The authors describe current guideline for management of preterm birth

1. Preterm Labour
Dr Ibanda Hood
Dr Nicholas Mugagga

2. objectives
• Definitions
• Risk factors
• Presentation
• Management

3. Risk factors
From History
• Black race
• Socioeconomic factors
• Low levels of education
• Poverty
• Age (PG<16, and PG>30yrs)
• Stressful jobs
• Past history of preterm labour
• Smoking
• Cocaine use
• Past Hx of elective Termination of pregnancy
• In utero exposure to DES
• Past Mid-trimester loss of pregnancy
Obstetric risk factors for Preterm
Labour
• Upper urinary tract infection
• ASB
• Pyelonephritis
• Maternal diseases
• Hypertension
• Preeclampsia & Eclampsia
• Asthma
• Heart Disease
• Drug Addiction
• Cholestasis
• Anaemia with Haemoglobin less than
9g/dl
• Uterine overdistension

4. Definition
Preterm labour is defined as labour after 28 weeks gestation and
before 37 weeks gestation

5. Risk Factors
Obstetric
• Overdistension of uterus
• Multifoetal gestation
• Gross anomalies leading to
polyhydramnios
• Diabetes
• Rh Isoimmunisation
• Antepartum haemorrhage
Risk factors
• Placental abruption
• Foetal death
• Maternal abdominal surgery
• Maternal sepsis
• Intrauterine infection
• Fibroids
• Abnormalities of Cervix & Fundus
• Foetal anomalies
• Idiopathic: a large group lies here

6. Management of Preterm delivery
1. Early detection of premature labour
a) Patient education about the early Symptoms of preterm labour
• Menstrual-like cramping
• Low backache
• Pelvic pressure
• Increased vaginal discharge
• Increased frequency of urination
• Vaginal bleeding
b) Monitoring patients at risk of preterm labour
c) Using ultrasound scan cervical changes suggestive on impending labour can be monitored. The changes include
• Dilation of external and internal os
• Cervical Effacement and softening
• Change in Cervix direction from posterior to anterior
• Change in station of presenting part
d) Hospitalisation: This is done if the Cervix changes(as above) or uterine irritability with cramping is noted
e) Thorough Evaluation of suspected cases of preterm labour.

7. Management of Preterm delivery
2) Proper evaluation and management of Cervical insufficiency.
a) History (pregnancy loss without cramping, RPL)
b) Examination: Cervical changes without cramping
c) Investigation
• Vaginal ultrasound scan (cervical length)
• Preconception HSG (may show Mullerian anomaly, wide cervical canal)
• Internal cervix opening in second trimester (not funnelling)
d)Treatment of incompetent Cervix
• Cervical Cerclage (stitch, pesaries, laparoscopic)
• Progesterone

8. 3). Therapy for preterm labour
a. Anticipate preterm labour
b. Appropriate Examinations and investigations for monitoring mother and
foetus
c. Treat likely cause of the preterm labour
d. Think of referral for NICU and other Emergency obstetric services
e. Magnesium sulphate for neuroprotection
f. Tocolysis
g. corticosteroids
h. Antibiotics
i. Mode of delivery
j. Other very important issues to consider (psychotherapy, psychiatric care,
smoking cessation, Bed rest in left lateral position)

9. Foetal monitoring
• There is no evidence that CTG is superior to Intermittent auscultation,
women should be told and allowed to chose.
• After 28/40, if there are other risk factors, CTG should be used.
Specialist Obstetrician must be on the team.
• Avoid scalp electrodes before 34 weeks
• Avoid foetal blood sampling before 34 weeks, and if you must, do it
with caution before 37 weeks.

10. Tocolysis
• Tocolysis helps delay delivery as we give corticosteroids, treat any
offending/causative factors, and transfer to appropriate hospital.
However, Tocolysis does NOT change birth outcomes (NICE& RCOG).
• Atosiban, an oxytocin receptor antagonist is used.

11. Prerequisites for Using Atosiban
• Regular uterine contractions lasting 30 seconds at a rate of ≥ 4 in
30 minutes
• Cervical dilation of 0 to 3 cm
• Gestation from 24+0 to 33+6 weeks
• Normal fetal heart rate
• Fetal Fibronectin >200units (if appropriate to test)
• Agreement from consultant on call (who may also consider use at
>3cm, 33+6 weeks)

12. Contra-indications to Using Atosiban
• Foetal Fibronectin <200ng/ml
• Evidence of foetal compromise
• Intrauterine infection
• Any maternal or foetal condition that warrants delivery (e.g. pre-eclampsia)
• Known hypersensitivity to Atosiban or any of the contents in Tractocile®
Relative Contra-indications to using Atosiban
• Rupture of membranes –unless requiring transfer out to another unit
• Antepartum haemorrhage, unless reviewed by an Obstetric Consultant
• Fetal Growth Restriction

13. Corticosteroids
We use IM Betamethasone (12mg od for 48 hours) or IM Dexamethasone
6mg bd for 4 doses (48 hours).
• The benefits of steroids include: Reduced NICU admission, IVH, RDS,
surfactant need, 02 need, long-term complications, NEC, Death. Optimal
benefit is got if delivery is between 1-7 days (24hr-7 days).
• Other steroids than the 2 above (e.g. prednisolone) and other routes drug
administration like (e.g. oral) are not effective. This is due to limited
placental transfer and ineffectiveness.
• Corticosteroids should be given at/between 24-34 6/7weeks.

14. Antibiotics
• Give intrapartum Antibiotics to all regardless of GBS status, ROM or
intact membrane. This prevents GBS transmission.
• Don’t give antibiotics in threatened preterm labour without ROM.
• Antibiotics prophylaxis (IAP) are not essential for preterm C-section if
the C-section is not preceded by ROM

15. Magnesium Sulphate for neuroprotection
Magnesium Sulphate given to mothers shortly before delivery reduces the
risk of cerebral palsy and protects gross motor function in those infants born
preterm. The effect may be greatest at early gestations. We give when we
plan to deliver preterm of if preterm labour and Cx dilation is > 4cm.
Protocol (regime)
A loading dose of 4 grams (8 ml of 50% Magnesium Sulphate), diluted with
12 ml of saline 0.9% (total 20 ml), is given IV over 5-10 minutes using a 20 ml
syringe
A maintenance dose of 10 grams (20ml Magnesium Sulphate), diluted with
30ml of saline 0.9% (total 50 ml) is set up to deliver 1 gram per hour
(5mls/hr) using a syringe driver, until delivery. If delivery is imminent it is
appropriate to give only the loading dose. For a planned LSCS delivery start
the regime 4 hours prior to expected delivery time

16. Management of Labour and Delivery
• If cephalic presentation and no addition risk factors, we should aim for
vaginal delivery
• Do not use vacuum extraction before 34 weeks.
• Safety of Vacuum extraction before 36 weeks is not confirmed.
• If presentation is not vertex, senior obstetrician decides after weighing
choices (C-section/vaginal birth).
• Delayed cord clamping is recommended, with the baby in a position below
placenta. Delay clamping for 3 minutes.
• Milk cord if you have to clamp the cord immediately
• Leave a long cord stamp in case its needed for IV access.
• Have neonatologist available
• Nurse the neonate in warm place (heat source).

17. References
RCOG Guidelines (October 2018)