Preterm Labour and Preterm Birth
Dr Damulira Adam
Objectives
• recognize preterm labour
• manage preterm labour
• apply preventive strategies for preterm birth
Clinical Definition
– Preterm Labour:
• regular uterine contractions accompanied by progressive
cervical dilatation and/or effacement after viability but at
less than 37 completed weeks.
Definition
– Preterm Birth:
• any birth regardless of weight occurring after viability but
before 37 completed weeks from the first day of last
menstrual period (LMP)
• increased perinatal morbidity and mortality is associated
with birth < 34 weeks
Cont..
• Epidemiology
• 7% labours are preterm
• 30% babies born at 24wks survive (UK)
• 80% babies born at 28wks survive (UK)
Etiology
• APH
• preterm pre-labour rupture of membranes
(PPROM)
• multiple pregnancy
• polyhydramnios
• incompetent cervix
• uterine anomaly
• fetal anomaly
Cont..
• Idiopathic
• Chorioamnionitis
• Systemic dz (pyelonephritis)
• Drug abuse - cocaine
• Trauma to abdomen
• procedures – e.g amnioscentesis
Additional Risk Factors
– prior preterm birth
– bacteriuria
– maternal weight/age/smoking/stress
– bacterial vaginosis (BV) in women with a prior preterm birth
increases the risk of preterm PROM and low birth weight
(LBW)
– Low socio economic class
– malnutrition
Clinical Features
• +/- watery vaginal discharge
• +/- PV Bleeding
• +/- back ache
• +/- low abd. Pain
• +/- reduced fetal movements
• Signs of labour
- Painful regular contractions
- rupture of membranes
- Cx effacement
- Cx dilatation
Diagnosis
• history: contractions, back ache, bleeding, uterine
anomalies ,previous preterm labour, etc
• establish dates: LNMP,EDD, U/S at 20wks
• identify risk factors
• Physical exam:
• Abd. exam: tenderness, guarding, masses,
contractns
• Obstetric exam
• V/E:PV discharge, Cx dilatn, effacement
investigations
• dx: mainly clinical
• But inv. To treat possible causes
- CBC+ ESR
- High vaginal swab
- Blood cultures
- urinalysis
- Amnioscentesis
- TV Ultrasound
Supportive mgt
• Correct dehydration
• analgesia
• Allay anxiety
• ABCs
Definitive management
• Consists of tocolysis or allowing labour to progress
• Tocolysis:aims to delay lbr till steroids tkn effect
• Attempt tocolysis if:
• GA< 37wks
• Cx <3cm
• No amnionitis, pre-eclampsia or active bleeding
• No fetal distress
• Give steroids: dexa 12mg bd or betamethasone
Tocolytics
• Beta agonists: ritodrine, salbutamol, terbutaline
• Ca channel blockers: nifedipine
• NSAIDS: rectal indomethacin
• Glceryltrinitrate :transdermal or IM
• 17OH Progesterone (obsolete in devpd world)
• Dose: salbutamol 10mg in 1L IV 10drops/min,
increase by 10drops/30min til thy stop
• indomethacin:100mg then 2mg 6hrly for 48hrs
Allow labour to progress
• If GA>37, CX>3cm, active bldg,fetal distress,
amnionitis or pre eclampsia
• Monitor lb with partograph
• Prep mgt for preterm/LBW baby &rescusitation
• Don’t rupture membr early
• Small prematures may be delivered in their sacs
• C/S if twins or higher order multiple gestation
Premature Rupture of the Membranes
(PROM)
Objectives
• recognize the clinical criteria for the
diagnosis of PROM
• manage term and preterm PROM
Cont..
Definition
• rupture of membranes before the
onset of labour
- preterm < 37 weeks’ gestation
(PPROM)
- term 37 weeks’ gestation
(PROM)
Cont..
Latent Period
• time from rupture until onset of labour
• the earlier the gestation, the longer the latent period
• at term
- 90% go into labour within 24 hours
• at 28 to 34 weeks
- 50% go into labour within 24 hours
- 80% to 90% go into labour within 1 week
Etiology of PROM
• idiopathic
• infection
• polyhydramnios
• cervical incompetence
• uterine abnormality
• following cervical cerclage or amniocentesis
• trauma
• previous cervical surgery (conization)
• Other ( smoker, stress, lifestyle, nutrition, drugs)
Diagnosis of PROM
• history: dates,LNMP,EDD, gush of fluid P.V.
• Physical exam: +/- flushing, fever, signs of
oligohydramnios – tense abd, Low FH for dates
• V/E: wet vulva, cx closed
• speculum: pool of flluid in posterior fornix or d/c
coming from cx
• ultrasound
- PROM less likely if normal fluid volume
Complications of PROM – Preterm
• preterm labour and delivery
• infection
• cord compression/prolapse
• caesarean section rate
• early, severe oligohydramnios
- pulmonary hypoplasia
- fetal deformation
Management – General
• assess maternal and fetal well-being
• confirm diagnosis
• assess cervical status by speculum exam
cultures if indicated
• avoid digital cervical exam until induction or labour
• GBS management
• assess for
infection
conditions requiring concurrent management
indications for immediate delivery
investigations
• Baseline- CBC, GP & x-match, CRP
• Specific
• Vaginal swab for microscopy
• Microscopy of discharge – reveals fetal
squames, lanugo hairs, vernix
• Urinalysis – for protein
• Ferning test – fern leaf pattern on slide
• Nitrazine test – alkaline colour change
• U/S for GA
Management – Preterm (< 34 weeks)
• Supportive: bed rest, analgesia
• steroids
• consider transfer
• antibiotics
Erythromycin 500mg 8hry for 1wk
- Prophylaxis against infection
- to prolong latency
- treat chorioamnionitis
Deliver at 37wks
GA >37wks
• If membr ruptured for >18hrs give
prophylactic ABCs agnst GpB strep.
• if CX is favourable induce Lbr (oxytocin)
• If no signs of infxn after delivery, discontinue
ABCs
• If CX unfavourable, ripen using pgdns
• Induce wz oxytocin or do C/S
Complications of PROM – Term
• fetal/neonatal infection
• maternal infection
• umbilical cord compression/prolapse
• caesarean section rate
