PRETERM LAboR

(Syn: Premature
Labor
• Preterm labor (PTL) is defined as one where the
labor starts before the 37th completed week (<
259 days), counting from the first day of the last
menstrual period. The lower limit of gestation
is not uniformly defined; whereas in developed
countries it has been brought down to 20 weeks,
in developing countries it is 28 weeks. Preterm
birth is the significant cause of perinatal
morbidity and mortality
 ETIoLoGY
• In about 50%, the cause of preterm labor is not known.
Often it is multifactorial. The following are, however,
related with increased incidence of preterm labor
• High risk factors:
• (A) History: There is an increased incidence of preterm
labor in cases such as: (1) Previous history of
• induced or spontaneous abortion or preterm delivery; (2)
Pregnancy following assisted reproductive
• techniques (ART); (3) Asymptomatic bacteriuria or
recurrent urinary tract infection; (4) Smoking
• habits (5) Low socioeconomic and nutritional status and
(6) Maternal stress
• (B) Complications in present pregnancy: May be due to
maternal, fetal or placental.
•  Maternal: (a) Pregnancy complications: Preeclampsia,
antepartum hemorrhage, premature rupture of the
membranes, polyhydramnios;
• (b) Uterine anomalies: Cervical incompetence,
malformation of uterus;
• (c) Medical and surgical illness: Acute fever, acute
pyelonephritis, diarrhea, acute appendicitis, toxoplasmosis
and abdominal operation. Chronic diseases: Hypertension,
nephritis, diabetes, decompensated heart lesion, severe
anemia, low body mass index (LBMI);
• (d) Genital tract infection: Bacterial vaginosis, beta-
hemolytic Streptococcus, bacteroides, chlamydia and
mycoplasma
• Fetal: Multiple pregnancy, congenital
malformations and intrauterine
death.
•  Placental: Infarction, thrombosis,
placenta previa or abruption.
• (C) Iatrogenic: Indicated preterm delivery due to
medical or obstetric complications.
• (D) Idiopathic: (Majority)—Premature
effacement of the cervix with irritable uterus
and early engagement of the head are often
associated. In the absence of any complicating
factors, it is presumed that there is premature
activation of the same systems involved in
initiating labor at term.
 DIAGNOSIS
• (1) Regular uterine contractions with or without
pain (at least one in every 10 minutes);
• (2) Dilatation (> 2 cm) and effacement (80%) of the
cervix; (3) Length of the cervix (measured by TVS)
< 2.5 cm and funneling of the internal os and (4)
Pelvic pressure, backache and/or vaginal discharge
or bleeding. It is better to overdiagnose preterm
labor than to ignore the possibility of its presence.
Preterm labor is very unlikely when cervical length
is > 30 mm, irrespective of uterine contractions
 MANAGEMENT oF PRETERM LAboR
• The management includes: (1) To prevent preterm onset
of labor, if possible; (2) To arrest preterm labor, if not
contraindicated; (3) Appropriate management of labor;
• (4) Effective neonatal care.
• Predictors of preterm labor: A. Clinical predictors: (i)
History of prior preterm birth; (ii) Multiple pregnancy;
(iii) Presence of genital tract infection; (iv) Symptoms of
PTL.
• B. Biophysical predictors: (i) Uterine contractions (UC) >
4/hr; (ii) Bishop score > 4; (iii) Cervical length (TVS) < 25
mm. C. Biochemical predictors: (i) Fetal fibronectin (fFN)
in cervicovaginal discharge (ii) Others IL-6, IL-8, TNF-α.
• Fibronectin is a glycoprotein that binds the
fetal membranes to the decidua. Normally it
is found in the cervicovaginal discharge before
22 weeks and again after 37 weeks of
pregnancy. Presence of fibronectin in the
cervicovaginal discharge between 24 weeks
and 34 weeks is a predictor of preterm labor.
When the test is negative it reassures that
delivery will not occur within next 7 days.
 PREVENTIoN oF PRETERM LAboR
• In about 50%, the cause remains unknown. Among the
remaining complicated groups, decision has to be taken
whether to allow the pregnancy to continue or not. The risk of
delivery of a low birth weight baby has to be weighed against
the risks involved to the fetus and/or to the mother in
continued pregnancy. However, the following guidelines are
adopted.
•  Primary care is aimed to reduce the incidence of preterm
labor by reducing the high-risk factors (e.g. infection, etc.).
•  Secondary care includes screening tests for early detection
and prophylactic treatment (e.g. tocolytics).
•  Tertiary care is aimed to reduce the perinatal morbidity and
mortality after the diagnosis (e.g. use of corticosteroids).
• Investigations: (1) Full blood count; (2)
Urine for routine analysis, culture and
sensitivity;
• (3) Cervicovaginal swab for culture and
fibronectin; (4) Ultrasonography for fetal
well being, cervical length and placental
localization and (5) Serum electrolytes
and glucose levels when tocolytic agents
are to be used
 MEASURES To Arrest Preterm Labor
• The scope to arrest preterm labor is limited, as
majority is associated with maternal and/or fetal
complicating factors where the early expulsion of
the fetus may be beneficial. It is indeed unwise to
attempt to arrest the onset of labor in such cases.
• Thus, in only negligible proportion of cases (about
10–20%) where the fetus is not compromised, the
maternal condition remains good and membranes
are intact, the following regime may be instituted
in an attempt to arrest premature labor
• Bed rest—The patient is to lie preferably in left lateral
position though the benefits are doubtful.
•  Adequate hydration is maintained. Prophylactic
antibiotic is not routinely given. It is recommended
when infection is evident or culture report suggests.
•  Prophylactic cervical cerclage for women with prior
preterm birth and short cervix in the present pregnancy
may be beneficial.
•  Tocolytic agents: Various drugs nifedipine, atosiban,
progesterone (micronized) have been used to inhibit
uterine contractions. Drugs that can be used.
• The tocolytic agents can be used as short-term (1–3
days) or long-term therapy. Tocolytics should preferably
be avoided as there is no clear benefit (RCOG–2002).
• Dose schedule of MgSO4 and monitoring are same as used for
seizure prophylaxis of preeclampsia (4 g IV over 3–5 minutes
followed by an infusion of 1 g/hr).
• Short-term therapy: It is commonly employed with success. The
objectives are: (1) To delay delivery for at least 48 hours for
glucocorticoid therapy to the mother to enhance fetal lung
maturation and
• (2) In utero transfer of the patient to a unit with an advanced
neonatal intensive care unit (NICU).
• Contraindications are — A. Maternal: Uncontrolled diabetes,
thyrotoxicosis, severe hypertension, cardiac disease,
hemorrhage in pregnancy, e.g. placenta previa or abruption. B.
Fetal: Fetal distress, fetal death, congenital malformation and
pregnancy beyond 34 weeks. C. Others: Rupture of membranes,
chorioamnionitis and cervical dilatation more than 4 cm.
• Glucocorticoid therapy: Maternal administration of
glucocorticoids is advocated where the pregnancy is
less than 34 weeks. This helps in fetal lung
maturation so that the incidence of RDS, IVH and
NEC are minimized. This is beneficial when the
delivery is delayed beyond 48 hours of the first dose.
• Benefit persists as long as 18 days. Either
betamethasone (Betnesol) 12 mg IM 24 hours apart
for two doses or dexamethasone 6 mg IM every 12
hours for 4 doses is given. Betamethasone is the
steroid of choice (RCOG – 2004)
• Risks of antenatal corticosteroid use: (a)
Premature rupture of the membranes especially
with evidence of infection as the infection may
flare-up; (b) Insulin-dependent diabetes mellitus
where patients need insulin dose readjustment; (c)
Transient reduction of fetal breathing and body
movements
 MANAGEMENT IN LAboR
• The principles in management of
preterm labor are:
• (1) To prevent birth asphyxia and
development of RDS;
• (2) To prevent birth trauma. Duration
of labor is usually short
 FIRST STAGE
• The patient is put to bed to prevent early rupture of
the membranes
• To ensure adequate fetal oxygenation by giving
oxygen to the mother by mask
• Epidural analgesia is of choice
• Labor should be carefully monitored preferably with
continuous EFM
• Cesarean delivery is done for obstetric reasons only
(hypertension, abruption or malpresentation)
• NICU is a sine qua non for good outcome
 SECOND STAGE
• The birth should be gentle and slow to avoid rapid
compression and decompression of the head
• Episiotomy may be done to minimize head
compression if there is perineal resistance
• Tendency to delay is curtailed by low forceps. As
such, routine forceps is not indicated
• The cord is to be clamped immediately at birth to
prevent hypervolemia and hyperbilirubinemia
• To shift the baby to neonatal intensive care unit
under the care of a neonatologist
• Place of cesarean section: Routine cesarean
delivery is not recommended. Preterm
fetuses before 34 weeks presented by breech
are generally delivered by cesarean section.
Lower segment vertical or “J”-shaped incision
may have to be made to minimize trauma
during delivery. This is due to poor formation
of the lower uterine segment
• Immediate management of the preterm baby
following birth—.
• PROGNOSIS: Preterm labor and delivery of a low birth
weight baby results in high perinatal mortality and
morbidity. However, with NICU, the survival rate of
the baby weighing between 1,000 g and 1,500 g is
more than 90%. With the use of surfactant , survival
rate of infants born at 26 weeks is about 80%.
• Late preterm labor—Birth of infants between 34
weeks and 36 weeks gestation. These infants do
better than those infants born before 34 weeks