Queensland Health

Queensland Health

Queensland Clinical Guidelines

Translating evidence into best clinical practice

Preterm labour and birth

Clinical Guideline Presentation

45 minutes
Towards CPD Hours
 References:
Queensland Clinical Guideline: Preterm labour and birth is the primary reference for this package.

Recommended citation:
Queensland Clinical Guidelines. Preterm labour and birth clinical guideline education presentation E20.6-1-V4-R25. Queensland
Health. 2020.

Disclaimer:
This presentation is an implementation tool and should be used in conjunction with the published guideline. This information does
not supersede or replace the guideline. Consult the guideline for further information and references.

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M: GPO Box 48 Brisbane QLD 4001 | E: guidelines@health.qld.gov.au | URL: www.health.qld.gov.au/qcg
Funding: Queensland Clinical Guidelines is supported by the Queensland Health, Healthcare Improvement Unit.

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Queensland Clinical Guidelines: Preterm labour and birth 2

 Objectives

• In relation to preterm labour (PTL) and

preterm birth (PTB), the participant will be
able to:
◦ Identify risk factors
◦ Identify risk reduction measures
◦ Outline the assessment process
◦ Outline clinical management options

Queensland Clinical Guidelines: Preterm labour and birth 3

 Abbreviations
BMI Body mass index
CTG Cardiotocograph
CS Caesarean section
fFN Fetal fibronectin
FHR Fetal heart rate
GBS Group B streptococcus
MSU Mid stream urine
MC&S Microscopy / culture / sensitivity
PROM Premature rupture of membranes
PPROM Preterm premature rupture of membranes
PTB Preterm birth
PTL Preterm labour
QCC Queensland Emergency Medical System Coordination Centre
ROM Rupture of membranes
TVCL Transvaginal cervical length
USS Ultrasound scan
VE Vaginal examination
> Greater than
< Less than

Queensland Clinical Guidelines: Preterm labour and birth 4

 Introduction
Preterm birth: Occurring before 37 completed weeks

• PTB occurred in 9.4% of all pregnancies in

Queensland in 2017
• Cause unidentified in up to 50% of PTB
• Majority of women with risk factors will not have PTB
• Many women who have a PTB have no risk factors
• 8.7% of singleton births
• 66% of multiple births

Queensland Clinical Guidelines: Preterm labour and birth 5

 Risk factors for PTB
Maternal, medical and pregnancy risk factors
• Previous PTB* Fetal fibronectin positive
• Assisted reproduction Short cervical length
• Cigarette smoking Genital/urinary tract infections
• Low socio-economic status Vaginal bleeding
• High or low body mass index (BMI) Multiple pregnancy
• Late or no antenatal care Preterm premature rupture of
membranes (PPROM)
• Uterine anomalies Chronic/acute medical conditions
• Ethnicity (non-Caucasian) Previous cervical trauma
• < 18 or > 35 years of age Previous cervical surgery
*Most important historical risk factor is prior spontaneous PTB

Queensland Clinical Guidelines: Preterm labour and birth 6

 Risk screening
• Comprehensive history review including maternal characteristics and previous
History
medical/pregnancy history

• Psychosocial needs, smoking, lifestyle, chronic disease

Counselling
• Involve a multidisciplinary team and refer when needed/appropriate

• Offer screening and treatment to women with symptoms of BV and/or history of PTB
Bacterial
vaginosis

• Offer routine ward test urine screening and treatment to women

Bacteriuria

• If history of PTB: recommend serial TVCL screening from 14–24 weeks

Transvaginal • If low risk of PTB: consider a single TVCL measurement during mid-trimester USS
cervical length

Queensland Clinical Guidelines: Preterm labour and birth 7

 Progesterone therapy
Reduces risk of PTB in women with a history of
spontaneous PTB and/or short cervix

• Consider for:
• Singleton pregnancy from 16–24 weeks with a
history of prior spontaneous PTB
• Asymptomatic women with incidentally diagnosed
short cervix in the second trimester
• Not recommended for use in multiple pregnancies

Queensland Clinical Guidelines: Preterm labour and birth 8

 Cervical cerclage
Compared with no treatment cerclage reduces
incidence of PTB in women at risk

Consider cervical cerclage for women with a history of:

• One or more prior spontaneous PTB and/or second-trimester loss related
to painless/painful cervical dilation and in the absence of labour or
placental abruption or
• Prior cerclage due to painless cervical dilation in second trimester or
• Cervical incompetence

Cerclage may be indicated if TVCL is less than 25 mm before 24 weeks if:

• Preterm prelabour rupture of membranes (PPROM) in a previous
pregnancy or
• A history of cervical trauma/surgery or
• Prior spontaneous PTB before 34 weeks gestation and
• Current pregnancy singleton

Queensland Clinical Guidelines: Preterm labour and birth 9

 Clinical assessment
Rationale: to determine risk of birth within the next 7 days
• Assess maternal and fetal wellbeing
• Review history and risk factors
◦ Medical, surgical, obstetric, psychosocial
• Assess for signs and symptoms of PTL
◦ Cervical effacement/dilatation
◦ Pelvic pressure
◦ Lower abdominal cramping/back pain
◦ Vaginal loss (mucous, blood, fluid)
◦ Regular uterine activity

Queensland Clinical Guidelines: Preterm labour and birth 10

 Physical examination
• Vital signs
• Abdominal palpation
• Sterile speculum examination
◦ Confirm/exclude PPROM
◦ Assess cervix, liquor
◦ Collect high vaginal swab for MC&S for bacterial
vaginosis
◦ Collect either vaginal-rectal or vaginal-perianal
swab for Group B streptococcus
◦ Obtain fFN test (if not contraindicated)
• Sterile digital VE
◦ Unless contraindicated by ROM/placenta praevia
Queensland Clinical Guidelines: Preterm labour and birth 11
 Fetal surveillance and
investigations
• Fetal surveillance
◦ FHR
◦ Continuous CTG (interpret with caution if less than
28 weeks gestation)
◦ USS, if feasible
• Maternal laboratory investigations
◦ Collect high vaginal swab for MC&S for bacterial
vaginosis
◦ Collect either vaginal-rectal or vaginal-perianal
swab for Group B streptococcus
◦ Midstream urine for MC&S

Queensland Clinical Guidelines: Preterm labour and birth 12

 Transvaginal cervical length

Risk of PTB increases with a shorter cervical length

• If history of PTB: recommend serial TVCL screening
from 14–24 weeks
• If low risk of PTB: consider a single TVCL
measurement during mid-trimester USS
• Consider therapeutic interventions when TVCL is
< 25 mm

Queensland Clinical Guidelines: Preterm labour and birth 13

 Fetal fibronectin testing
Screening test to assess the risk of PTB in next 7–14 days

Indications for symptomatic women with threatened preterm

labour:
• Between 22+0 and 37+0 weeks gestation and
• Intact membranes and
• Cervical dilatation less than or equal to 3 cm

Indications for asymptomatic women, greater than 22 weeks

gestation, with a history of:
• Cervical surgery/trauma or
• PTB in previous pregnancy or
• Late miscarriage in previous pregnancy

Queensland Clinical Guidelines: Preterm labour and birth 14

 Is admission required?

• Consider admission if:

◦ fFN result greater than 50 ng/mL
◦ Cervical dilation
◦ Cervical change over 2–4 hours
◦ Ruptured membranes
◦ Regular contractions
◦ Further observation or investigation indicated
◦ Other maternal or fetal concerns

Queensland Clinical Guidelines: Preterm labour and birth 15

 Management
Use clinical judgement and appropriate consultation

• Admit for observation

• Consider if in-utero transfer is indicated
• Offer analgesia
• Administer corticosteroids
• Measure TVCL (if available)
• Communicate with multidisciplinary team
• Discuss plan with woman and document
• Clinical reassessment as required

Queensland Clinical Guidelines: Preterm labour and birth 16

 In-utero transfer
Improved neonatal outcomes with appropriate transfer

• Aim for in-utero transfer

• Accept a high level of risk for birth en-route if
gestation less than 28 weeks
• Contact & discuss with relevant obstetric medical
co-ordinator via Queensland Emergency Medical
System Coordination Centre (QCC) on 1300 799 127

Queensland Clinical Guidelines: Preterm labour and birth 17

 Antenatal corticosteroids

Reduces fetal mortality and morbidity

• Recommend with viable fetus before 35+0 weeks

• If risk of PTB persists 7 days after initial course,
consider repeat dose(s)
• If maternal diabetes present, monitor blood glucose
levels

Queensland Clinical Guidelines: Preterm labour and birth 18

 Tocolysis

• May delay birth and allow:

◦ In-utero transfer
◦ Corticosteroid administration
◦ Magnesium sulfate administration
◦ No evidence for prophylactic use after contractions
have ceased

Queensland Clinical Guidelines: Preterm labour and birth 19

 Tocolysis contraindicated

If prolongation of pregnancy is contraindicated

• In-utero fetal death

• Suspected fetal compromise
• Maternal bleeding/haemodynamic instability
• Lethal fetal anomalies
• Severe pre-eclampsia
• Chorioamnionitis

Queensland Clinical Guidelines: Preterm labour and birth 20

 Nifedipine

• Tocolytic of choice
• Calcium channel blocker that relaxes smooth muscle
• Effective tocolytic with fewer side effects than other
tocolytics

Queensland Clinical Guidelines: Preterm labour and birth 21

 Antibiotics
Routine administration in threatened PTB with intact
membranes and without infection not recommended

• If established PTL or imminent risk of PTB, give

prophylactic antibiotics for GBS
• If PTL does not ensue and no other indications, then
with:
◦ Intact membranes, cease antibiotics

Queensland Clinical Guidelines: Preterm labour and birth 22

 Signs of chorioamnionitis

• Temperature > 38 ◦C, maternal/fetal tachycardia,

uterine tenderness, offensive discharge, elevated
white cell count
• If intact or ruptured membranes and signs of
chorioamnionitis, do not inhibit labour
• Consider hastening the birth and use broad spectrum
IV antibiotics

Queensland Clinical Guidelines: Preterm labour and birth 23

 Magnesium sulfate
Reduces the risk of cerebral palsy and protects gross
motor function in the preterm infant

• Recommend between 24+0 and 30+0 weeks where

birth is expected or planned within 24 hours
• Consider for women between 30+0 and 33+6 weeks
• If urgent birth indicated, do not delay birth to
administer

Queensland Clinical Guidelines: Preterm labour and birth 24

 Mode of birth

• Singleton vertex ≥ 26+0 weeks

◦ Recommend vaginal birth unless caesarean
section (CS) indicated for other reasons
• Breech ≥ 26+0 weeks
◦ CS not generally recommended if vaginal birth
imminent
• ≤ 25+0 weeks* (vertex or breech)
◦ CS for fetal indications not generally
recommended at less than 25+0 weeks
*Refer to Queensland Clinical Guideline: Perinatal care at the threshold of viability

Queensland Clinical Guidelines: Preterm labour and birth 25

 After threatened PTL

• Provide care according to clinical circumstances

◦ Prolonged admission
◦ Back transfer
◦ Discharge if usual criteria met (e.g. consider
maternal vital signs, membrane status,
contractions infrequent, cervical changes, CTG,
fFN test result)
• Refer and follow-up as indicated

Queensland Clinical Guidelines: Preterm labour and birth 26

 Provide discharge information

• Provide the woman information that:

◦ Aids recognition of PTL signs and symptoms
◦ Identifies risk reduction measures
◦ Provides instruction about when to seek clinical
advice
• Offer social worker or other relevant referral/s
• Notify GP of diagnosis and plan of care

Queensland Clinical Guidelines: Preterm labour and birth 27