PRE-TERM LABOR

MANAGEMENT
By DR : SHOHAIL AHMAD
Class: 4TH
Teacher:HFEEZA SAHAK

AND

Dr: NORINA KAMAWAL

Subject: PREGNANSY

AND

DELIVERY
Management of Preterm Labour
Obstetrices: All issues, physiological and pathological, related to
pregnancy and child bearing.

Gynaecology: All diseases of the female, and specific to the female, not
related to pregnancy. While these may occur in the gravid lady, they are
neither a cause nor effect of pregnancy. E.g. A fibroid or ovarian cyst
present in a female who is carrying a fetus.
As such, the treatment of Infertility, and all forms of contraception, also fall
in gynecology. Obstetrics is used only when the uterus or an ectopic site is
gravid, and continues till the end of puerperium , which is six weeks from
the delivery of the placenta.

Preterm Labor
When the labor starts before 37th completed weeks (<259days)
Counting from the first day of the last menstrual period.
Preterm Birth:defined as delivery before 37 completed weeks.
Early preterm, those occurring between 34 and 36 completed weeks.
Small for gestational age: Newborns whose birthweight is usually <10th
Percentile for gestational age.
Large for gestational age; Newborns whose birthweight is >90th percentile
for gestational age.
Appropriate for gestational age; Newborns whose weigh is between the
10th and 90th percentiles.
Law birthweight Neonates weight 1500 to 2500 g;
Very law birthweight Neonates weighting between 500 and 1500 g; and
Extremely low birthweight Neonates weighing between 500 and 1000 g.
Etiology:
It is multifactorial
High risk factors
1. History
2. Complication in present pregnancy
3. Iatrogenic
4. Idiopathic

History
1. Previous history of induced / spontaneous abortion/preterm delivery.
2. Pregnancy followed by assisted reproductive techniques
3. Asymptomatic bacteriuria/Recurrent UTI
4. Smoking habit
5. Low socio-economic and nutritional status
6. Maternal stress

Complication in resent pregnancy

Maternal:
1. Preeclampsia
2. Antepartum hemorrhage
3. Premature rupture of membrane
4. Polyhydramnios
5. Cervical incompetency
6. Malformation of uterus
7. Acute fever
8. Acute appendicitis
9. Toxoplasmosis
10. Abdominal operation
Complication in present pregnancy Maternal:
8. Hypertension
9. Nephritis
10. Diabetes
11. Low BMI
12. Genital tract infections
13. Bacterial vaginosis
14. B Hemolytic streptococcus
15. Bacterivores
16. Chlamydia

Complication in present pregnancy Fetal Complications:

1. Multiple pregnancy
2. Congenital malformation
3. Intrauterine death

Placental complication
1. Infraction 2. Thrombosis
3. Placenta Previa
4. Abruption
Iatrogenic:
1. Indicted preterm delivery due to medical or obstetric complication
Idiopathic:
1. Premature effacement of the cervix .
2. Early engagement of head.

Predictors of preterm labor Clinical predictors:

(i) Multiple pregnancy;

(ii) History of preterm birth;

(iii) Presence of genital tract infection;
(iv) Symptoms of PTL.
Biophysical predictors:
(i) Uterine contractions (UC) > 4/hr;
(ii) Bishop score > 4;
(iii) Cervical length (TVS) < 25 mm.
Biochemical predictors:
(i) Fetal fibronectin (fFN) in cervico vaginal discharge
(ii) Others IL-6, IL-8, TNF-a. Fibronectin
Fibronectin

Diagnosis
Preterm labor is primarily diagnosed by symptoms and physical
examination.

Diagnosis
Symptoms
1. Uterine contractions,
(Irregular, no rhythmical, and either painful or painless
( at least one in every 10 min))
2. Pelvic pressure
3. Menstrual-like cramps
4. Watery vaginal discharge
5. Lower back pain

Diagnosis
Cervical Change
• Dilatation: ≥ 2 cm
• Effacement: 80 % of the cervix
• Length of cervix (measured by TVS) ≤ 2.5 cm
• Funneling of the internal OS
Management
1. To prevent preterm onset of labor, if possible
2. To arrest preterm labor
3. Appropriate management of labor
4. Effective neonatal car

Prevention of preterm labor

Risk of delivery of LBW baby against risk to fetus and mother

Adopt following guidelines:

1. Primary care is aimed to reduce incidence of preterm labor by reducing
high risk factors
2. Secondary care: Screening test for early detection and prophylactic
treatment (Tocolytics)
3. Tertiary care:
Aimed to reduce perinatal morbidity and mortality after diagnosis
(corticosteroids)
Investigations:
1. Full blood count
2. Urine for routine analysis culture and sensitivity
3. Cervical vaginal swab for culture and fibronectin
4. USG for fetal well being, cervical length, placental localization
5. Serum electrolyte and glucose level when tocolytics used

Measures to arrest preterm labor

• Bed rest in left lateral position
• Adequate hydration
• Prophylactic cervical circlage: Women with prior preterm birth and
short cervix in present pregnancy
• Tocolytics: Inhibit uterine contraction Commonly used: prostaglandin
syntheses inhibitors, magnesium sulphate, calcium channel blockers,
oxytocin receptor antagonists, NO
 Drugs MOA Dose S/E

CCB (nifidipine, Blocks the entry of 10-20mg every 3-6 Hypotension,

verapamil) calcium inside cell hours headache, nausea

Magnesium Competitive 4-6 g IV over 20 Relatively safe

sulphate inhibition of calcium minutes followed Flushing,
ions by infusion of 1- perspiration,
2gm/hour muscle weakness

Headache,
Activation of palpitation,
intracellular Ritrodin: 50ug/min hypotension,
Betamimetics enzyme(adenylate IV every 10 minute cardiac arrest,
cyclase, cAMP) till contraction hypokalemia
reduces cease and infusion
intracellular free 12 hours after that
calcium Terbutalin:
subcutaneous,
0.25 mg every 3-4
hours

Oxytocin Blocks myometrial 300ug/min IV Nausea, vomiting,

antagonist oxytocin receptors chest pain (rare)

Nitric oxide Smooth muscle Patches Headache

relaxant
Principles of management
1. Glucocorticoids:
To reduce neonatal RDS, IVH and NEC 
Helps fetal lung development
• Dexamethasone: 6 mg IM every 12 hourly for 4 doses
• Betamethasone: 12mg IM 24 hours apart for 2 doses
• Betamethasone better than dexamethasone but betamethasone is not
available.

Risk of antenatal corticosteroid use:

 Prelabor rupture of membrane 
Insulin dependent diabetes mellitus 
Transient reduction of fetal breathing and body movement

2. Antenatal transfer of the mother with fetus in utero to a center

equipped with NICU
3. Tocolytics drugs to the mother for short period unless
contraindicated 
Commonly used: prostaglandin synthetase inhibitors, magnesium
sulphate, calcium channel blockers, oxytocin receptor antagonists, NO.

4.Antibiotics to prevent neonatal infection with Group B Streptococcus :

• 18 hour after leaking
• Crystalline penicillin (Penicilin G)
• 5 million unit, IV, one dose at the onset of labour
• 2.5 million unit, IV, every 4 hourly till delivery.

Short-term therapy :
It is commonly employed with success.
The objectives:
 (1)To delay delivery for at least 48 hours for glucocorticoid therapy to
the mother to enhance fetal lung maturation;
(2) In utero transfer of the patient to a unit with an advanced NICU.
Contraindications:
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, pregnancy
beyond 34 weeks.
C. Others: Rupture of membranes, chorioamnionitis, cervical dilatation
more than 4 cm.

Principals in management of preterm labor are:

To prevent birth asphyxia and development of RDS
To prevent birth trauma. Duration of labor is usually short
First stage Second stage

• The patient is put to bed to prevent
early rupture of membranes.
• To ensure adequate fetal
oxygenation by giving oxygen to the
mother by mask.
• Epidural analgesia is of choice.
• Labor should be carefully monitored.
• Cesarian delivery is done for
obstetric reasons.
• NICU
• 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
• The cord is to be clamped
immediately at birth to prevent
hypervolemia and hyperbilirubinemia
• To shift the baby to neonatal intensive
care unit.

Cesarean Section:
• Routine CS not recommended.
• Only for Preterm fetuses before 34 weeks presented by breech.
• Lower segment vertical/ J shaped incision made to minimize trauma
during delivery.

Prognosis:
• Preterm labor and delivery of low birth weight baby results in high
perinatal mortality and morbidity.
• If NICU care given, survival rate is more than 90% for (1000g- 1500g).

References
Cunningham et.al., Williams OBSTETRICS, 24E, McGraw-Hill
Education, 2014, DC Dutta’s textbook of Obstetrics
Contents
Management of Preterm Labour ........................................................................................................2
Preterm Labor....................................................................................................................................2
High risk factors .................................................................................................................................3
Complication in resent pregnancy ......................................................................................................3
Complication in present pregnancy Fetal Complications: .....................................................................4
Placental complication .......................................................................................................................4
Predictors of preterm labor Clinical predictors: ...................................................................................4
Biochemical predictors: ......................................................................................................................5
Adopt following guidelines: ................................................................................................................6
Measures to arrest preterm labor.......................................................................................................6
Principles of management ..................................................................................................................9
Principals in management of preterm labor are: ............................................................................... 10
Cesarean Section: ............................................................................................................................ 11
Prognosis: ........................................................................................................................................ 11