reduce morbidity

associated with preterm birth. If negative, discharge after a 6- to 12-hour period of observation.
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REFERENCES
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Topic 6798 Version 79.0

Preterm Labor

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Preterm labor: Clinical findings, diagnostic evaluation, and initial treatment - UpToDate 10/13/20, 12:13 PM

Author: Charles J Lockwood, MD, MHCM

PATHOGENESIS OF PRETERM LABOR

● Premature activation of the maternal or fetal hypothalamic-pituitary-adrenal axis

COMPONENTS OF THE DIAGNOSTIC EVALUATION

disorder (eg, appendicitis, bowel obstruction or strangulation, pyelonephritis, acute cholecystitis,

Speculum examination — We perform a speculum examination using a wet non-lubricated speculum

Overview — We order the following laboratory tests:

(See "Urinary tract infections and asymptomatic bacteriuria in pregnancy".)

APPROACH TO TRIAGE: SINGLETON PREGNANCIES

APPROACH TO TRIAGE: TWIN PREGNANCIES

INITIAL TREATMENT OF WOMEN WITH PRETERM LABOR <34 WEEKS

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

• Cervical length 25 to 35 mm – fFN testing. If positive, initiate interventions to reduce morbidity

Use of UpToDate is subject to the Subscription and License Agreement.

2. Sotiriadis A, Papatheodorou S, Kavvadias A, Makrydimas G. Transvaginal cervical length measurement

5. Committee on Practice Bulletins—Obstetrics and the American Institute of Ultrasound in Medicine.

Database Syst Rev 2019; 7:CD006843.

20. http://www.ffntest.com/pdfs/rapid_ffn_product_insert_lettersize.pdf (Accessed on May 04, 2015).

Ultrasound Obstet Gynecol 2003; 21:552.

51. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics.

Topic 6798 Version 79.0

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