PRETERM LABOUR AND BIRTH NG25 (2015)

Preterm= less than 37 weeks extreme preterm : bet 22-26

weeks
It is the single biggest cause of neonatal mortality and morbidity
in the UK.
The major long-term consequence of prematurity is neurodevelopmental disability.

Symptoms of preterm labour = symptoms before 37 weeks of pregnancy that might be

+0

indicative of preterm labour (such as abdominal pain), but no clinical assessment has

been done (including speculum or digital vaginal examination) .

Suspected preterm labour= symptoms of preterm labour + clinical assessment

(including a speculum or digital vaginal examination) that confirms the possibility of preterm

labour BUT rules out established labour.

Diagnosed preterm labour = suspected

preterm labour + positive
diagnostic test for preterm labour.

Established preterm labour = progressive cervical dilatation from 4 cm with regular

contractions .

Preterm prelabour rupture of membranes (P-PROM)= ruptured membranes

before 37 weeks + no established labour.
+0

NOTE : ( Offer= STRONG recommendation based on clear

evidence of benefit
Consider = evidence of benefit is less certain)

>>Information and support

>> giving information and support to women at increased risk of preterm labour, with suspected,
diagnosed or established preterm labour, or having a planned preterm birth (and their family members or carers as appropriate):

>as early as possible > both oral and written

information
>follow the principles in the NICE guideline on patient experience in adult NHS
services

>bear in mind that the woman (and her family members or carers) may be particularly
anxious
>describe the symptoms and signs of preterm labour
>explain about the care that may be offered.

>>For women who are having a planned preterm birth or are

offered treatment for
preterm labour ( tocolysis, corticosteroids, MgSO4) provide
information and support that includes:
> likelihood of the baby surviving and other outcomes (including long-term outcomes) and risks for the baby,
> giving values as natural frequencies (for example, 1 in 100)
>the neonatal care of preterm babies, including location of care
 >the immediate neonatal problems
> long-term neonatal consequences of prematurity
>ongoing opportunities to talk about and state their wishes about resuscitation of the
baby
>an opportunity to tour the neonatal unit

​
Diagnosing preterm prelabour rupture of membranes (P-PROM),

>>offer a speculum examination> +ve= pooling of amniotic fluid is observed>> do not perform any
diagnostic test >> offer care consistent with the woman having P-PROM

>> consider performing an insulin-like growth factor binding protein-1

test or placental alpha-microglobulin-1 test of vaginal fluid if negative pooling.

​
>> If diagnostic tests are positive,
>do not use the test results alone to decide what care to offer
the woman, but also take into account her clinical condition, her medical and pregnancy
history and gestational age, and
>either: offer care consistent with the woman having P-PROM or re-evaluate later the woman's
diagnostic status

>> If the diagnostic tests are negative and no amniotic fluid is observed:
>do
not offer antenatal prophylactic antibiotics
>explain to the woman that it is unlikely that she has P-PROM, but that she should
return if she has any further symptoms suggestive of P-PROM or
preterm labour.

>> Donot use nitrazine to diagnose P-PROM.

>> Do not perform diagnostic tests for P-PROM if labour becomes established in a
woman reporting symptoms suggestive of P-PROM.
>> Antenatal prophylactic antibiotics for women with P-PROM
>>Offer women with P-PROMoral erythromycin 250 mg 4 times a day[ ] for a maximum of 10 days or
1

until the woman is in established labour .

>> For women with P-PROM who cannot tolerate erythromycin or in whom erythromycin is contraindicated,

consider oral penicillin for a maximum of 10 days or until the woman is in

established labour.
>> Do not offer women with P-PROM co-amoxiclav as prophylaxis for intrauterine infection. ​
>> For guidance on the useof intrapartum antibiotics, see the NICE guideline on antibiotics for
early-onset neonatal infection.

>>Identifying infection in women with P-PROM

>>Use a combination of clinical assessment AND tests (C-
reactive protein, white
blood cell count and measurement of fetal heart rate using
cardiotocography) to
diagnose intrauterine infection in women with P-PROM.

>> Do not use any one of the following in isolation to confirm or

exclude intrauterine infection in women with P-PROM:
>a single test of C-reactive protein
>white blood cell count
>measurement of fetal heart rate using cardiotocography.

>>If the results of the clinical assessment or any of the tests are not consistent with each
other>> continue to observe the woman and consider repeating the tests.

Screening And Prophylaxis Of PTL:

Screening
>> for women who has history of spontaneous preterm birth or mid-trimester loss between 16+0
and 34+0 weeks of pregnancy
>> By TVS for cx length bet 16-24 weeks
> +ve if cx length =/< 2.5cm >> Offer a choice of either prophylactic vaginal progesterone
or prophylactic cervical cerclage (take the patient preferences into
account.)

NOTE: IF transvaginal ultrasound between 16 +0 and 24+0 weeks of reveals a cx length of

less than 25 mm( eg in the routine 20 week scan ) with
A) No Hx of spontaneous preterm birth or mid-trimester loss> Offer prophylactic vag
progesterone
B) Hx of P-PROM or cx trauma> Consider prophylactic cervical cerclage

>>'Rescue' cervical cerclage

>>Do not offer with:
>signs of infection or
>active vaginal bleeding or
>uterine contractions.

Consider
>> between 16 and 27 weeks of pregnancy with a
'rescue' cervical cerclage for women +0 +6

dilated cervix and exposed, unruptured fetal membranes:>> take

into account

(being aware that the benefits are likely to be greater for

>gestational age

earlier gestations)
> and the extent of cervical dilatation
>discuss with a consultant obstetrician and consultant paediatrician.

>> Explain to women for whom 'rescue' cervical cerclage is being considered (and their family members or carers as appropriate):
>about the risks of the procedure
>that it aims to delay the birth, and so increase the likelihood of the baby
surviving and
of reducing serious neonatal morbidity.

​
Evaluation of a woman presented with Symptoms of PTL+ Intact Memberanes:

>> Explain: clinical assessment and diagnostic tests ( how, consequences, false +ve& -ve)
>> Offer: >>clinical assessment ( initial assessment + examination)
> Initial assessment
History
Analysis of Symptoms
Review the ANC records
Vital signs, Abd examination, fetal heart auscultations
>Speculum examination +/- PV
>> If clinical assessment suggests suspected preterm
>Advise treatment if GA 29 week+6 days or less
> Offer treatment if GA 30 weeks suspected PTL+ has no confirmatory test
>Consider confirmatory test if GA 30 weeks or more
>> Confirmatory test for PTL with intact membranes:
 Transvaginal US:
with training in, and experience of, TVS
by healthcare professionals

measurement of cervical length

>cx length =/< 1.5cm = diagnosed PTL = treatment
>cx length > 1.5cm (think
about alternative diagnoses+ discuss
benefits and risks of going home compared with continued
monitoring and treatment in hospital+ advise her that if she
does decide to go home, she should return if symptoms
suggestive of preterm labour persist or recur)
Fetal Fibronectin testing:
If TVS not available or not accepted
>Concentration > 50ng/ml = positive test =diagnosed PTL = treatment
>Concentration =/< 50 ng/nl = negative test (think
about alternative
diagnoses+ discuss benefits and risks of going home
compared with continued monitoring and treatment in hospital+
advise her that if she does decide to go home, she should return
if symptoms suggestive of preterm labour persist or recur)
>> DO NOT use the 2 confirmatory test in combination.
​
Management Of patient with PTL

>>Medications

>Tocolysis
>>Take in account the following:
Patient in suspected or diagnosed PTL?
Gestational age
Exclude contraindication of tocolysis
Availability of NICU
Possible corticosteroid thereby
Patient preference

>>NIFEDIPINE: ( intact memberanes + suspected PTL)

>Consider : bet 24 – 25week+6 days
>Offer : bet 26 – 33week+6days
.>Dose: loading dose of 20 mg orally, followed by 10–20 mg 3 to 4 times daily adjusted according to uterine
activity

>Does not have a UK marketing authorisation for this

indication>Informed consent should be obtained and
documented
>If contraindicated >> Offer oxytocin receptor antagonist

>> Do Not Offer Betamimetics

>Maternal Corticosteroids
>Discuss (with patient, or her family members or carers as appropriate) between 23 and 23 +0 +6

weeks in suspected or established preterm labour, are having a planned

preterm birth or have PPROM the use of maternal corticosteroids in the context of her
individual case.

>Consider bet 24+0 and 25+6 weeks in suspected or established preterm labour, planned preterm
birth or P-PROM.
>Offer ‫زم‬# between 26+0 and 33+6 weeks in suspected, diagnosed or established preterm labour,
having a planned preterm birth or have P-PROM.

>Consider between 34+0 and 35+6 weeks in suspected, diagnosed or established preterm labour,
having a planned preterm birth or have P-PROM.

>>NOTES:
>Discuss with the woman (and her family members or carers as appropriate):
how corticosteroids may help
the potential risks associated with them.
>Do not routinely offer repeat courses of maternal
corticosteroids.
>Take into account:
the interval since the end of last course
gestational age
the likelihood of birth within 48 hours

>Intravenous Magnesium sulfate for neuroprotection

​
> Offer ‫زم‬#between 24+0 and 29+6 weeks in established preterm labour or having a
planned preterm birth within 24 hours.

>Consider between 30+0 and 33+6 weeks in established preterm labour or having a
planned preterm birth within 24 hours.

>Dose: 4 g intravenous bolus over 15 minutes,

followed by an intravenous infusion of 1 g per hour until the birth or for
24 hours (whichever is sooner).

>Monitor for clinical signs of magnesium toxicity

at least every 4 hours
by recording pulse, blood pressure, respiratory rate and deep tendon reflexes.
If oliguria or other signs of renal failure
monitor more frequently for magnesium toxicity +think about reducing the dose of
magnesium sulfate.

>> Fetal monitoring:

>Monitoring options: cardiotocography and intermittent auscultation

>>Discuss with women in suspected, diagnosed or established preterm labour (and their family members or carers as
appropriate):

> Involve a senior obstetrician in discussions about whether

and how to monitor the fetal heart rate for women who are
between 23+0 and 25+6 weeks pregnant
> type and purpose of monitoring , interpretation in different

GA, option not to monitor eg in threshold of viability

>> Explain
 a- limited evidence about the usefulness of specific features to
suggest hypoxia or acidosis in preterm babies
b- the available evidence is broadly consistent with that for

babies born at term

c-a normal cardiotocography= reassuring BUT
abnormal trace does not necessarily indicate that fetal hypoxia
or acidosis is present.
d-No evidence that using cardiotocography improves the
outcomes of preterm labour for the woman or the baby compared with intermittent
auscultation

>> Offer women in established preterm labour but with no other risk
factors a choice of using either:
cardiotocography using external ultrasound or intermittent
auscultation.

>Fetal scalp electrode

>Do not use a fetal scalp electrode for fetal heart rate monitoring if less than 34+0 weeks
unless all of the following apply:
> external cardiotocography and or intermittent
auscultation is not possible
> it has been discussed with a senior obstetrician
> benefits are likely to outweigh the potential risks
> the alternatives (immediate birth, intermittent ultrasound and no monitoring) have
been discussed
with the woman and are unacceptable to her.

> Discuss with the woman (and her family members or carers as appropriate) the possible use of a fetal scalp
electrode between 34+0 and 36+6 weeks if it is not possible to

monitor the fetal heart rate using either external cardiotocography or intermittent auscultation.

>Fetal blood sampling

> Do not carry out fetal blood sampling if the woman is less than 34+0 weeks

> Discuss with the woman the possible use of fetal blood sampling between 34 +0 and 36+6 if the
benefits are likely to outweigh the potential risks.

when offeredand advise her that if a blood sample cannot be

>>

obtained a caesarean section is likely.

>>Mode of birth

>>Discuss the general benefits and risks of caesarean section and

vaginal birth
with women in suspected, diagnosed or established preterm labour and women
with P-PROM(and their family members or carers as appropriate)
>>Explain to women in suspected, diagnosed or established preterm labour and women with P-PROM about
> the benefits and risks of CS that are specific to gestational age.
> highlight the difficulties a CS for a preterm
associated with performing

birth especially the increased

likelihood of a vertical uterine incision and the implications of this for future

pregnancies.
>no known benefits or harms for the baby from CS, but the
evidence is very limited.

Consider CS for women presenting in suspected, diagnosed or established preterm labour between 26
>> +0

and 36 weeks of pregnancy with breech presentation.

+6

>>Timing of cord clamping for preterm babies(born vaginally or by CS)

>> mother and baby are stable= Wait at least 30 seconds, but no
longer than 3 minutes.
​
>> if significant materenal bleeding of preterm baby needs to be moved
for resuscitstion=

consider milking the cord and clamp the cord as soon as

possible.

>> Position the baby at or below the level of the placenta before clamping the cord.
​
Numbers in PTL:
Incidence in England and Wales: 7.3% of live birth
25% of PTL >> planned ( elective) due to fetal or maternal
causes ( eg: PE, IUGR,..)