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Course: Maternity Nursing

Topic: Preterm Labour

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Module Goals

The learner will be able to:

Define Preterm labour
Identify its risk factors and diagnosis
Describe the management of preterm labour

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What is Preterm Labour?

Also called premature labour
Regular uterine contractions before 37 weeks of pregnancy, together with either of the following:

Cervical effacement and/or dilatation
Rupture of the membranes

Preterm labour can be spontaneous or planned.
Preterm labour is categorized as:

Extremely preterm (less than 28 weeks)
Very preterm (28-31 weeks plus six days)
Moderate to late preterm (32 - 36 weeks plus six days)

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Preterm Labour: Fetal Risks

The earlier the gestational age, the more vulnerable the fetus

Infants may have health and developmental problems because their systems have not fully developed

Preterm babies need special care in a speciality facility

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Preterm Labour: Risk Factors

Risk factors for preterm labour:

Prelabour rupture of membranes (PROM)
Uterine abnormalities
Infection- Group B streptococci, STDs, pyelonephritis, chorioamnionitis
Cervical incompetence
Prior preterm birth
Multifetal pregnancy
Fetal or placental abnormalities
Teenage pregnancies

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Preterm Labour: Prevention

Adequate prenatal care
Identify patients with past history of preterm labour
Education about the dangers of smoking, alcohol use and habit-forming drugs
Advise against coitus during late second and third trimester at high risk for preterm labour or PROM, and strongly recommend using condoms if couitus occurs, to reduce risk of chorioamnionitis
At 14-16 weeks, McDonald suture ( cerclage) is inserted in proven incompetent internal cervical os cases
Prevent teenage pregnancies
Prevent heavy manual labour during pregnancy, healthy diet

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Patient Teaching

Patient education to seek medical advice/care for:

Regular contractions or abdominal tightenings
Menstrual (period)-type pains
A ‘show’- when the plug of mucus that has sealed the cervix during pregnancy and is discharged from the vagina
A gush or trickle of fluid from their vagina which could be amniotic fluid (water breaking)
New onset of persistent backache

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According to Bettercare/Primary Maternal Care/ 5. Preterm labour and preterm rupture of the membranes:

Prevention of preterm Labour

· Women must receive antenatal care

· Identify patients with a history of preterm labour

· Advise about the dangers of smoking, alcohol, and the use of habit-forming drugs

· Advise against coitus during late second and third trimester in pregnancies that are at high risk for preterm labour or preterm rupture of membranes. If coitus occurs then the use of condoms must be recommended to reduce the risk of chorioamnionitis

· at 14-16 weeks, McDonald suture is inserted in proven incompetent internal cervical os cases

· Prevent teenage pregnancies

· Prevent heavy manual labour during pregnancy, eat a healthy diet.

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Preterm Labour: Diagnosis

Diagnosis of preterm Labour is based on signs of labour and gestation

Uterine contractions are regular, at least 1 per 10 minutes
Contractions are painful
Contractions increase in frequency and duration
Effacement and dilation of the cervix is found on vaginal examination

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Preterm Labour: Management of at-risk Patients

Must have two weekly ultrasound or vaginal examinations from 24 weeks, in order to make an early diagnosis of preterm cervical effacement and/or dilatation.
In all women with cervical effacement or dilation before 34 weeks, the following preventive measures should be taken:

Bed rest (current research recommends home rest)
Admit to hospital if home circumstances are not adequate
Coitus not permitted
Immediately report contractions or rupture of the membranes
Women with preterm labour or preterm rupture of the membranes must be seen as soon as possible, and measures to prevent delivery of a severely preterm infant must be taken

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Preterm Labour: Management Strategies

Provide information to the woman, and any accompanying family members about her diagnosis, treatment options and estimated time for inpatient care if required
Maternal interventions are aimed at improving outcomes of preterm infants when preterm birth is inevitable:

Antenatal corticosteroid therapy, 24 weeks to 34 weeks of gestation
Administration of magnesium sulfate, up to 32 weeks of gestation
Antibiotics administration, in preterm PROM and/or clinical signs of infections
Administration of tocolytics

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Preterm Labour: Antenatal Corticosteroids

Improves fetal lung maturity and chances of neonatal survival for woman at risk of preterm birth from 24 -34 weeks of gestation
Condition to be met before administration:

Determine Gestational age
Preterm birth is considered imminent
No clinical evidence of maternal infection

If above conditions are met following doses are administered:

betamethasone 12 mg IM, two doses 24 hrs apart
or dexamethasone 6 mg IM, four doses 12 hours apart

Note: Consider home and family preparations for preterm infant

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Case study:

A primigravida is 32 weeks pregnant. She arrives at the clinic complaining of pelvic cramping and back pain for the past 8 hours. Vaginal examination shows that the cervix is 2 cm dilated and 50 percent effaced.

What are the nursing actions at this time?

How should the nurse expect this patient to be managed?

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Preterm Labour: Tocolysis

Administration of medicine to try to slow or stop labour
Provides a window for administration of antenatal corticosteroids, and/or in-utero fetal transfer to an appropriate neonatal healthcare setting
Administer a loading dose 20 mg nifedipine immediate-release capsule sublingually

if required, additional 10 mg every 15 minutes to maximum 40 mg in the first hour
Follow-up with 20 mg sustained release tablet orally daily for up to 48 hours or until transfer is completed, whichever comes first

Maternal and fetal condition must be monitored- Pulse, BP, respiratory distress, uterine contractions, loss of amniotic fluid or blood, fetal heart rate, fluid balance)

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Preterm Labour: Tocolysis

Inform patient of side effects of nifedipine:

Headache, flushing, dizziness, tiredness, palpitations, and itching

Tocolytic drugs should not be given for more than 48 hours
Combination of tocolytic agents should not be given as there is no additional benefit
Tocolytic drugs should not be used in following conditions:

Preterm PROM
Chorioamnionitis
Placental abruption
Cardiac disease
Pre-eclampsia
Fetal distress
Cervical dilation of more than 6 cm (unless to temporarily suppress contraction until transferred to hospital
Intrauterine death
Severe intrauterine growth restriction

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Preterm Labour: Magnesium Sulfate

Given if gestational age is < 32 weeks
To prevent preterm birth related neurologic complications such as cerebral palsy
Possible dosage regimen:

Urinary output ( 30 mL/hour) and signs of magnesium overdose or toxicity must be monitored (respiratory rate < 16 breaths/min and/or absent patellar (deep tendon reflexes)

Route	Initial dose	Maintenance dose
IV	4 gm over 20 minutes	1 gm/hr for 24 hr or until birth, whichever occurs earlier
IM	5 gm	5 gm every four hours for 24 hours or until birth, whichever occurs earlier

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Preterm Labour: Antibiotics

To prevent chorioamnionitis in mother and risk of neonatal infections
Antibiotic is administered if amniotic membranes are ruptured or there are clinical signs of infection

Oral erythromycin 250 mg, QID for 10 days (or until birth), Or
IV ampicillin 2 gm, QID

For confirmed Group B streptococcal colonization, Amoxicillin 500 mg PO , TID for seven days is advised
Amoxicillin plus clavulanic acid (co-amoxiclav) must not be used in case of preterm PROM; it increases the risk of necrotizing enterocolitis

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Management of Preterm Labour

If the Labour continues and gestation is less than 37 weeks:

Progress of labour is monitored using the partograph
Preparation for management of preterm or low birth weight baby
Resuscitation arrangements

Routine caesarean birth is not recommended to improve newborn outcomes for preterm infants, regardless of cephalic or breech presentation
Vacuum assisted birth is avoided, as the risks of intracranial bleeding in the preterm baby are high

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Reference:

Bettercare (n.d.). Primary Maternal Care/5. Preterm labour and preterm rupture of the membranes. Retrieved from: https://bettercare.co.za/learn/primary-maternal-care/text/05.html#preterm-labour-and-preterm-rupture-of-the-membrane s

NHS UK (November 2019). Premature Labour and Birth. Retrieved from: https://www.nhs.uk/conditions/pregnancy-and-baby/premature-early-labour/

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Reference:

Moldenhauer, J.S. (January 2020). Preterm Labour. MSD Manual Professional Version (Online). Retrieved from: https://www.msdmanuals.com/professional/gynecology-and-obstetrics/abnormalities-and-complications-of-Labour-and-delivery/preterm-Labour#

WHO (2017). Managing complications in pregnancy and childbirth: a guide for midwives and doctors (2nd ed.) Geneva: World Health Organization. Licence: CC BY-NC-SA 3.0 IGO. Retrieved from: https://apps.who.int/iris/handle/10665/255760

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