SELLERS PRETERM BIRTH AND PROM

Preterm birth is defined as birth before 37 completed weeks of pregnancy. Currently, many
infants survive after 20 weeks of gestation because of sophisticated interventions. Almost all
foetuses under 500g are considered unviable. Viability is considered from 500g in developed
countries and 1000g in developing countries. Preterm birth can be defined as a birth that
occurs after foetal viability but before 37 completed weeks of pregnancy. Birth can be
spontaneous or induced before term if the mother’s health is threatened. The survival of a
preterm infant depends on the developmental stage, weight, presence of complications
such as placental abruption or infections and care received.

Factors contributing to preterm birth.

Contributing factors can be maternal, foetal, obstetrical and/or lactogenic.
Maternal causes are associated with known and unknown infections that increase the risk of
preterm birth.
Infections that cause pyrexia such as urinary tract infection, appendicitis, pneumonia, or
amniotic fluid infection syndrome.
Conditions such as pre-eclampsia, diabetes, cardiac conditions, and antepartum
haemorrhage.
Causes related to the fetoplacental unit include over-distension of the uterus as in multiple
pregnancies or polyhydramnios. Congenital abnormalities of the neonate often lead to
preterm spontaneous birth or birth by intervention.
Obstetric causes are associated with antepartum haemorrhage, abruption placenta and
asphyxia, which are the second most common causes of perinatal death.
Previous preterm births.
-Cervical incompetence or previous cervical surgery or cone biopsy.
-Idiopathic or unknown causes.

THE DIAGNOSIS OF PRETERM BIRTH/LABOUR.

-Preterm birth is diagnosed when there is a history of regular, rhythmic uterine contractions
before 37 completed weeks of pregnancy. Occasionally there is an accompanying descent of
the presenting part and a dilatation of the cervix.
The diagnosis can be very difficult. Generally, three factors are involved:
- Documentation of prematurity.
-Regular, rhythmic uterine contractions.
-Progressive changes in cervical effacement and dilatation and occasionally descent of the
presenting part.
The diagnosis of preterm birth is confirmed by the observation of the presence of uterine
contractions through abdominal auscultation or the use of the electronic uterine activity
assessment using a cardiotocograph to confirm the presence of contractions. Vaginal
examinations are usually not performed because these stimulate contractions. The
performance of a vaginal examination will be indicated if a woman has strong contractions,
and there is no medical practitioner available, or the woman is in a primary healthcare unit
and needs to be transported to a higher level of care. Vaginal examination is avoided if the
membranes are ruptured, and the contractions are mild.

Special investigations in preterm labour

-Ultrasound scan to determine the condition of the foetus and amount of amniotic fluid to
guide the management.
-Full blood count to exclude the presence of infection.
-High vaginal swabs to rule out infection or culture and sensitivity in case of infection.
Clinical signs and symptoms of preterm birth
-Spontaneous onset of regular, rhythmic uterine contractions as in normal labour.
-Membranes may or may not rupture spontaneously, if ruptured this is usually followed by
the onset of painful regular contractions.
-History of vague backache or low-grade abdominal discomfort. The same symptoms can be
caused by urinary tract infection; hence it is important to rule out urinary tract infection.
General Principles of Care
The care of a woman in preterm labour by a midwife includes:
-Total bed rest in the hospital until the threat is over.
-Sedation to allay anxiety and pain.
-Drugs are administered per medical practitioners’ prescription.
- No digital vaginal examination except a speculum examination to note the state of the
cervix.
-Monitor uterine contractions half hourly or continuously until the danger has passed.
-Observe the presence of show or rupture of membranes.
-Monitor foetal heart by CTG or intermittent auscultation half-hourly.
- Monitor vital signs (blood pressure, pulse, temperature and respiration).

Complications of preterm labour

-Spontaneous preterm labour and premature rupture of membranes are associated with
higher perinatal mortality and morbidity and maternal problems emanate mainly from the
interventions carried out to stop the contractions.
- The birth process in a preterm baby may be complicated because the soft parts of the baby
do not put enough pressure on the cervix and there is slow dilation.
- Preterm birth can be complicated by malpresentation, breech, and prolapsed cord. It may
take longer to be fully dilated and the breech may prolapse before full dilatation.
- After birth, the baby may have:
-Birth asphyxia
- Respiratory distress syndrome
- Jaundice
- Hypoglycaemia
- Hypothermia
- Feeding problems
- Infections (septicaemia, pneumonia or meningitis)
- Intraventricular haemorrhage
- Congenital malformations.
Indications for suppressing labour.
- Preterm labour may be suppressed using tocolytics. Labour can be suppressed if:
- The membranes are intact and the cervical os is less than 3 cm dilated.
- No major congenital abnormality is present.
- The foetus is alive and no foetal distress is present.
- Gestational age is less than 36 weeks and the risks of prematurity exceed those of
infection.
- There is no infection or severe maternal disease present.
- There is no intrauterine growth restriction.

Indications to allow labour to continue and delivery to take place:

-The woman is usually allowed to deliver if the cervix is 3-4 cm dilated or the woman is in
active labour.
-The foetus is more than 36 weeks gestation, as the chance of survival is good.
- There is an infection or severe maternal comorbidities such as diabetes mellitus.
-There is intrauterine growth restriction.
- Membranes have ruptured and liquor is draining or has drained out.
Clinical Relevance

Preterm babies are more prone to serious illness and death in the hours, days, and weeks following
delivery. Those who survive are at greater risk of lifelong complications.

Risk comes from the increased difficulties that they encounter with breathing, feeding, and body
temperature regulation, along with susceptibility to infection and neurological injury.

Prematurity is the leading cause of neonatal death globally and the second most common factor
underlying mortality in children under the age of 5 years.