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Queensland Health

Maternity and Neonatal Clinical Guideline

Preterm labour and birth

Queensland Clinical Guideline: Preterm labour and birth

Document title:

Preterm labour and birth

Publication date:

December 2014

Document number:

MN14.6-V7.R19

Document
supplement:

The document supplement is integral to and should be read in conjunction


with this guideline.

Amendments:

Full version history is supplied in the document supplement.

Amendment date:

June 2016

Replaces document:

MN14.6-V6.R19

Author:

Review date:

Queensland Clinical Guidelines


Health professionals in Queensland public and private maternity and
neonatal services
December 2019

Endorsed by:

Queensland Clinical Guidelines Steering Committee

Audience:

Statewide Maternity and Neonatal Clinical Network (Queensland)


Contact:

Email: Guidelines@health.qld.gov.au

URL: www.health.qld.gov.au/qcg
Disclaimer
This guideline is intended as a guide and provided for information purposes only. The information has
been prepared using a multidisciplinary approach with reference to the best information and evidence
available at the time of preparation. No assurance is given that the information is entirely complete,
current, or accurate in every respect.
The guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice.
Variation from the guideline, taking into account individual circumstances may be appropriate.
This guideline does not address all elements of standard practice and accepts that individual
clinicians are responsible for:

Providing care within the context of locally available resources, expertise, and scope of practice
Supporting consumer rights and informed decision making in partnership with healthcare
practitioners including the right to decline intervention or ongoing management
Advising consumers of their choices in an environment that is culturally appropriate and which
enables comfortable and confidential discussion. This includes the use of interpreter services
where necessary
Ensuring informed consent is obtained prior to delivering care
Meeting all legislative requirements and professional standards
Applying standard precautions, and additional precautions as necessary, when delivering care
Documenting all care in accordance with mandatory and local requirements

Queensland Health disclaims, to the maximum extent permitted by law, all responsibility and all
liability (including without limitation, liability in negligence) for all expenses, losses, damages and
costs incurred for any reason associated with the use of this guideline, including the materials within
or referred to throughout this document being in any way inaccurate, out of context, incomplete or
unavailable.
State of Queensland (Queensland Health) 2016

This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 3.0 Australia licence. In essence, you are free to copy and
communicate the work in its current form for non-commercial purposes, as long as you attribute Queensland Clinical Guidelines, Queensland Health and abide
by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit http://creativecommons.org/licenses/by-ncnd/3.0/au/deed.en
For further information contact Queensland Clinical Guidelines, RBWH Post Office, Herston Qld 4029, email Guidelines@health.qld.gov.au,
phone (07) 3131 6777. For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld
4001, email ip_officer@health.qld.gov.au, phone (07) 3234 1479.

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Page 2 of 26

Queensland Clinical Guideline: Preterm labour and birth

Flow Chart: Assessment and management of preterm labour (< 37 weeks)


In-utero transfer
Aim for in-utero transfer wherever possible
If gestation 2328 weeks, accept a high level of risk
for birth en-route (unless it puts mothers life at risk)
Coordinate transfer via RSQ phone: 1300 799 127

Review History
Medical, surgical, obstetric, social
Assess for signs and symptoms
Pelvic pressure
Lower abdominal cramping
Lower back pain
Vaginal loss mucous, blood, fluid
Regular uterine activity

Antenatal corticosteroids (< 35+0 weeks)


Recommend course of Betamethasone (2 doses)
o 11.4 mg IM then 2nd dose in 24 hours
o Consider 2nd dose at 12 hours if PTB likely within 24
hours
If risk of PTB remains ongoing in 7 days, repeat dose

Physical examination
Vital signs
Abdominal palpation
Fetal surveillance FHR, CTG
Sterile speculum exam
o Identify if ROM
o Visualise cervix/membranes
o High vaginal swab
o Test for fFN
Low vaginal/anorectal GBS swab
Cervical dilatation
o Sterile digital vaginal exam
unless ROM, placenta praevia
Ultrasound if available
o Fetal growth and wellbeing

Consider admission if:


fFN > 50 ng/mL or
Cervical dilation or
Cervical change over 24 hours or
ROM or
Contractions regular & painful or
Further observation or investigation
indicated or
Other maternal or fetal concerns

No

Discuss with Obstetrician/Paediatrician


If contraindications exist
If other options required (Indomethacin, Salbutamol)

Consider as clinically appropriate

Laboratory
High vaginal swabs for MC&S
One swab (low vaginal + anal) for
GBS
Midstream urine for MC&S

Tocolysis
Nifedipine 20 mg oral
If contractions persist after 30 minutes repeat
Nifedipine 20 mg oral
If contractions persist after further 30 minutes repeat
Nifedipine 20 mg oral
Maintenance therapy 20 mg every 6 hours for 48
hours

Admission
indicated?
Yes

Admit
Analgesia if required
Clinical surveillance
Fetal monitoring/continuous CTG
TVCL if available
Consult as required
Plan care

Discharge
Provide information re: signs and
symptoms and returning for care
Arrange follow-up as indicated

Antibiotics:
If established labour (or imminent risk of PTB) give
intrapartum GBS prophylaxis regardless of GBS
status or membrane status
If chorioamnionitis (membranes intact or ruptured)
o Ampicillin (or Amoxycillin) 2 g IV initial dose, then
1 g IV every 6 hours
o Gentamicin 5 mg/kg IV daily
o Metronidazole 500 mg IV every 12 hours
If Penicillin hypersensitivity and chorioamnionitis:
o Lincomycin OR Clindamycin 600 mg IV every 8
hours and
o Gentamicin 5 mg/kg IV daily and
o Metronidazole 500 mg IV every 12 hours
If labour does not ensue (and no evidence of
chorioamnionitis) and if:
o Membranes intact then cease antibiotics
o PPROM, then convert to Erythromycin 250 mg oral
every 6 hours for 10 days
Magnesium Sulfate
Gestational age 2430 weeks
Labour established or birth imminent
o Loading dose: 4 g IV bolus over 20 minutes
o Maintenance dose: 1 g/hour for 24 hours or until
birth whichever occurs first
Prepare for birth
Recommend vaginal birth unless there are specific
contraindications to vaginal birth or maternal
conditions necessitating caesarean section
Management after threatened preterm labour
Plan care according to clinical circumstances
o Maternal and fetal assessments
o Transfer back to referring hospital where feasible
o Discharge if usual criteria met
o Inform the woman, GP and usual care provider
about recommendations for future care

Queensland Clinical Guideline: Preterm labour and birth Guideline No: MN14.6-V7.R19

CTG: Cardiotocograph, fFN: Fetal fibronectin, FHR: Fetal heart rate, g: grams, GBS: Group B Streptococcus, IV: Intravenous, kg: kilogram, MC&S:
microscopy, culture & sensitivity, mg: milligrams, PROM: Prelabour rupture of membranes, PPROM: Preterm prelabour rupture of membranes, PTB:
Preterm birth, RSQ: Retrieval Services Queensland, ROM: Rupture of membranes, TVCL: Transvaginal cervical length, >: greater than, <: less than

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Queensland Clinical Guideline: Preterm labour and birth

Abbreviations
BP
BV
CI
CSCF
CTG
GBS
fFN
FHR
IV
MC&S
PROM
PPROM
PTB
RSQ
TVCL
RR

Blood pressure
Bacterial vaginosis
Confidence interval
Clinical Services Capability Framework
Cardiotocograph
Group B streptococcus
Fetal fibronectin
Fetal heart rate
Intravenous
Microscopy, culture and sensitivity
Prelabour rupture of membranes
Preterm prelabour rupture of membranes
Preterm birth
Retrieval Services Queensland
Transvaginal cervical length
Relative risk

Definitions of terms

Fetal fibronectin

Health care
team
Imminent risk of
PTB

Informed choice

Informed
consent

Obstetrician

Preterm

In this guideline the quantitative Fetal Fibronectin (fFN) test is preferred because of its
ability to provide a quantifiable test result that better informs management over and above
other tests that only provide a positive or negative result (e.g. non-quantitative
fFN/Quickcheck, or Actim Partus).
The health care team includes members from a range of health disciplines as relevant to
the circumstances. This may include but is not limited to: obstetrics, midwifery,
anaesthetics, neonatology/paediatrics General Practice, maternal-fetal medicine, social
work, pharmacy, dietetics.
Substantial risk of birth within 24 hours as clinically determined by the womans health
care provider.
When a woman has the autonomy and control to make decisions about her care after a
process of information exchange that involves providing her with sufficient, evidencebased information about all options for her care, in the absence of coercion by any party
1
and without withholding information about any options.
When a woman consents to a recommendation about her care after a process of
information exchange that involves providing her with sufficient, evidence-based
information about all the options for her care so that she can make a decision, in the
1
absence of coercion by any party, that reflects self-determination, autonomy and control.
Local facilities may as required, differentiate the roles and responsibilities assigned in this
document to an Obstetrician according to their specific practitioner group requirements;
for example to General Practitioner Obstetricians, Specialist Obstetricians, Consultants,
Senior Registrars and Obstetric Fellows.
Gestational age less than 37+0 completed weeks. Subcategories include:
Extremely preterm: less than 28 weeks gestational age
Very preterm: 28 to less than 32 weeks gestational age
Moderate to late preterm: 32 to less than 37 weeks gestational age

Short cervix

In this document, short cervix is defined as less than 25 mm.

Woman centred
care

Woman centred care includes the affordance of respect and dignity by supporting the
3
4
woman to be central and active in her own care through :
Holistic care taking account of the womans physical, psychosocial, cultural,
emotional and spiritual needs
Focussing on the womans expectations, aspirations and needs, rather than the
institutional or professional needs
Recognising the womans right to self-determination through choice, control and
continuity of care from a known or known caregivers
Recognising the needs of the baby, the womans family and significant others.

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Queensland Clinical Guideline: Preterm labour and birth

Table of Contents
1

Introduction ..................................................................................................................................... 6
1.1
Communication ...................................................................................................................... 6
1.2
Clinical standards .................................................................................................................. 6
2 Risk assessment ............................................................................................................................ 7
3 Risk reduction ................................................................................................................................. 8
3.1
Progesterone therapy ............................................................................................................ 9
3.2
Cervical cerclage ................................................................................................................... 9
4 Clinical assessment of preterm labour ......................................................................................... 10
4.1
Cervical length ..................................................................................................................... 11
4.2
Fetal fibronectin testing........................................................................................................ 12
4.3
Assess need for admission .................................................................................................. 13
5 Management of preterm labour .................................................................................................... 14
5.1
Planning care ....................................................................................................................... 14
5.2
In-utero transfer ................................................................................................................... 15
5.3
Antenatal corticosteroids ..................................................................................................... 16
5.4
Tocolysis .............................................................................................................................. 17
5.4.1 Nifedipine ......................................................................................................................... 18
5.4.2 Other tocolytics ................................................................................................................ 18
5.5
Antibiotics............................................................................................................................. 19
5.6
Magnesium Sulfate for neuroprotection ............................................................................... 20
5.7
Mode of preterm birth .......................................................................................................... 20
6 Management after threatened preterm labour ............................................................................. 21
References .......................................................................................................................................... 22
Appendix A: Magnesium Sulfate for fetal neuroprotection .................................................................. 24
Appendix B: Consumer advice after threatened preterm labour ......................................................... 25
Acknowledgements.............................................................................................................................. 26

List of Tables
Table 1. Risk factors associated with preterm birth ............................................................................... 7
Table 2. Risk reduction measures ......................................................................................................... 8
Table 3. Progesterone therapy .............................................................................................................. 9
Table 4. Cervical cerclage ..................................................................................................................... 9
Table 5. Clinical assessment ............................................................................................................... 10
Table 6. Cervical length assessment................................................................................................... 11
Table 7. Cervical length and risk of preterm birth ................................................................................ 11
Table 8. Fetal fibronectin testing ......................................................................................................... 12
Table 9. Assessment of need for admission........................................................................................ 13
Table 10. Planning care ....................................................................................................................... 14
Table 11. In-utero transfer ................................................................................................................... 15
Table 12. Antenatal corticosteroids ..................................................................................................... 16
Table 13. Tocolysis .............................................................................................................................. 17
Table 14. Nifedipine ............................................................................................................................. 18
Table 15. Other tocolytics .................................................................................................................... 18
Table 16. Antibiotics ............................................................................................................................ 19
Table 17. Magnesium Sulfate for neuroprotection .............................................................................. 20
Table 18. Mode of preterm birth .......................................................................................................... 20
Table 19. Management after threatened preterm labour ..................................................................... 21

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Queensland Clinical Guideline: Preterm labour and birth

Introduction

Preterm is commonly defined as gestational age less than 37+0 completed weeks with subcategories
2
of preterm birth based on weeks of gestational age [refer to Definition of terms]. Preterm labour is a
multifactorial condition associated with a high risk of neonatal morbidity and mortality, especially at
2
lower gestational ages. The incidence of preterm birth (PTB) continues to rise world-wide. In
5
Australia in 2011, 7.5% of babies were born preterm (less than 37 weeks). In Queensland in 2011,
6
PTB accounted for :
7% of singleton births
60% of multiple births
Almost 13% of the births to Aboriginal and/or Torres Strait Islander women
82% of the 610 perinatal deaths

1.1

Communication

Share and discuss information with the woman in a manner that enables informed choice and
consent and supports woman centred care [refer to Definition of terms].
Discuss the womans preferences for management
Establish welcoming methods of communication between women with prior PTB and
7
knowledgeable caregivers
7
Assess personal and family resources and barriers to receiving care
A multidisciplinary health care approach to care is essential
Involve and communicate with members of the health care team in a timely manner

1.2

Clinical standards
Provide care in accordance with the Clinical Service Capability Framework (CSCF)
9
Undertake clinical observations in accordance with the National Consensus Framework
o Consider use of maternity early warning tools to monitor for clinical deterioration
Ensure necessary resources (human and equipment) are available to provide the level of
care required (e.g. cardiotocograph (CTG), one to one midwifery care when indicated)
Develop locally agreed protocols to support management including :
o Consultation mechanisms or processes with higher service capabilities
o Referral for ultrasound scan, CTG and other assessments where access to expertise
or equipment is limited
o In areas where access to professional ultrasound scanning is limited, support visiting
specialists and GP Obstetricians to undertake training in basic obstetric scanning
Where gestational age is less than 26+0 weeks, refer to the Queensland Clinical
10
Guideline Perinatal care at the threshold of viability
8

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Queensland Clinical Guideline: Preterm labour and birth

Risk assessment
11

The cause of spontaneous preterm labour remains unidentified in up to half of all cases and
2
although many factors have been associated with an increased risk of spontaneous PTB , there is a
2,12,13
The majority of women with traditional risk factors will not
relative paucity of high level research.
experience PTB and of those women who do, many have no identifiable risk factors. Whether or not
some risk factors are markers for other conditions and/or other risk factors is unknown.
Table 1. Risk factors associated with preterm birth

Aspect

Maternal
characteristics

Medical and
pregnancy
conditions

Risk factors associated with preterm birth (PTB)


2,14
Age of mother
o Younger than 18 years
o Older than 35 years
15
Ethnicity compared to Caucasians
14
o African: increased by 60%
14
o South Asian: increased by 40%
5
o Indigenous: increased by 70%
14
Cigarette smoking: increased by 30%
15
High levels of psychological stress
15
Late or no health care in pregnancy
15
Low socio-economic status
16
17,18
High or low body mass index (BMI)
19
Presence of fetal fibronectin in the vaginal secretions
11,20
Short cervical length
14
Previous PTB recurrence risk related to:
11
o Gestational age of prior PTB
Approximately 30% of women who give birth between 20 and 31
weeks in a prior pregnancy will give birth before 37 weeks in a
subsequent pregnancy and 10% of these will occur at a similar
21
gestational age
11,14
o Number of prior PTB
15% recurrence risk with single prior PTB, 32% recurrence risk with
21
two prior PTB
Genital tract infections
20
22
o Bacterial vaginosis risk of PTB doubled
23
Urinary tract infections
20
Vaginal bleeding
7
Assisted reproduction associated with 2 fold increased risk of PTB
18
Preterm prelabour rupture of membranes (PPROM)
24
Surgical procedures involving the cervix
Uterine anomalies
Polyhydramnios/oligohydramnios
15
Multiple gestation60% of twins born preterm
Chronic medical conditions
Acute medical conditions (e.g. preeclampsia, antepartum haemorrhage)

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Queensland Clinical Guideline: Preterm labour and birth

Risk reduction

Table 2. Risk reduction measures

Aspect

Counselling

Bacterial
vaginosis (BV)

Bacteriuria

Cervical length
measurement

Considerations
Assess risk factors preconception
Perform a comprehensive review of all previous pregnancies because the
7,25
most important historical risk factor is prior spontaneous PTB
12
Counsel women about modifiable risk factors
o Smoking cessation interventions reduce PTB rate by 18% (RR 0.82,
12,26
95% CI 0.700.96)
13
o Optimisation of control of underlying chronic diseases reduces risk
o Lifestyle (e.g. balanced diet, activity limitations, stress management)
Preform a psychosocial assessment and refer as appropriate to mental
health services
27
Bacterial vaginosis (BV) has been associated with increased risk of PTB
Routine screening and treatment for asymptomatic BV not found to prevent
22,27
PTB
27
Offer screening and treatment to women with previous PTB as there may
28
be benefit
In women with abnormal vaginal flora, treatment with antibiotics may
22,29
reduce the risk of PTB
Refer to Section 5.5 Antibiotics for management of Group B Streptococcal
disease (GBS) in preterm labour
23
Asymptomatic bacteriuria has been associated with risk of PTB
Urinary tract infection is associated with threatened preterm labour
Screen for and recommend treatment for urinary tract infections
23
(asymptomatic bacteriuria, cystitis, pyelonephritis) with antibiotics
Recommend serial transvaginal cervical length (TVCL) measurement for
women with prior PTB
o The optimal frequency has not been established
o From 1424 weeks gestation, serial TVCL every 2 weeks may be
30,31
appropriate
Routine TVCL measurement as a screening tool for PTB in low risk women
is not currently recommended

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Queensland Clinical Guideline: Preterm labour and birth

3.1

Progesterone therapy

Table 3. Progesterone therapy

Aspect

Context

Recommendation

Considerations
Progesterone therapy for women with a history of spontaneous PTB,
reported to reduce the risk of PTB before 34 weeks (RR 0.31, 95% CI 0.14
21
0.69) and before 37 weeks (RR 0.55, 95% CI 0.420.74)
Progesterone therapy reported to reduce the risk of PTB before 28 weeks
21
21
(RR 0.59, 95% CI 0.370.93) and 34 weeks (RR 0.64, 95% CI 0.450.90)
32,33
in women with short cervical length
Further studies with more relevant populations are awaiting full publication
34,35
and may influence future recommendations
There is limited evidence about the optimal Progesterone regimen and about
21,36
longer term health effects
36
One meta-analysis showed no difference in effect between 90 mg, 100 mg
and 200 mg Progesterone pessaries for women with a short cervix
12,21,36,37
for
Consider Progesterone therapy from 1624 weeks gestation
women with a singleton gestation and a prior spontaneous PTB
Consider Progesterone therapy for asymptomatic women with an incidentally
37
diagnosed short cervix on TVCL assessment in the second trimester
No intervention has yet been shown to improve outcomes for women with a
38
short cervix and a multiple gestation
If indicated, recommend vaginal Progesterone suppository 200 mg daily until
34 weeks gestation, rupture of membranes or birth, whichever occurs first

*Refer to an Australian pharmacopoeia for complete drug information

3.2

Cervical cerclage

Table 4. Cervical cerclage

Aspect

Context

Recommendations

Considerations
Compared with no treatment, cervical cerclage reduces the incidence of
39
PTB in women at risk of recurrent PTB (RR 0.80, 95% CI 0.69 to 0.95)
Take into account individual clinical circumstances and the potentially
40
serious risks associated with the procedure
If cervical cerclage is offered, counsel women about the risk of uterine
39
contractions, bleeding, ruptured membranes or infection
May be indicated (individualise decisions) for women with history of either:
o One or more prior spontaneous PTB and/or second-trimester loss related
to painless cervical dilation and in the absence of labour or abruptio
placentae, or
o Prior cerclage due to painless cervical dilation in second trimester
41
May be indicated if TVCL less than 25 mm before 24 weeks if :
o Prior spontaneous PTB before 34 weeks gestation and
o Current pregnancy singleton
There is limited data about the effectiveness of rescue cerclage particularly
beyond 24 weeks of gestation therefore individualise decisions
Multiple dilation and evacuations or cervical surgery (e.g. cone biopsy, large
loop excision of the transformation zone, laser ablation, diathermy) or other
abnormalities (e.g. Mullerian anomaly) are not themselves an indication for
cerclage
Not recommended for women with:
o Funnelling of the cervix in the absence of cervical shortening to 25 mm or
42
less
o An incidentally identified short cervix without a history of spontaneous
42
PTB or second trimester loss
42
o Multiple pregnancy (and may be detrimental )

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Queensland Clinical Guideline: Preterm labour and birth

Clinical assessment of preterm labour

Table 5. Clinical assessment

Aspect

Review history

Signs and
symptoms

Physical
examination

Fetal surveillance

Laboratory
investigations

Consideration
Medical
Surgical
Obstetric
Psychosocial and lifestyle
Refer to Table 1. Risk factors associated with preterm birth
The most common sequence preceding PTB is cervical ripening
(shortening of the cervix), followed by decidual membrane activation and
7
then contractions characterised by:
o Cervical effacement/dilatation
o Pelvic pressure
o Lower abdominal cramping
o Lower back pain
o Vaginal loss (mucous, blood or fluid)
o Regular uterine activity
Vital signs
Abdominal palpation to assess uterine tone, contractions, fetal size and
presentation
Sterile speculum examination to:
o Confirm/exclude rupture of membranes
o Visualise cervix/membranes
o Assess liquor (e.g. clear, meconium stained, bloody)
o Collect high vaginal swab for microscopy culture and sensitivity (MC&S)
o Perform test for the presence of fetal fibronectin (if not contraindicated)
[refer to Section 4.2 Fetal fibronectin testing]
Collect combined low vaginal and anorectal swab for Group B
streptococcus (GBS)
o Insert swab 2 cm into vagina and then insert same swab 1 cm into
43
anus
Assess cervical dilatation by sterile digital vaginal examination unless
contraindicated by:
o Ruptured membranes
o Suspected placenta praevia
Fetal heart rate (FHR)
Continuous CTG
o Take into account gestational age (interpret with caution if less than 28
weeks gestation)
Ultrasound examination for fetal growth and wellbeing
o Fetal number, presentation, liquor volume and placenta localisation
High vaginal swabs for MC&S
Genital swab for GBS (low vaginal and anal)
Midstream specimen of urine for bacteriology (MC&S)

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Queensland Clinical Guideline: Preterm labour and birth

4.1

Cervical length

Transvaginal ultrasound of cervical length (TVCL) can aid in assessing the risk of PTB.
TVCL must be performed by a credentialed clinician
Lack of local capability to perform TVCL is not a reason for transfer
Table 6. Cervical length assessment

Aspect

Context

Recommendation

Consideration
Various cervical lengths usually before 24 weeks of gestation, have been
used to define cohorts of women at high risk of PTB (TVCL less than 25
7,36,38
44
32,33
, less than 20 mm or less than 15 mm
)
mm
Short cervical length is associated with an increased risk of PTB and the
30,45
shorter the cervical length, the greater the risk
o Refer to Table 7. Cervical length and risk of preterm birth
When performed by trained operators, transvaginal ultrasound is more
reliable, reproducible and predictive for cervical length assessment
38
compared to transabdominal ultrasound
Recommend TVCL measurement to women with identified or suspected
preterm labour (where available)
Consider therapeutic interventions when the TVCL is measured at less
38
than 25 mm

Table 7. Cervical length and risk of preterm birth

Cervical length
(mm)

Likelihood ratio for birth at:


2830 weeks
3133 weeks
74.29
44.22

<2

<28 weeks
745.29

3436 weeks
99.36

119.19

36.81

24.26

18.10

62.08

27.80

19.08

11.15

10

26.79

18.24

13.31

6.53

12

16.29

13.77

10.47

4.93

15

8.26

9.04

7.30

3.47

18

4.45

5.93

5.09

2.60

20

3.03

4.48

4.01

2.20

22

2.10

3.38

3.15

1.89

25

1.25

2.22

2.20

1.53

Source: Celik E, To M, Gajewska K, Smith GC, Nicolaides KH. Cervical length and obstetric history predict spontaneous
preterm birth: development and validation of a model to provide individualized risk assessment. Ultrasound Obstet Gynecol.
2008; 31(5):549-54.

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Queensland Clinical Guideline: Preterm labour and birth

4.2

Fetal fibronectin testing

In this guideline the quantitative Fetal Fibronectin (fFN) test is preferred because of its ability to
provide a quantifiable test result that better informs management over and above other tests that only
provide a positive or negative result (e.g. non-quantitative fFN/Quickcheck or Actim Partus).
Table 8. Fetal fibronectin testing

Aspect

Context

Indications

Contraindications

Relative
contraindications

Procedure

Quantitative fFN
testing

fFN < 50 ng/mL


(negative)

fFN 50 ng/mL
(positive)

Consideration
Fetal fibronectin (fFN) is a glycoprotein thought to promote adhesion
between the fetal chorion and maternal decidua. It is normally present in
low concentrations in the cervicovaginal secretions between 18 and 3436
19
weeks gestation, rising as term approaches
Elevated levels of fFN (typically greater than 50 ng/mL) in cervicovaginal
secretions after 22 weeks gestation are associated with an increased risk of
46
PTB
A negative fetal fibronectin (fFN) is associated with a 99.5% negative
47,48
predictive value for PTB within 7 days and 99.2% in the next 14 days
Quantitative fetal fibronectin testing may improve assessment of overall
47
risk , reduce unnecessary transfer and ultimately reduce longer term costs
Symptomatic preterm labour between 22+0 and 36+0 weeks gestation and
Intact membranes and
Cervical dilatation less than or equal to 3 cm
Cervical dilatation more than 3 cm
Ruptured membranes
Cervical cerclage insitu
Presence of soaps, gels, lubricants or disinfectants
Visual evidence of moderate or gross bleeding
Within 24 hours of coitus
A negative fFN result of less than 10 ng/mL is still valid:
o If a woman reports having intercourse in the previous 24 hours
o In the presence of moderate or gross vaginal bleeding
Performed during sterile speculum examination prior to any examination or
manipulation of the cervix or vagina
Use only sterile water as a lubricant
Obtain the sample for testing from the posterior fornix of the vagina
As per test kit instructions
47
Quantitative fFN testing can :
o Quantify the likelihood of PTB
o Assist with risk assessment and planning
o Avoid unnecessary interventions
o Identify women for targeted interventions
o Provide reassurance to health care providers and the woman
47
Low risk of birth within 714 days
19
False negative result may occur due to :
o Use of lubricant with speculum examination
o Intravaginal disinfectants
Refer to Section 5 for management considerations
False positive may occur as a result of recent:
o Coitus
o Digital vaginal examination
o Transvaginal ultrasound
o Bleeding
Refer to Section 5 Management of preterm labour

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Queensland Clinical Guideline: Preterm labour and birth

4.3

Assess need for admission

Use clinical judgement and appropriate consultation in assessing the need for admission. Consider
the fFN result in the context of the overall clinical circumstances, the resources available and the
service capability of the facility. If membranes are ruptured use alternate care pathways.
Table 9. Assessment of need for admission

Care

Admission
indicated

Admission not
indicated

Assessment (assumes intact membranes)


Consider admission for reassessment and/or therapeutic interventions if any of
the following:
o fFN test greater than or equal to 50 ng/mL
o Cervical dilation
o Cervical change over 24 hours
o Ruptured membranes
o Contractions regular and painful
o Further observation or investigation indicated
o Other maternal or fetal concerns
Refer to Table 10. Planning care
If fFN less than 50 ng/mL and admission not otherwise indicated, discharge
home if:
o Maternal vital signs within normal parameters
o Normal FHR/CTG relevant to gestational age
o No signs of chorioamnionitis
o Contractions infrequent/irregular
o No/minimal cervical change
Provide the woman with information that:
o Aids her recognition of the signs and symptoms of preterm labour
o Identifies risk reduction measures appropriate to the circumstances (e.g.
fluids)
o Provides instruction about when to seek clinical advice
Arrange follow-up:
o If fFN 09 ng/mL routine follow-up as per usual model of care
Less than 2% birth within two weeks
Less than 2% birth before 34 weeks
o If fFN 1049 ng/mL return for medical review within 7 days
Less than 2% birth within two weeks
515% birth before 34 weeks

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Queensland Clinical Guideline: Preterm labour and birth

Management of preterm labour

Tocolysis and steroids are the main strategies to manage preterm labour. Transfer to a centre with
higher service capability may also be necessary. Management options will depend on:
Resource (equipment and human) availability
Acuity level of the facility
Gestational age and individual clinical circumstances
If necessary, contact a service with higher level capability for further advice

5.1

Planning care

Use clinical judgement and appropriate consultation in planning care.


Table 10. Planning care

fFN
ng/mL

Care considerations

% birthing
within 2 before
wks
34 wks

All women
requiring
admission

50199

200-499

> 500

Admit for observation


Consider in-utero transfer (as relevant to service capability)
Offer analgesia
Administer corticosteroids if less than 35+0 weeks
Measure TVCL if resources available
Communicate with multidisciplinary team as relevant to the
circumstances (e.g. neonatology consultation, social worker
referral, anaesthetic involvement)
Discuss plan for ongoing care with the woman in a manner
that supports informed choice
Document plan of care in the health record
Clinical reassessment as required
If labour is established or birth appears imminent, and
gestational age is less than 30 weeks, commence Magnesium
Sulfate for neuroprotection of the fetus
Refer to Appendix A: Magnesium Sulfate for fetal
neuroprotection
As for all women requiring admission and
Consider tocolysis if delay of birth indicated and no
contraindications
Take into account all clinical circumstances including history
of PTB
As for all women requiring admission and
Commence tocolysis if delay of birth indicated and no
contraindications
As for all women requiring admission and
Commence tocolysis if delay of birth indicated and no
contraindications
Prepare for administration of Magnesium Sulfate (if
gestational age less than or equal to 30 weeks)

Refer to online version, destroy printed copies after use

515

1015

30

30

50

75

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Queensland Clinical Guideline: Preterm labour and birth

5.2

In-utero transfer

Table 11. In-utero transfer

Aspect
Context

Principles for
transfer at 2328
weeks gestational
age

Recommendation

Consideration
Neonatal outcomes are improved if PTB occurs in centres that manage high
2
volumes of preterm newborns
If transfer required, contact Retrieval Services Queensland to coordinate
transfer ph:1300 799 127
Accept a high level of risk of birth occurring en-route when gestational age is
2328 weeks because the benefit is so substantial
If birth is considered a possibility en-route:
o Clinical assessment of the woman is performed by the transferring
Consultant (or equivalent e.g. most Senior Medical Officer)
o Transfer discussions and decisions occur between senior clinicians
o Use RSQ conference calls to facilitate involvement of all relevant
clinicians in the most time efficient manner
o Discuss with RSQ medical coordinator the tasking of a second
aeromedical clinician to accompany the flight nurse
Transfer decisions involve both obstetric and neonatal clinicians, particularly
at the receiving site and the RSQ medical coordinator from an aeromedical
asset allocation perspective
Accountability and responsibility for transfer decisions and their outcomes
reside with the transferring and receiving consultants
o Accountability and responsibility for transfer decisions and outcomes does
not reside with the flight nurse
Recognise that retrieval platforms may not be immediately available (e.g.
due to pilot and crew hours, weather or aircraft service needs)
Decisions about transfer may be escalated within RSQ by receiving or
transferring clinicians or by the flight nurse as required
Reassess the woman after initial stabilisation to review timelines around
transfer decisions, particularly if there are delays in transfer or transfer is not
immediately feasible
Intubation and/or full resuscitation is not generally feasible within the aircraft
environment. Neonatal resuscitation measures (should birth occur en-route)
may include (but are not necessarily limited to) keeping baby warm,
administering oxygen, providing CPAP via bag and mask)
The transferring consultant (or equivalent) is responsible for ensuring that
the risks and benefits of in-utero transfer are discussed with the
woman/partner/family including the limited resuscitation that will be provided
should birth occur en-route
The transferring consultant (or equivalent) is responsible for ensuring that
there is comprehensive documentation in the health record and transfer
documents regarding:
o Discussions with the woman/family about the transfer including limited
resuscitation if birth occurs en-route
o Clinical assessment of the woman and the assessed risk of PTB
o Discussions between receiving and transferring clinicians about the
planned transfer
Should birth occur en-route, contact RSQ to task a neonatal retrieval team to
meet the aircraft
RSQ will coordinate a combined services audit of births of 2328 weeks
gestational age occurring outside a level 6 neonatal unit
When transfer is indicated, aim for in-utero transfer wherever possible
o If gestational age is 2328 weeks, accept a high level of risk for birth enroute unless such transfer puts the mothers life at risk
If clinically appropriate, use tocolysis to allow in-utero transfer

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Queensland Clinical Guideline: Preterm labour and birth

5.3

Antenatal corticosteroids

Table 12. Antenatal corticosteroids

Aspect

Context

Recommendation

Administration*

Consideration
Antenatal corticosteroids are associated with a significant reduction in rates
of neonatal death, respiratory distress syndrome and intraventricular
49,50
haemorrhage (IVH)
Antenatal corticosteroid use is also associated with a reduction in
necrotising enterocolitis, respiratory support, intensive care admissions and
systemic infections in the first 48 hours of life compared with no treatment
49,50
or treatment with placebo
49
Beneficial effect demonstrated regardless of membrane status
There is no evidence of long term harm or benefit (in early childhood) from
51,52
multiple courses of antenatal corticosteroids
If the risk of PTB persists seven or more days after initial course, repeat
52
dose(s) are associated with :
o Less respiratory distress and fewer serious health problems in the first
few weeks after birth
o Small reduction in size at birth
Routinely recommend corticosteroids to women with a viable fetus who are
49
50
at increased risk of PTB before 35+0 weeks gestational age
Determine the need for further weekly repeat dose(s) based on clinical
assessment of the ongoing risk of PTB
o If the risk of PTB persists seven or more days after initial course,
52
recommend a repeat dose of corticosteroids
o Seek expert obstetric/neonatal advice if uncertainty exists about
continued risk of PTB
o If there is maternal diabetes, monitor blood glucose levels
Initial course of antenatal corticosteroids (2 doses, 24 hours apart)
st
o 1 : dose: Betamethasone 11.4 mg IM
nd
st
o 2 dose: Betamethasone 11.4 mg IM, 24 hours after 1 dose (if PTB
likely within 24 hours, consider repeat dose at 12 hours)
Repeat dose of antenatal corticosteroids (single dose)
o Betamethasone 11.4 mg IM

*Refer to an Australian pharmacopoeia for complete drug information

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Queensland Clinical Guideline: Preterm labour and birth

5.4

Tocolysis

Table 13. Tocolysis

Aspect

Context

PPROM

Contraindications

Consideration
Tocolytic drugs may delay birth and allow:
o Administration of corticosteroids
o Administration of Magnesium Sulfate for neuroprotection
o In-utero transfer to an appropriate level facility
Tocolysis not associated with a clear reduction in perinatal mortality or
53
serious neonatal morbidity
No evidence to support the use of prophylactic tocolytic therapy after
54
contractions have ceased
Recommend when a 48 hour delay in birth will benefit the newborn
There is limited evidence about the use of tocolytics in the setting of
55
PPROM
Gestational age is a major determinant for management
55
Tocolysis in women with PPROM before 34 weeks associated with :
o A lower risk of birth within 48 hours
o An increased risk of chorioamnionitis without significant maternal or
neonatal benefit
55
Tocolysis before viability not generally recommended
Maternal contraindications to tocolysis (agent specific)
Any condition where prolongation of pregnancy is contraindicated including
but not limited to:
o In-utero fetal death
o Lethal fetal anomalies
o Suspected fetal compromise
o Maternal bleeding with hemodynamic instability
o Severe preeclampsia
o Placental abruption
o Chorioamnionitis

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Queensland Clinical Guideline: Preterm labour and birth

5.4.1

Nifedipine

Table 14. Nifedipine

Aspect
Context

Contraindications*

Dose*

Maintenance*

Comments*

Observations

5.4.2

Consideration
56
Nifedipine is a calcium channel blocker that relaxes smooth muscle
57,58
Nifedipine is the tocolytic of choice
If there are contraindications to Nifedipine, liaise with an Obstetrician to
determine alternate tocolysis
56
Contraindications include :
o Maternal hypotension or cardiac disease
o Previous adverse reaction to calcium channel blockers
56
Nifedipine 20 mg oral stat
56
If contractions persist after 30 minutes repeat Nifedipine 20 mg oral
If contractions persist after a further 30 minutes repeat Nifedipine 20 mg
oral
If BP stable, Nifedipine 20 mg oral every 6 hours for 48 hours
54
Further maintenance therapy is ineffective
56
Maximum dose is 160 mg/day
Do not use sustained release formulation
Concomitant use with Magnesium Sulfate may increase effects of
Magnesium Sulfate and the risk of hypotension. Use cautiously with
56
Magnesium Sulfate
CTG until contractions cease (relative to gestation)
BP, pulse and respiratory rate
o Every thirty minutes for first hour, then hourly for four hours
o Review frequency in accordance with clinical circumstances
Temperature every four hours

Other tocolytics

Table 15. Other tocolytics

Tocolytic

Betamimetics
(Salbutamol)*

Inhibitors of
prostaglandin
synthesis
(Indomethacin)*

Considerations
59,60
but
Compared to placebo, betamimetics are effective tocolytic agents
significant adverse side effects including maternal death from pulmonary
60
oedema have been reported
No evidence to support oral betamimetics for maintenance after threatened
61
preterm labour
Not recommended unless there are contraindications to other tocolytics
Potent inhibitor of uterine contractility by inhibiting cyclo-oxygenase (COX)
59
62
enzyme but limited high level evidence with few adequate trials
62
Risks for the fetus and neonate include :
o Constriction of the fetal ductus arteriosus (increased risk with advancing
gestational age; the effects are transient and reversible with short term
administration; longer administration may lead to pulmonary
hypertension in the fetus and neonate)
o Alteration of fetal, especially cerebral, blood flow
o Reduced renal function (may result in oligohydramnios)
o Necrotising enterocolitis
Because of the potential adverse fetal and neonatal effects, consider use
of Indomethacin only where:
o Gestational age is less than 28+0 weeks
o There is failure to achieve tocolysis with other tocolytic regimens
o Contraindications to other tocolytics exist (e.g. cardiac disease)
With Indomethacin administration, ensure close monitoring of fetal
wellbeing

*Refer to an Australian pharmacopoeia for complete drug information

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Queensland Clinical Guideline: Preterm labour and birth

5.5

Antibiotics

Table 16. Antibiotics

Aspect
Preterm labour
(or imminent risk
of PTB) without
evidence of
chorioamnionitis*

Signs of
chorioamnionitis
(Intact or
ruptured
membranes)*

Preterm labour
does not
commence

Consideration
If preterm labour ensues or there is imminent risk of PTB, give intrapartum
antibiotic prophylaxis for prevention of Early onset Group B streptococcal
disease irrespective of GBS status or membrane status
Refer to Queensland Clinical Guideline Early onset Group B Streptococcus
63
disease
Signs of chorioamnionitis include:
64
o Maternal fever greater than 38C (present in 95100% of cases)
o Maternal tachycardia greater than 100 beats per minute (bpm) (present
64
in 5080% of cases)
64
o Fetal tachycardia greater than160 bpm (present in 4070% of cases)
64
o Uterine tenderness
64
o Offensive smelling vaginal discharge
64
9
o Increased white cell count (greater than 15x10 /L)
64
o Elevated C-Reactive Protein (CRP)
Do not inhibit labour, but consider hastening birth under broad spectrum
intravenous antibiotic cover
Suspect chorioamnionitis in women with PPROM if labour ensues
Optimal antibiotic regimen not established. If no local protocols exist
65
suggested regimen :
o Ampicillin (or Amoxycillin) 2 g IV initial dose, then 1 g IV every 6 hours
o Gentamicin 5 mg/kg IV daily
o Metronidazole 500 mg IV every 12 hours
If allergic to Penicillin
o Lincomycin 600 mg IV in 100 mL over 1 hour every 8 hours OR
^Clindamycin 600 mg IV in 50100 mL over at least 20 minutes every 8
hours
o Gentamicin 5 mg/kg IV daily
o Metronidazole 500 mg IV every 12 hours
Continue antibiotic treatment after birth
o Consider oral antibiotics once afebrile and tolerating oral medication
Routine administration of prophylactic antibiotics to women in threatened
preterm labour with intact membranes and without evidence of infection is
66
not recommended
If preterm labour does not commence and no other indications, then with:
o Intact membranes, cease antibiotics
67
o PPROM give Erythromycin 250 mg oral every 6 hours for 10 days

*Refer to an Australian pharmacopoeia for complete drug information


^Clindamycin IV is not on the Queensland Health (QH) List of Approved Medications (LAM) therefore QH
clinicians should give Lincomycin

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Queensland Clinical Guideline: Preterm labour and birth

5.6

Magnesium Sulfate for neuroprotection

Table 17. Magnesium Sulfate for neuroprotection

Aspect

Context

Recommendation*

Considerations
Magnesium Sulfate (MgSO4) given to mothers shortly before birth is
believed to reduce the risk of cerebral palsy and protect gross motor
68
function in those infants born preterm
o Number needed to treat (NNT): 63 babies for one baby to avoid cerebral
69
palsy (95% CI 44155)
o NNT to benefit (NNTB): 42 babies for combined death or cerebral palsy
69
(95% CI 24346)
o The effect may be greatest at early gestations and is not associated with
68,70
adverse long-term fetal or maternal outcome
In one follow-up RCT study MgSO4 was not associated with improved
neurological, cognitive, behavioural, growth or functional outcomes in
71
school age children although mortality advantage could not be excluded
Recommend MgSO4 to women between 24+0 and 30+0 weeks gestation
where birth is expected or planned within 24 hours
When birth is planned, commence administration as close to four hours
70
prior to birth as possible
Best effect when given for at least four hours within the six hours prior to
birth
If birth is expected to occur within four hours, commence MgSO4
70
immediately, as there may still be benefit from administration
In situations where urgent birth is necessary, do not delay birth to
70
administer MgSO4
If birth does not occur after giving MgSO4 and PTB (less than 30 weeks
gestation) again appears imminent (planned or expected within 24 hours),
a repeat dose of MgSO4 may be considered at the discretion of the
70
obstetrician
Refer to Appendix A: Magnesium Sulfate for fetal neuroprotection

*Refer to an Australian pharmacopoeia for complete drug information

5.7

Mode of preterm birth

Table 18. Mode of preterm birth

Aspect

Context

Singleton vertex
Breech
presentation
26+0 weeks
25+6 weeks
gestation
(vertex or breech)

Considerations
There is insufficient high quality evidence about whether mode of birth
72
affects neonatal morbidity and outcomes
Preterm CS is usually technically more difficult to perform and is not
73
without risk to the baby as the lower segment is usually not well formed
o A classical incision may be required with risks to future pregnancies
including scar dehiscence, uterine rupture, placental adherence and
74
maternal death
o Discuss implications of decision with the woman
o Early consultation with anaesthetic team required
Recommend vaginal birth unless there are specific contraindications to
vaginal birth or maternal conditions necessitating CS
The evidence regarding optimal mode of birth for preterm breech is
61,64,65
conflicting and unclear due to a lack of high quality studies
Base decisions on individual circumstances and maternal preferences
CS is not generally recommended where vaginal birth is imminent
CS for fetal indications alone not generally recommended at less than 25+0
10
weeks gestation

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Queensland Clinical Guideline: Preterm labour and birth

Management after threatened preterm labour

When PTB does not occur following admission for threatened preterm labour, coordinate care and
discharge planning with the family, relevant health care professionals and the referring hospital (as
required).
Table 19. Management after threatened preterm labour

Aspect

Prolonged
admission

Back transfer

Discharge

Referral and
follow-up

Considerations
Plan care relevant to the underlying clinical circumstances
Use clinical judgement and as clinically appropriate consider:
o Consultation/Referral/Transfer
o Serial TVCL
o Progesterone
o Fetal assessments
o Maternal investigations and assessments
o Repeat fFN testing
o Planning for PTB
o Frequency of clinical observations (e.g. temperature, blood pressure)
If discharge home is not considered an option, transfer back to the referring
hospital where feasible
Take into account:
o Individual clinical circumstances and likelihood of PTB
o Gestational age and maternity and neonatal clinical service capability of
the receiving hospital
o Access to required ongoing monitoring/clinical surveillance
o Preferences of the woman and her family
o Retrieval logistics and aircraft availability
Consider usual discharge criteria including:
o Maternal vital signs
o Signs of chorioamnionitis
o Membrane status
o Contractions infrequent/irregular
o Cervical change/TVCL (if measured)
o Normal CTG relevant to gestational age
o fFN test result
Provide the woman with information that:
o Aids her recognition of the signs and symptoms of preterm labour
o Identifies risk reduction measures appropriate to the circumstances (e.g.
fluids, sexual activity)
o Provides instruction about when to seek clinical advice
o Refer to Appendix B: Consumer advice after threatened preterm labour
Determine follow-up and on-going clinical surveillance requirements
Inform the woman, the usual health care provider and/or referring hospital
about the recommendations for follow-up and ongoing clinical surveillance
Offer social worker referral as indicated
Inform the General Practitioner about the episode of care

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Queensland Clinical Guideline: Preterm labour and birth

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Queensland Clinical Guideline: Preterm labour and birth

Appendix A: Magnesium Sulfate for fetal neuroprotection


Aspect
Resources

Contraindications

Route
Loading dose
Maintenance
dose
Side effects

Baseline
observations

Monitoring during
loading dose

Monitoring during
maintenance
dose

Considerations
One to one midwifery care in birth suite or high dependency unit for the
duration of therapy
Resuscitation and ventilator support immediately available
Calcium Gluconate 1 g available in case of respiratory depression
Maternal cardiac conduction defects (heart block) contraindicated
Hypermagnesaemia contraindicated
Maternal myasthenia gravis use cautiously and monitor closely
Concomitant Nifedipine use cautiously and monitor closely
Reduced renal function monitor plasma magnesium level/urine output
IV infusion via controlled infusion device
4 g IV bolus over 20 minutes
1 g/hour for 24 hours or until birth, whichever occurs first

Monitoring post
infusion

Discontinuation
and urgent
medical review

Related to hypermagnesaemia
Common (> 1%): nausea and vomiting, flushing
Infrequent (0.11%): headache, dizziness
Vital signs: BP, pulse, respiratory rate
Oxygen saturation (SpO2)
Patellar reflex
Abdominal palpation
Monitor contractions for 10 minutes
FHR/CTG
BP, pulse, and RR every 5 minutes (for minimum 20 minutes) until stable
SpO2 continuously
Contractions for 10 mins every 30 mins
Continuous CTG if greater than or equal to 24 weeks gestation
o Interpret CTG relevant to gestational age if less than 28 weeks
o Document reason if CTG not able to be performed
Auscultate FHR every1530 minutes if less than 24 weeks gestation
Observe for side effects
Check deep tendon reflexes (patellar or, if epidural insitu, biceps) after
completion of loading dose
o Notify obstetrician if absent and do not commence maintenance dose
BP, pulse, respiratory rate, SpO2 every 30 minutes
Temperature every 2 hours
Contractions for 10 mins every 30 mins
Continuous CTG if greater than or equal to 24 weeks gestation
o Interpret CTG relevant to gestational age if less than 28 weeks
Auscultate FHR every1530 minutes if less than 24 weeks gestation
Strict fluid balance monitoring and documentation
o Notify medical officer if urine output less than 25 mL/hour
Deep tendon reflexes hourly
o Record as A=Absent, N=Normal, B=Brisk
Repeat baseline observations/vital signs
Minimum 4 hourly or more frequently as clinically indicated
Serum monitoring not usually required if renal function normal
o Therapeutic serum magnesium levels are 1.73.5 mmol/L
Respiratory rate less than 12 breaths/minute or more than 4
breaths/minute below baseline
Diastolic BP decreases more than 15 mmHg below baseline
Absent deep tendon reflexes
Urine output less than 25 mL/hour or less than 100 mL over 4 hours
Magnesium serum levels greater than 3.5 mmol/L

Adapted from: The Antenatal Magnesium Sulphate for Neuroprotection Guideline Development Panel. Antenatal magnesium
sulphate prior to preterm birth for neuroprotection of the fetus, infant and child: national clinical practice guidelines. The
University of Adelaide. 2010 [cited 2014, May 14]. Available from: www.nhmrc.gov.au.

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Queensland Clinical Guideline: Preterm labour and birth

Appendix B: Consumer advice after threatened preterm labour


Aspect
What is preterm
labour?

Signs of preterm
labour

Call your health


care provider
immediately if:

Activity

Discussion point
It is normal for your uterus to contract now and then during pregnancy
Preterm labour is when you have frequent contractions along with the
th
opening of your cervix before the 37 completed week of pregnancy
Even if you do everything right, you can still have preterm labour
Contractions that make your belly tighten up like a fist every 10 minutes or
more often
Cramps that feel like your period
Low dull backache
The feeling that your baby is pushing down, called pelvic pressure
Belly cramps with or without diarrhoea
Change in the colour of your vaginal discharge
General feeling that something is not right
Bleeding from your vagina
Your baby stops moving
Your waters break
You have regular contractions
You have any bleeding from your vagina
You have a low dull backache. The pain may be felt in your lower back or
move to your sides or front

You have a high temperature more than 38 C


You are worried or unsure
Many women have more contractions when they are active. This is normal
and there is no proof that restricting your activity will reduce your risk of
preterm birth. However, your health care provider may recommend that you
limit your activity level for a period of time
If you begin to have contractions while active, stop what you are doing and
lie down on your side. Drink 23 glasses of water or juice, monitor your
contractions and call your care provider. If you have diabetes do not drink
juice

Limited activity
Most of the time you should lie down on your side. You may be up during the
day for short periods of time (less than 30 minutes). No heavy work or lifting

Extended activities
You should lie down at least once in the morning and once in the afternoon for
about 2 hours. No heavy work, gardening or lifting. You need to be off work
outside the home

No activity restrictions
Sexual activity
Diet

Fluids

Stool softeners

You may resume your normal activities


Having sex or orgasm may cause uterine contractions
Do not have sex until your health care provider says it is okay
You need to eat well for you and your babys health
Pick foods that are high in iron, calcium and fibre such as red meat, cheese
and bran muffins
Women who get dehydrated sometimes have more uterine contractions
Drink 68 glasses of fluid a day
Water, non-fat or low fat milk and fruit juice are good choices. If you have
diabetes do not drink juice
Constipation (hard stools) is a common problem. The stool softener is to
prevent constipation. If you get constipated, drink lots of water and eat foods
with fibre
You can also ask your health care provider for help with constipation

Adapted from: March of Dimes Preterm Labour Assessment Toolkit (2013)

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Page 25 of 26

Queensland Clinical Guideline: Preterm labour and birth

Acknowledgements
Queensland Clinical Guidelines gratefully acknowledge the contribution of Queensland clinicians and
other stakeholders who participated throughout the guideline development process particularly:
Working Party Clinical Lead
Associate Professor Rebecca Kimble
Working Party Members
Ms Michelle Barrett, Clinical Nurse Consultant, Retrieval Services Queensland
Ms Karen Bettenay, Pharmacist, Royal Brisbane and Womens Hospital
Dr Anthony Brown, GP Obstetrician, Mareeba
Dr Yogesh Chadha, Staff Specialist, Obstetrics and Gynaecology, Royal Brisbane and Womens
Hospital
Dr Lindsay Cochrane, Staff Specialist, Obstetrics and Gynaecology, Caboolture Hospital
Dr Mark Davies, Neonatologist, Royal Brisbane and Womens Hospital
Ms Louisa Dufty, Director of Nursing/Operations Manager, Emerald Hospital
Dr Hasthika Ellepola, Staff Specialist, Obstetrics and Gynaecology, Logan Hospital
Associate Professor Vicki Flenady, Director Translating Research into Practice (TRIP) Centre, Mater
Medical Research Institute, Brisbane
Ms Kim-Lee Foran, Consumer Representative, Miscarriage, Stillbirth and Neonatal Death Support
(SANDS)
Ms Susan Foyle, Maternity Unit Manager, Caboolture Hospital
Ms Sara Haberland, Clinical Midwife, Birth Suite, Royal Brisbane and Womens Hospital
Mrs Tracey Johnson, Registered Nurse/Eligible Midwife, Warwick Hospital
Dr Christopher King, Obstetrician, Mt Isa Hospital
Dr Alka Kothari, Staff Specialist, Obstetrics and Gynaecology, Redcliffe Hospital
Associate Professor Kassam Mahomed, Staff Specialist, Obstetrics and Gynaecology, Ipswich
Hospital
Dr Bruce Maybloom, Medical Officer, Queensland
Dr Thomas McHattie, Clinical Director Obstetrics and Gynaecology, Bundaberg Hospital
Ms Nickie Morton, Midwifery Unit Manager, Royal Brisbane and Womens Hospital
Dr Edwin Ozumba, Senior Staff Specialist, Obstetrics and Gynaecology, Rockhampton Base Hospital
Dr Carol Portmann, Staff Specialist, Obstetrics and Maternal Fetal Medicine, Royal Brisbane and
Womens Hospital
Dr Renuka Sekar, Staff Specialist, Maternal Fetal Medicine, Royal Brisbane and Womens Hospital
Ms Pamela Sepulveda, Clinical Midwifery Consultant, Logan Hospital
Professor Andrew Shennan, Professor of Obstetrics, Kings College London
Ms Rhonda Taylor, Clinical Midwifery Consultant, Health & Wellbeing Service Group, The Townsville
Hospital

Queensland Clinical Guidelines Team


Associate Professor Rebecca Kimble, Director
Ms Jacinta Lee, Manager
Ms Lyndel Gray, Clinical Nurse Consultant
Dr Brent Knack, Program Officer
Steering Committee
Funding
This clinical guideline was funded by Queensland Health, Healthcare Innovations and Research
Branch.

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Page 26 of 26

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