PRETERM LABOUR

Objectives
Define the term preterm labour
State the aetiology of preterm labour
Identify risk factors to preterm labour
State the clinical features
List the differential diagnosis
Identify investigations to be done
State measures to prevent preterm labour
Discuss the management of preterm labour
List complications of preterm labour

Definition:

Preterm Labour is defined as labour that occurs before the 37th week of pregnancy

Babies delivered before 37 completed weeks of pregnancy are regarded as preterm. on the other
handed babies weighing less than 2500 gms at birth irrespective of their gestational ages are referred to
as low birth weight infants. So also, infant of diabetic mother’s are regarded as immature even at fully
term.
Preterm births contribute significantly to perinatal mortality and morbidity.Preterm births accounts
for75 -90% of all neonatal deaths not due to congenital abnormalities.

AETIOLOGY

1 Elective preterm delivery

Labour may have to be induced prematurely in serous maternal medical conditions like severe
pre-eclampsia, eclampsia, diabetes mellitus, severe anaemia and chronic kidney disease

2. Infection
Subclinical infection of the choriodecidual space and amniotic fluid is the most widely studied
aetiological factor. A variety of genital tract micro-organisms, including bacterial vaginosis has been
associated with an increased risk of spontaneous preterm delivery. ) Illnesses
Acute febrile illnesses like influenza pneumonia, urinary tract infection, pyelonephritis, genital
tract infections may cause preterm labour.

Premature rupture of the membranes.

3) Over distension
Multiple pregnancy and polyhydramnios are two main causes of uterine over distension.

4) Vascular
Antepartum haemorrhage and placental abruption in pregnancy may cause spontaneous
preterm delivery. Blood is known to irritate the inyometrium and weaken the membranes

5) Social behavioural practices

These are factors that can bring about preterm labour. These include smoking, alcoholism, drug
abuse, poor clinic attendance, inter pregnancy interval less than one year, poverty and lack of
family support

6) Abnormalities of the pelvic organs

These include uterine fibromyomata, congenital malformation of the uterus, incompetent cervix and
huge ovarian tumour

7) Trauma
Domestic violence in pregnancy motor vehicle accident, fall, and surgical operations in pregnancy
e.g myomectomy. Previous caesarean section scar can be traumatized when the uterus is over
distended.
8) Fetal factors
Multiple pregnancy, congenital abnormalities (hydrocephalus), polyhydramnios and rising anti-Rh
titre may cause premature labour

9) Foreign body in the uterus

Retention of intra uterine contraceptive device (IUCD) can cause preterm labour

10) Strenous physical activities

These include driving for long hours cycling weight lifting, prolonged standing or walking,
frequent sexual intercourse especially in the second trimester even cause premature labour

Risk Factor for preterm labour

- Women younger than 17 years old or older than 35 years

- Women carrying twin/multiple pregnancy
- Women who under –weight
- Women who have a history of preterm labour
- Women who have had more than 3 abortions
- Women with incompetent cervix eg. weight lifting
- Multiparous women
- Women with generalized infections
- Hx of renal disease, DM or HTN

Clinical features

History

The patient will give history of regular contractions and or vague backache. She may give history of
recent urinary tract infection or gastro-enteritis. History of nausea, vomiting, urinary frequent,
haematuria may be relevant. She may also give history of bleeding in early pregnancy or uterine
malformation.

Signs and symptoms

- Tachycardia
- Mild pyrexia
- Palpable contractions
- Cervical effacement and dilation
- Membranes may be intact or ruptured
- Abdominal pain/cramping
- Backache
- Nausea and vomiting
- Increased viginal discharged
- Vaginal bleeding
- Reduced fatal movement
- Pelvic pressure
Differential diagnosis

- Urinary tract infection

- Constipation
- Gastroenteritis
- Placental abruption
- Red degeneration of fibroid

Investigations

- Blood for culture and sensitivity

- Complete blood count
- Blood for erythrocyte sedimentation rate
- Urine “ dipstick”
- Midstream specimen of urine microscopic, culture and sensitivity
- High vaginal swab
- A transvaginal ultrasound scan of the cervix to know its length a normal cervix measures
approximately 35mm in length. Since shortening is often accompanied by dilation and
funnelling of the membranes down the cervical canal therefore measurement of the cervix will
give a diagnostic accuracy
- Bedside fibronectin offers a rapid assessment of risk symptomatic women with minimal
cervical dilatation. It has a greater predictive value than digital examination. This method is not
common.

Prevention

Some of the contributory factors that cause premature labour can be prevented with proper and timely
intervention. The following steps if taken may reduce the incidence of premature labour

- Regular attendance to the antenatal clinic to detect and treat abnormalities promptly
- Balanced diet to prevent anaemia
- Adequate spacing of pregnancy to allow the whole body to recover from the effects of child
bearing
- Avoidance of bad behavioural patterns like smoking, drug abuse and alcoholism
- Rehabilitation of unmarried or single mothers by the social workers
- Avoidance of stress factors through daily activities of sports, weight lifting, scrubbing etc
- Understanding her personnal body language
- Adequate rest and sleep
- Avoidance of prolonged standing
- If patient is commuting she is advised not to run to catch a bus or train
- Sexual activity must not be regular in pregnancy
- All illnesses must be promptly treated in pregnancy
- Antibiotics /anti-inflammatory medications may be ordered to treat
Acute infections

- Elective abdominal surgery and extensive dental procedures must be postponed till after
delivery
- Patient with multiple pregnancy must be admitted for rest between the 28th – 36th weeks of
pregnancy
- Uterine fibroids when a symptomatic are managed by bed rest and analgesics
- Incompetent cervix can be managed with cervical cerelafe in the early part of second trimester
- Pressure symptoms of polyhydramnios is relieved by amniocentesis
- Placental praevia if not troublesome is managed by complete bed rest and blood transfusions (if
necessary) to allow the fetus to reach a viable size

Management

Admission

Assess patient’s general appearance check skin tugor, mouth and tongue for dryness. Check to see
whether the eyes are sunken to rule out dehydration
- Ask patient for the 1st day of the last menstrual period and work out the expected date of
delivery
- Find out if she is having fatal movement
- Ask if there has been any bleeding
- Ask if she has ruptured her membranes or passed show
- Check patient for flushing or sweating which may be as a result of systemic infection
- Check vital signs and record

Abdominal Examination
Gentle abdominal examination is conducted. Abdomen is palpated for tenderness, irritability and mass.
So also, same is palpated to know the fundal height, lie, presentation, position and engagement of the
head. Fatal heartbeat is schedule.

Vaginal Examination
If membranes are intract a gentle digital vaginal examination is done under strict asepsis to know the
extent of cervical dilation and effacement, absence or presence of blood.

All findings will be recorded any adverse finding will be reported at once. The patient and relatives are
reassured. The patient will be educated on her condition.
Palliative Management

This is instituted when the membranes have not ruptured, cervical dilation is less than 3cm and uterine
contractions are not strong. The patient is admitted and made comfortable. All admission procedures
will be carried by the midwife. Consent form is signed by patient. The patient and relatives are
reassured. The doctor will order investigations as previously stated. Doctor will conduct a general
physical and vaginal examinations. If infection is suspected, doctor will order a combination of
Amoxicillin and flagyl or many available broad spectrum antibiotics pending the outcome of
investigations. He will also order analgesics inform of panadol tablets for pain. The condition of the
fetus will be monitored by cardiotocograph or Doppler ultrasound. The doctor may also order any of
the following tocolytic agents:

a) Ritrodrine Hydrochloride
50mg/min via intravenous infusion until contractions are suppressed. As much as 300-350 ug/min
can be given. The infusion is continued for about 12-48 hours after cessation of contractions. This is
followed by oral therapy, dosage of 10mg 6 hourly for about 4 weeks or until pregnancy reaches 37
weeks.

b) Salbutamol
It reduces uterine activity. Dosage is 10 ug/min by intravenous infusion but may be increased to 45
ug/min

c) Calcium channel blockers

Nifedipine may be used. It inhabits muscles contraction by interfering with the movement of
calcium ions across the plasma membrane

Steroids eg. Dexamethasone can be ordered to accelerate the production of surfactant for fetal lung
maturity.

ACTIVE MANAGEMENT

This is when the membranes have ruptured and cervical dilatation is more than 3cm. if there are no
fetal or maternal complications labour is allowed to continue. The paediatrician is informed.

Conduct of Premature Labour

Labour

The premature baby is susceptible to trauma therefore the patient and fetus must be handed with care.
Where possible excessive uterine contractions and precipitate labour must be avoided. Use of oxytocin
to accelerate labour is seldom necessary. The patient is kept in bed throughout because delivery is
often precipitate and unexpected. Narcotics of any kind must not be given because premature fetus is
sensitive to drugs given to the mother/ Delivery Is safe under local infiltration or pudenda block

Delivery

The obstetrician and paediatrician must be present at delivery

- Monitoring of uterine contractions fatal heart beat are carried out every 5 minutes
- All tocolytic agents are stopped
- Birth should be controlled slow and gentle to prevent expulsion, compression and
decompression of the head
- Mother is given oxygen via face mask
 - The membranes must not be ruptured artificially. The bag of membranes acts as a cushion for
the skull premature skull with its widely separated sutures
- An episiotomy is necessary as it reduces pressure on the baby’s delicate brain structure
- Low forceps may help in dilating maternal soft parts and in guiding the head over the
perineum. However, spontaneous delivery is preferred where possible. Vaginal delivery gives
better results than caesarean section.
NB. Always remember to include care and monitoring such as hygienic care, observing for signs
of impending delivery, ensuring bed rest , assisting with activities of daily living, monitoring of
vital signs, observing: perineal pad, contractions, fetal heart rate, gestational age,Providing
psychological support, patient education, etc.

Complications
- Injury to maternal soft tissues
- Intracranial injury
- Cerebral haemorrhage
- Cyanotic attacks
- Anaemia
- Heart failure and pulmonary edema
- Jaundice
- Infection
- Poor mental and intellectual development in later years
Bibliography

1) Baker P.N 2006 Obstetric by Ten Teachers 18TH Edition. Book Power Hiuse

2) Beischer N. A etal 1997. Obstetrics and the Newborn 3rd Edition W.B Saunders

3) Fraser D.M and Cooper M.A 2003 Myles Textbook for Midwives 14th Edition. Churchill
Livingston

4) Ojo AO and Briggs E.N 2006. A Textbook for Midwives in the Tropics 1st Indian Edition. Hodder
Arnold

5) World Health Organization 2003 Managing Newborn Problems: A guide to doctors, nurses and
midwives