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Preterm labour and birth (NG25)

Care of women at risk of preterm labour
A history of A history of A history of
• spontaneous PREM BIRTH (up to 34 • spontaneous PREM BIRTH (up to 34 • P-PROM in a previous pregnancy or
wks) or wks) or • Cervical trauma
• LOSS (from 16 wks onwards) • LOSS (from 16 wks onwards)

PLUS OR PLUS
TVS b/t 16 & 24 wks TVS b/t 16 & 24 wks TVS b/t 16 & 24 wks
• a cervical length of 25 mm or less. • a cervical length of 25 mm or less. • a cervical length of 25 mm or less.

Offer choice between Consider Consider

• vaginal progesterone or vaginal progesterone prophylactic cervical cerclage
• cervical cerclege
When using vaginal progesterone, start treatment between 16+0 and 24+0 weeks of pregnancy and continue until at least 34 weeks.

Mehm Hong Prite

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Care of women with suspected or established preterm labour

Women reporting signs and symptoms of preterm labour Remarks

History taking
SSE
F/b digital examinination if the extent of cervical dilatation cannot be assessed. If a swab testing is
anticipated, the swab
should be taken first.

Suspected Preterm Labour

<30 weeks 30 weeks or more
Offer treatment TVS for cervical length Diagnostic test to
determine the likelihood of
• Tocolysis >15 mm - Unlikely to be preterm labour
birth within 48 hours.
• Corticosteroids 15 mm or less- Diagnosed preterm labour

Alternative of TVS (not avalible or not acceptable)

Both TVS and Fibronectin
Use Fibronectin test
test – not available
Negative - concentration 50 ng/ml or less Offer treatment
Unlikely preterm labour
Positive - concentration more than 50 ng/ml
Offer treatment

Mehm Hong Prite

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Diagnosing P-PROM

Reporting symtoms
SSE – look for pooling of amniotic fluid
Observed Not observed
Offer Management Perform an insulin-like growth factor binding protein-1 test or placental alpha-
• Antibiotics microglobulin-1 test of vaginal fluid.
• Corticosteriods

Positive Negative - Unlikely PPROM

Do not use nitrazine to diagnose P-PROM.

Do not perform diagnostic tests for P-PROM if labour becomes established.

Identifying infection in women

• Use a combination of clinical assessment and tests (CRP, WBC and FHR using CTG) to diagnose intrauterine infection.

Antenatal prophylactic antibiotics for women with P-PROM

Offer women with P-PROM oral Emycin 250 mg QID for a max 10 days or until the woman is in established labour (whichever is
sooner).
Who cannot tolerate Emycin or in whom Emycin is contraindicated, consider an oral penicillin for a max 10 days or until the
woman is in established labour (whichever is sooner).
Do not offer women with P-PROM co-amoxiclav as prophylaxis for intrauterine infection.

Mehm Hong Prite

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Tocolysis

Intact membranes + suspected preterm labour

First line – Nefidipine
If Nefidipine is CI, oxytocin Rc antagonists
Do not offer betamimetics for tocolysis.
24+0 and 25+6 - Consider
26+0 and 33+6 - Offer

Maternal corticosteroids

Suspected or established preterm labour + having a planned preterm birth/ have P-PROM
22+0 and 23+6 weeks - Individualized
24+0 and 33+6 weeks - Offer
34+0 and 35+6 weeks - Consider
Repeated course of corticosteroids
• <34+0 weeks + a course of corticosteroids when this was >7 days ago + Very high risk of giving birth in the next 48
hours.
• Caution - Possible impact on fetal growth in <30 weeks, Suspected FGR
• Do not give more than 2 courses of maternal corticosteroids for preterm birth.

Mehm Hong Prite

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Magniseum Sulphate For neuroprotection

Use in
• A woman is in established preterm labour if she has progressive cervical dilatation from 4 cm with regular contractions.
• Having a planned preterm birth within 24 hours.
23+0 and 23+6 weeks - Individualized
24+0 and 29+6 weeks - Offer
30+0 and 33+6 weeks - Consider
4 g IV bolus of MgSo4 over 15 minutes, followed by an IVI of 1 g/hour until the birth or for 24 hours (whichever is sooner)
Monitor for clinical signs of Mg toxicity at least every 4 hours by recording PR, BP, RR and deep tendon (for example, patellar)
reflexes.
If a woman has or develops oliguria or other evidence of renal failure:
• Monitor more frequently for magnesium toxicity
• Reduce or stop the dose of magnesium sulfate.

Timing of cord clamping for preterm babies (born vaginally or by caesarean birth)

Wait at least 60 seconds before clamping the cord of preterm babies unless there are specific maternal or fetal conditions that need
earlier clamping.

Mehm Hong Prite