2. Pre-term labour
Labour starts before the 37th
completed week (<259 days),
counting from the first day of the
last menstrual period
Lower limit of gestation: 20 weeks
(developed) & 28 weeks (developing
countries)
2
3. History
Complications in
present pregnancy
Iatrogenic
Idiopathic
Aetiology *multifactorial
Previous history of
induced or spontaneous
abortion or preterm
delivery
Pregnancy following
assisted reproductive
techniques (ART)
Asymptomatic bacteriuria
or recurrent UTI
Low socio-economic &
nutritional status
Maternal stress
Maternal
Pregnancy complications –pre
eclampsia, antepartum
haemorrhage, PROM,
polyhydramnios
Uterine anomalies –cervical
incompetence, malformations of
uterus
Medical & surgical illness –acute fever, acute
pyelonephritis, diarrhoea, acute appendicitis,
toxoplasmosis, abdominal operation.
*hypertension, nephritis, severe anaemia,
diabetes, decompensated heart lesion, low BMI
Genital tract infection –bacterial vaginosis,
beta haemolytic streptococcus, bacteroides,
chlamydia, mycoplasma
Fetal
Multiple pregnancy,
congenital anomalies,
IUD
Placental
Infarction,
thrombosis, placenta
previa or abruption
Indicated preterm delivery d/t medical or
obstetric conditions
Idiopathic(Majority): Premature effacement of the
cervix with irritable uterus & early engagement of the
head
3
5. Diagnosis
Regular uterine
contractions with or
without pain (at least 1
every 10 minutes)
Dilatation (≥2 cm) and
effacement (80%) of
cervix
Length of cervix
(measured by TVS)
≤2.5 cm and
funnelling of the
internal os
Pelvic pressure ,
backache or vaginal
discharge or bleeding
6
7. Management
Principles
1) Prevent the preterm onset of labour, if possible
2) Arrest preterm labour if not contraindicated
3) Appropriate management of labour
4) Effective neonatal care
8
8. 1. Prevention of PTL
Primary care : Reducing high risk factors.
Secondary care : Screening tests for early detection and prophylactic
treatment. (tocolytics)
Tertiary care : Reduce perinatal morbidity & mortality after diagnosis
(corticosteroids)
Investigations
• FBC
• Urinalysis and C&S
• Cervicovaginal swab –culture & fibronectin
• USG –fetal wellbeing, cervical length & placental localisation
• Serum electrolytes and glucose levels ( for tocolytics usage)
9
9. 2. Measures to arrest PTL
Only in negligible proportion of
cases
Bed rest (left lateral)
Adequate hydration
Prophylactic antibiotics –not routinely
given
Prophylactic cervical cerclage *
Tocolytic agents Short term therapy
• To delay delivery for at least 48 hours for glucocorticoid
therapy to enhance fetal lung maturation
• In utero transfer of patient >> advanced NICU
For cervical incompetence
–reinforces the weak cervix by non-
absorbable tape, placed around the
cervix at the level of internal os
1. Shirodkar’s operation
2. Mc Donald’s operation
• Fetus is not compromised
• Maternal conditions remain good
• Intact membranes
10
10. 2. Measures to arrest PTL
CONTRAINDICATIONS
• Uncontrolled DM
• Thyrotoxicosis
• Severe HTN
• Cardiac disease
• Hemorrhage in pregnancy
Maternal
• Fetal distress
• Fetal death
• Congenital malformation
• Pregnancy > 34 weeks
Fetal
• ROM
• Chorioamnionitis
• Cervical dilatation > 4cm
Others
Glucocorticoid
< 34 weeks
Minimize RDS, IVH & NEC
Benefit persists as long as 18 days
Betamethasone* 12mg IM 24 hours apart 2
doses OR
Dexamethasone 6 mg IM every 12 hours for 4
doses
Risks:
PROM (~infection)
Insulin dependent DM needs insulin readjustment
Transient reduction of fetal breathing and body
movements
11
11. 3. Management of labor in PTL
*prevent birth asphyxia, RDS
*prevent birth trauma (duration of labour : short)
FIRST STAGE SECOND STAGE
1. Patient is put to bed [to prevent PPROM]
1. The birth should be gentle and slow [to avoid
compression & decompression of the head]
2. Oxygen mask to mother [Adequate fetal
oxygenation]
2. Episiotomy may be done [to minimise head
compression d/t perineal resistance]
3. Epidural analgesia of choice. 3. Tendency to delay is curtailed by low forceps.
4. Monitor the labour carefully by using continuous
Electronic Fetal Monitoring (EFM).
4. The cord is to be clamped immediately [prevent
hypervolemia & hyperbilirubinemia]
5. C-section only if indicated.
5. Shift baby > NICU
6. NICU for good outcome.
12
12. Principle management of PTL
Glucocorticoids • Reduce neonatal RDS, IVH, NEC
Antenatal
transfer
• NICU
Tocolytics drugs • For short period (48 hours)
Antibiotics
• Prevent infection by Group B streptococcus
[GBS]
Careful
intrapartum
monitoring
• Minimal trauma, neonatologist
Vaginal delivery • Otherwise –indications for C-section
13
13. Premature Rupture of Membranes
(PROM)
Spontaneous rupture of the membranes any time
beyond 28th week of pregnancy but before the onset
of labour
> 37 completed weeks : term
< 37 weeks of gestation: pre term
Rupture of membranes > 24 hours before delivery :
prolonged rupture of membrane
10% of all pregnancies
14
14. PROM
-causes
Increased friability
of the membranes
Decreased tensile
strength of the
membranes
Polyhydramnios
Cervical
incompetence
Multiple pregnancy
Infection
chorio-amnionitis,
UTI, lower genital
tract infection*
Cervical length
< 2.5cm
Prior Pre-term
Labor
Low BMI
(<19 kg/m2)
15
15. PROM
-diagnosis
Escape of watery
discharge per vaginum;
gush or slow leak.
Differential
diagnosis
• Hydrorrhoea
gravidarum [periodic
watery discharge occurs
probably d/t excessive
decidual glandular
secretion]
• Incontinence of urine
16
16. PROM
-confirmation of diagnosis
Inspect liquor
escaping out
through cervix
Speculum
examination
pH detection
[Lithmus /Nitrazine
paper]
Ferning pattern on
smearing
Orange blue
colouration of cells
(centrifuged cells
stained with 0.1%
Nile blue sulphate)
Vaginal pool
examination
(fluid from
posterior
fornix) Support diagnosis
+ assess fetal well
being
USG
pH 6-6.2 [Normal vaginal pH
during pregnancy is 4.5-5.5;
liquor amnii is 7-7.5]
Nitrazine paper: Yellow Blue
at pH >6
Exfoliated fat containing
cells from sebaceous
glands of the fetus
17
17. PROM
INVESTIGATIONS DANGERS
1. FBC
2. Urinalysis and culture
3. High vaginal swab – culture
4. Vaginal pool : Estimation of
phosphatidyl glycerol and L:S ratio
5. USG : Fetal biophysical profile
6. CTG
1) Term PROM, labour starts in 80-90%
cases within 24 hours PTL &
prematurity
2) Ascending infection is more (if labour
fails to start within 24 hours)
~choriamnionitis
3) Cord prolapse -malpresentation
4) Dry labour d/t continuous escape of
liquor
5) Placental abruption
6) Fetal pulmonary hypoplasia
7) Neonatal sepsis, RDS, IVH, NEC
8) Perinatal morbidities (cerebral palsy)
18
18. PROM
-preliminaries
1. Aseptic examination [to confirm the diagnosis, assess the state of cervix, to detect any cord
prolapse]
2. Avoid vaginal digital speculum
3. Patient is put to bed rest + sterile vulval pad is applied [to observe any further
leakage]
Diagnosis is confirmed, management depends on:
a) Gestational age of fetus
b) In labor or not
c) Sepsis evidence
d) Fetal survival
*monitor maternal pulse, temperature & FHR for 4 hourly
19
19. PROM
Term
• Watch carefully (if not in
labour)
• Usually starts within 24
hours. If not > induce by
oxytocin.
• C-section if indicated.
Preterm
• Balance risk of infection
vs prematurity. *NICU
Antibiotics
Ampicillin, amoxicillin or
erythromycin for 48 hours
followed by oral therapy
for 5 days or until delivery
Corticosteroids
Controversial as PROM
may accelerate fetal lung
maturation
* Combined both reduced
risk of RDS, IVH & NEC
Gestational age > 34 weeks: Infection >>
perinatal mortality d/t prematurity
20
