G PTL PDF

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-V8.R19
Document The document supplement is integral to and should be read in conjunction
supplement: with this guideline.
Amendments: Full version history is supplied in the document supplement.
Amendment date: November 2016
Replaces document: MN14.6-V7.R19
Author: Queensland Clinical Guidelines
Health professionals in Queensland public and private maternity and
Audience:
neonatal services
Review date: December 2019
Endorsed by: Queensland Clinical Guidelines Steering Committee
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-nc-
nd/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.
Refer to online version, destroy printed copies after use Page 2 of 26

Flow Chart: Assessment and management of preterm labour (< 37 weeks)
Review History In-utero transfer

Medical, surgical, obstetric, social Aim for in-utero transfer wherever possible
If gestation 2328 weeks, accept a high level of risk
Assess for signs and symptoms
for birth en-route (unless it puts mothers life at risk)
Pelvic pressure
Coordinate transfer via RSQ phone: 1300 799 127
Lower abdominal cramping
Lower back pain Antenatal corticosteroids (< 35+0 weeks)
Vaginal loss mucous, blood, fluid Recommend course of Betamethasone (2 doses)
Regular uterine activity o 11.4 mg IM then 2nd dose in 24 hours
Physical examination o Consider 2nd dose at 12 hours if PTB likely within 24
Vital signs hours
Abdominal palpation If risk of PTB remains ongoing in 7 days, repeat dose
Fetal surveillance FHR, CTG Tocolysis
Sterile speculum exam Nifedipine 20 mg oral
o Identify if ROM If contractions persist after 30 minutes repeat
o Visualise cervix/membranes Nifedipine 20 mg oral
o High vaginal swab If contractions persist after further 30 minutes repeat
o Test for fFN Nifedipine 20 mg oral
Low vaginal/anorectal GBS swab Maintenance therapy 20 mg every 6 hours for 48
Cervical dilatation hours
o Sterile digital vaginal exam
unless ROM, placenta praevia Discuss with Obstetrician/Paediatrician
Ultrasound if available If contraindications exist
o Fetal growth and wellbeing If other options required (Indomethacin, Salbutamol)
Laboratory Antibiotics:
High vaginal swabs for MC&S
Consider as clinically appropriate
If established labour (or imminent risk of PTB) give

One swab (low vaginal + anal) for intrapartum GBS prophylaxis regardless of GBS
GBS status or membrane status
Midstream urine for MC&S If chorioamnionitis (membranes intact or ruptured)
o Ampicillin (or Amoxycillin) 2 g IV initial dose, then
1 g IV every 6 hours
Consider admission if: o Gentamicin 5 mg/kg IV daily
fFN > 50 ng/mL or o Metronidazole 500 mg IV every 12 hours
Cervical dilation or If Penicillin hypersensitivity and chorioamnionitis:
Cervical change over 24 hours or o Lincomycin OR Clindamycin 600 mg IV every 8
ROM or hours and
o Gentamicin 5 mg/kg IV daily and
Contractions regular & painful or
o Metronidazole 500 mg IV every 12 hours
Further observation or investigation
indicated or If labour does not ensue (and no evidence of
chorioamnionitis) and membranes intact then cease
Other maternal or fetal concerns
antibiotics
If PPROM, refer to Queensland Clinical Guideline:
EOGBSD for regimen
No Admission Magnesium Sulfate
indicated? Gestational age 2430 weeks
Labour established or birth imminent
Yes 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
Admit
Analgesia if required
Clinical surveillance Prepare for birth
Fetal monitoring/continuous CTG Recommend vaginal birth unless there are specific
TVCL if available contraindications to vaginal birth or maternal
Consult as required conditions necessitating caesarean section
Plan care
Management after threatened preterm labour
Plan care according to clinical circumstances
o Maternal and fetal assessments
Discharge o Transfer back to referring hospital where feasible
Provide information re: signs and o Discharge if usual criteria met
symptoms and returning for care o Inform the woman, GP and usual care provider
Arrange follow-up as indicated about recommendations for future care
Queensland Clinical Guidelines: Preterm labour and birth F14.6-1-V8-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

Abbreviations
BP Blood pressure
BV Bacterial vaginosis
CI Confidence interval
CSCF Clinical Services Capability Framework
CTG Cardiotocograph
GBS Group B streptococcus
fFN Fetal fibronectin
FHR Fetal heart rate
IV Intravenous
MC&S Microscopy, culture and sensitivity
PROM Prelabour rupture of membranes
PPROM Preterm prelabour rupture of membranes
PTB Preterm birth
RSQ Retrieval Services Queensland
TVCL Transvaginal cervical length
RR Relative risk
Definitions of terms
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
Fetal fibronectin 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
Health care the circumstances. This may include but is not limited to: obstetrics, midwifery,
team anaesthetics, neonatology/paediatrics General Practice, maternal-fetal medicine, social
work, pharmacy, dietetics.
Imminent risk of Substantial risk of birth within 24 hours as clinically determined by the womans health
PTB 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, evidence-
Informed choice based 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
Informed information exchange that involves providing her with sufficient, evidence-based
consent 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;
Obstetrician for example to General Practitioner Obstetricians, Specialist Obstetricians, Consultants,
Senior Registrars and Obstetric Fellows.
Gestational age less than 37+0 completed weeks. Subcategories include:
2 Extremely preterm: less than 28 weeks gestational age
Preterm
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 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
Woman centred Focussing on the womans expectations, aspirations and needs, rather than the
care 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.

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

1 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
Assess personal and family resources and barriers to receiving care
7
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)
8
Undertake clinical observations in accordance with the National Consensus Framework

9
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

2 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
relative paucity of high level research. The majority of women with traditional risk factors will not
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 Risk factors associated with preterm birth (PTB)

Age of mother
2,14
o Younger than 18 years

o Older than 35 years
Ethnicity compared to Caucasians
15
14
o African: increased by 60%
14
Maternal o South Asian: increased by 40%
5
characteristics o Indigenous: increased by 70%
Cigarette smoking: increased by 30%
14
High levels of psychological stress

15
Late or no health care in pregnancy

15
Low socio-economic status

15
High or low body mass index (BMI)

16 17,18
Presence of fetal fibronectin in the vaginal secretions

19
Short cervical length

11,20
Previous PTB recurrence risk related to:

14
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
Medical and two prior PTB
pregnancy Genital tract infections
20 22
conditions o Bacterial vaginosis risk of PTB doubled
Urinary tract infections
23
Vaginal bleeding
20
Assisted reproduction associated with 2 fold increased risk of PTB

7
Preterm prelabour rupture of membranes (PPROM)

18
Surgical procedures involving the cervix

24
Uterine anomalies
Polyhydramnios/oligohydramnios
Multiple gestation60% of twins born preterm
15
Chronic medical conditions

Acute medical conditions (e.g. preeclampsia, antepartum haemorrhage)

3 Risk reduction
Table 2. Risk reduction measures
Aspect 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
Counsel women about modifiable risk factors
12
Counselling 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
Bacterial vaginosis (BV) has been associated with increased risk of PTB
27
Routine screening and treatment for asymptomatic BV not found to prevent

22,27
PTB
Offer screening and treatment to women with previous PTB as there may
27
Bacterial 28
be benefit
vaginosis (BV)
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
Asymptomatic bacteriuria has been associated with risk of PTB
23
Urinary tract infection is associated with threatened preterm labour

Bacteriuria
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
Cervical length
o From 1424 weeks gestation, serial TVCL every 2 weeks may be
measurement 30,31
appropriate
Routine TVCL measurement as a screening tool for PTB in low risk women
is not currently recommended

3.1 Progesterone therapy

Table 3. Progesterone therapy
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
Context
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
One meta-analysis showed no difference in effect between 90 mg, 100 mg
36
and 200 mg Progesterone pessaries for women with a short cervix

Consider Progesterone therapy from 1624 weeks gestation
12,21,36,37
for
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
Recommendation
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
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
Context 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
May be indicated if TVCL less than 25 mm before 24 weeks if :
41
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
Recommendations
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 )

4 Clinical assessment of preterm labour

Table 5. Clinical assessment
Aspect Consideration
Medical
Surgical
Review history 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
Signs and
o Pelvic pressure
symptoms
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)
Physical o Perform test for the presence of fetal fibronectin (if not contraindicated)
examination [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
Fetal surveillance
weeks gestation)
Ultrasound examination for fetal growth and wellbeing
o Fetal number, presentation, liquor volume and placenta localisation
High vaginal swabs for MC&S
Laboratory
Genital swab for GBS (low vaginal and anal)
investigations
Midstream specimen of urine for bacteriology (MC&S)

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
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
mm , less than 20 mm or less than 15 mm )
Short cervical length is associated with an increased risk of PTB and the
30,45
Context 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)
Recommendation
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 Likelihood ratio for birth at:

(mm) <28 weeks 2830 weeks 3133 weeks 3436 weeks
<2 745.29 74.29 44.22 99.36
5 119.19 36.81 24.26 18.10
7 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.

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
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
Context 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
Indications Intact membranes and
Cervical dilatation less than or equal to 3 cm
Cervical dilatation more than 3 cm
Ruptured membranes
Contraindications
Cervical cerclage insitu
Presence of soaps, gels, lubricants or disinfectants
Visual evidence of moderate or gross bleeding
Within 24 hours of coitus
Relative
contraindications 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
Procedure 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
Quantitative fFN o Assist with risk assessment and planning
testing 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 :
fFN < 50 ng/mL
o Use of lubricant with speculum examination
(negative)
o Intravaginal disinfectants
Refer to Section 5 for management considerations
False positive may occur as a result of recent:
o Coitus
fFN 50 ng/mL o Digital vaginal examination
(positive) o Transvaginal ultrasound
o Bleeding
Refer to Section 5 Management of preterm labour

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 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
Admission o Cervical change over 24 hours
indicated 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
Admission not
o Identifies risk reduction measures appropriate to the circumstances (e.g.
indicated
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

5 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
% birthing
fFN
Care considerations within 2 before
ng/mL wks 34 wks
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)
All women
Discuss plan for ongoing care with the woman in a manner
requiring
that supports informed choice
admission
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
50199 contraindications 515 1015
Take into account all clinical circumstances including history
of PTB
200-499 Commence tocolysis if delay of birth indicated and no 30 30
contraindications
Commence tocolysis if delay of birth indicated and no
> 500 contraindications 50 75
Prepare for administration of Magnesium Sulfate (if
gestational age less than or equal to 30 weeks)

5.2 In-utero transfer

Table 11. In-utero transfer
Neonatal outcomes are improved if PTB occurs in centres that manage high
2
volumes of preterm newborns
Context
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
Principles for transferring clinicians or by the flight nurse as required
transfer at 2328 Reassess the woman after initial stabilisation to review timelines around
weeks gestational transfer decisions, particularly if there are delays in transfer or transfer is not
age 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 en-
Recommendation
route unless such transfer puts the mothers life at risk
If clinically appropriate, use tocolysis to allow in-utero transfer

5.3 Antenatal corticosteroids

Table 12. Antenatal corticosteroids
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
Beneficial effect demonstrated regardless of membrane status
49
Context
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
Recommendation 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
Administration*
likely within 24 hours, consider repeat dose at 12 hours)
Repeat dose of antenatal corticosteroids (single dose)
o Betamethasone 11.4 mg IM

5.4 Tocolysis
Table 13. Tocolysis
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
Context 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
Tocolysis in women with PPROM before 34 weeks associated with :
55
PPROM
o A lower risk of birth within 48 hours
o An increased risk of chorioamnionitis without significant maternal or
neonatal benefit
Tocolysis before viability not generally recommended
55
Maternal contraindications to tocolysis (agent specific)

Any condition where prolongation of pregnancy is contraindicated including
but not limited to:
o In-utero fetal death
Contraindications o Lethal fetal anomalies
o Suspected fetal compromise
o Maternal bleeding with hemodynamic instability
o Severe preeclampsia
o Placental abruption
o Chorioamnionitis

5.4.1 Nifedipine
Table 14. Nifedipine
Nifedipine is a calcium channel blocker that relaxes smooth muscle
56
Context
Nifedipine is the tocolytic of choice
57,58
If there are contraindications to Nifedipine, liaise with an Obstetrician to

determine alternate tocolysis
Contraindications include :
56
Contraindications*
o Maternal hypotension or cardiac disease
o Previous adverse reaction to calcium channel blockers
Nifedipine 20 mg oral stat
56
If contractions persist after 30 minutes repeat Nifedipine 20 mg oral

56
Dose*
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
Further maintenance therapy is ineffective
54
Maintenance*
Maximum dose is 160 mg/day
56
Do not use sustained release formulation

Concomitant use with Magnesium Sulfate may increase effects of
Comments*
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
Observations o Every thirty minutes for first hour, then hourly for four hours
o Review frequency in accordance with clinical circumstances
Temperature every four hours
5.4.2 Other tocolytics
Table 15. Other tocolytics
Tocolytic Considerations
Compared to placebo, betamimetics are effective tocolytic agents
59,60
but
significant adverse side effects including maternal death from pulmonary
60
Betamimetics oedema have been reported
(Salbutamol)* 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
Risks for the fetus and neonate include :
62
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)
Inhibitors of
o Alteration of fetal, especially cerebral, blood flow
prostaglandin
synthesis o Reduced renal function (may result in oligohydramnios)
(Indomethacin)* 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

5.5 Antibiotics
Table 16. Antibiotics
Preterm labour If preterm labour ensues or there is imminent risk of PTB, give intrapartum
(or imminent risk antibiotic prophylaxis for prevention of Early onset Group B streptococcal
of PTB) without disease irrespective of GBS status or membrane status
evidence of Refer to Queensland Clinical Guideline Early onset Group B Streptococcus
63
chorioamnionitis* 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
Signs of intravenous antibiotic cover
chorioamnionitis Suspect chorioamnionitis in women with PPROM if labour ensues
(Intact or Optimal antibiotic regimen not established. If no local protocols exist
65
ruptured suggested regimen :
membranes)* o Ampicillin (or Amoxycillin) 2 g IV initial dose, then 1 g IV every 6 hours
o Gentamicin 5 mg/kg IV daily
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
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
Preterm labour not recommended
does not If preterm labour does not commence and no other indications, then with:
commence o Intact membranes, cease antibiotics
If PPROM refer to Queensland Clinical Guideline: Early onset Group B
63
Streptococcal disease
^Clindamycin IV is not on the Queensland Health (QH) List of Approved Medications (LAM) therefore QH
clinicians should give Lincomycin

5.6 Magnesium Sulfate for neuroprotection

Table 17. Magnesium Sulfate for neuroprotection
Magnesium Sulfate (MgSO4) given to mothers shortly before birth is
believed to reduce the risk of cerebral palsy and protect gross motor
67
function in those infants born preterm
o Number needed to treat (NNT): 63 babies for one baby to avoid cerebral
68
palsy (95% CI 44155)
o NNT to benefit (NNTB): 42 babies for combined death or cerebral palsy
Context 68
(95% CI 24346)
o The effect may be greatest at early gestations and is not associated with
67,69
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
70
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
69
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
69
immediately, as there may still be benefit from administration
Recommendation*
In situations where urgent birth is necessary, do not delay birth to
69
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
69
obstetrician
Refer to Appendix A: Magnesium Sulfate for fetal neuroprotection

5.7 Mode of preterm birth

Table 18. Mode of preterm birth
There is insufficient high quality evidence about whether mode of birth
71
affects neonatal morbidity and outcomes
Preterm CS is usually technically more difficult to perform and is not
72
without risk to the baby as the lower segment is usually not well formed
Context o A classical incision may be required with risks to future pregnancies
including scar dehiscence, uterine rupture, placental adherence and
73
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
Singleton vertex
vaginal birth or maternal conditions necessitating CS
The evidence regarding optimal mode of birth for preterm breech is
Breech 61,64,65
conflicting and unclear due to a lack of high quality studies
presentation
Base decisions on individual circumstances and maternal preferences
26+0 weeks
CS is not generally recommended where vaginal birth is imminent
25+6 weeks
CS for fetal indications alone not generally recommended at less than 25+0
gestation 10
weeks gestation
(vertex or breech)

6 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
Plan care relevant to the underlying clinical circumstances
Use clinical judgement and as clinically appropriate consider:
o Consultation/Referral/Transfer
o Serial TVCL
Prolonged o Progesterone
admission 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
Back transfer 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
Discharge 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
Referral and about the recommendations for follow-up and ongoing clinical surveillance
follow-up Offer social worker referral as indicated
Inform the General Practitioner about the episode of care

References
1. National Health and Medical Research Council (NHMRC), Department of Health and Ageing, Australian Government. National guidance on
collaborative maternity care. Canberra: NHMRC; 2010.
2. March of Dimes, Partnership for Maternal NaCH, Save the Children, World Health Organisation. Born too soon: The global action report on
preterm birth. Geneva: World Health Organisation; 2012.
3. NHS, Quality Improvement Scotland. Pathways for maternity care. Keeping Childbirth Natural and Dynamic Programme. 2009.
4. Homer C, Brodie P, Leap N. Midwifery continuity of care: a practical guide. Sydney: Elsevier; 2008.
5. Li Z, Zeki R, Hilder L, Sullivan E. Australia's mothers and babies 2011. Perinatal statistics series no. 28. Cat. no. PER 59. Canberra.
Australian Institute of Health and Welfare, National Perinatal Epidemiology and Statistics Unit. 2013.
6. Queensland Government. Perinatal statistics 2011 annual report. Health Statistics Unit. 2011 [cited 2014, May 13]. Available from:
http://www.health.qld.gov.au/hsu/peri/peri2011/report2011.asp.
7. Iams JD, Berghella V. Care for women with prior preterm birth. Am J Obstet Gynecol. 2010; 203(2):89-100.
8. Queensland Health. Maternity services. In: Clinical services capability framework for public and licensed private health facilities v3.1.
Brisbane: Queensland Government Department of Health; 2012.
9. Australian Commission on Safety and Quality in Healthcare. National consensus statement: essential elements for recognising and
responding to clinical deterioration. 2010 [cited 2014, May 14]. Available from: http://www.safetyandquality.gov.au/.
10. Queensland Clinical Guidelines. Perinatal care at the threshold of viability. Queensland Health. 2014. Available from:
http://www.health.qld.gov.au/qcg/.
11. Iams JD. Prevention of preterm parturition. N Engl J Med. 2014; 370(19):1861.
12. Barros FC, Bhutta ZA, Batra M, Hansen TN, Victora CG, Rubens CE. Global report on preterm birth and stillbirth (3 of 7): evidence for
effectiveness of interventions. BMC Pregnancy Childbirth. 2010; 10 Suppl 1:S3.
13. Piso B, Zechmeister-Koss I, Winkler R. Antenatal interventions to reduce preterm birth: an overview of Cochrane systematic reviews. BMC
Res Notes. 2014; 7(1):265.
14. Beta J, Akolekar R, Ventura W, Syngelaki A, Nicolaides KH. Prediction of spontaneous preterm delivery from maternal factors, obstetric
history and placental perfusion and function at 11-13 weeks. Prenat Diagn. 2011; 31(1):75-83.
15. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet. 2008; 371(9606):75-84.
16. Hendler I, Goldenberg RL, Mercer BM, Iams JD, Meis PJ, Moawad AH, et al. The preterm prediction study: association between maternal
body mass index and spontaneous and indicated preterm birth. Am J Obstet Gynecol. 2005; 192(3):882-6.
17. Cnattingius S, Villamor E, Johansson S, Edstedt Bonamy AK, Persson M, Wikstrom AK, et al. Maternal obesity and risk of preterm delivery.
JAMA. 2013; 309(22):2362-70.
18. van Os M, van der Ven J, Kazemier B, Haak M, Pajkrt E, Mol BW, et al. Individualizing the risk for preterm birth: an overview of the
literature. Expert Review Obstetrics and Gynaecology. 2013; 8(5):435-442.
19. Kiefer DG, Vintzileos AM. The utility of fetal fibronectin in the prediction and prevention of spontaneous preterm birth. Rev Obstet Gynecol.
2008; 1(3):106-12.
20. Goldenberg RL, Iams JD, Mercer BM, Meis PJ, Moawad AH, Copper RL, et al. The preterm prediction study: the value of new vs standard
risk factors in predicting early and all spontaneous preterm births. NICHD MFMU Network. Am J Public Health. 1998; 88(2):233-8.
21. Dodd JM, Jones L, Flenady V, Cincotta R, Crowther CA. Prenatal administration of progesterone for preventing preterm birth in women
considered to be at risk of preterm birth. Cochrane Database Systematic Reviews 2013, Issue 7. Art. No.: CD004947. DOI:
10.1002/14651858.CD004947.pub3.
22. Brocklehurst P, Gordon A, Heatley E, Milan SJ. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database of Systematic
Reviews 2013, Issue 1. Art. No.: CD000262. DOI: 10.1002/14651858.CD000262.pub4.
23. Smaill F, Vazquez JC. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database of Systematic Reviews 2007, Issue 2. Art.
No.: CD000490. DOI: 10.1002/14651858.CD000490.pub2.
24. Jakobsson M, Gissler M, Paavonen J, Tapper AM. Loop electrosurgical excision procedure and the risk for preterm birth. Obstet Gynecol.
2009; 114(3):504-10.
25. Edlow AG, Srinivas SK, Elovitz MA. Second-trimester loss and subsequent pregnancy outcomes: What is the real risk? Am J Obstet
Gynecol. 2007; 197(6):581 e1-6.
26. Chamberlain C, O'Mara-Eves A, Oliver S, Caird JR, Perlen SM, Eades SJ, et al. Psychosocial interventions for supporting women to stop
smoking in pregnancy. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD001055.
DOI:10.1002/14651858.CD001055.pub4.
27. Australian Health Ministers Advisory Council. Clinical practice guidelines: antenatal care module 1. Australian Government Department of
Health and Ageing: Canberra. 2012 [cited 2014 May 25]. Available from: http://www.health.gov.au/antenatal.
28. Nygren P, Fu R, Freeman M, Bougatsos C, Klebanoff M, Guise J-M. Evidence on the benefits and harms of screening and treating pregnant
women who are asymptomatic for bacterial vaginosis: an update review for the U.S. Preventive Services Task Force. Annals of Internal
Medicine. 2008; 148(3):220-233.
29. Sangkomkamhang US, Lumbiganon P, Prasertcharoensook W, Laopaiboon M. Antenatal lower genital tract infection screening and
treatment programs for preventing preterm delivery. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:CD006178. DOI:
10.1002/14651858.CD006178.pub2.
30. Mella MT, Berghella V. Prediction of preterm birth: cervical sonography. Semin Perinatol. 2009; 33(5):317-24.
31. Owen J, Hankins G, Iams JD, Berghella V, Sheffield JS, Perez-Delboy A, et al. Multicenter randomized trial of cerclage for preterm birth
prevention in high-risk women with shortened midtrimester cervical length. Am J Obstet Gynecol. 2009; 201(4):375 e1-8.
32. Fonseca EB, Celik E, Parra M, Singh M, Nicolaides KH. Progesterone and the risk of preterm birth among women with a short cervix. N Engl
J Med. 2007; 357(5):462-9.
33. Hassan SS, Romero R, Vidyadhari D, Fusey S, Baxter JK, Khandelwal M, et al. Vaginal progesterone reduces the rate of preterm birth in
women with a sonographic short cervix: a multicenter, randomized, double-blind, placebo-controlled trial. Ultrasound Obstet Gynecol. 2011;
38(1):18-31.
34. Dodd JM, Crowther CA, McPhee AJ, Flenady V, Robinson JS. Study protocol: Progesterone after previous preterm birth for prevention of
neonatal respiratory distress syndrome (PROGRESS): a randomised controlled trial. BMC Pregnancy and Childbirth. 2009;
9(6):doi:10.1186/1471-2393-9-6.
35. Norman JE, Shennan A, Bennett P, Thornton S, Robson S, Marlow N, et al. Trial protocol OPPTIMUM Does progesterone prophylaxis for
the prevention of preterm labour improve outcome? BMC Pregnancy and Childbirth 2012; 12(79):doi:10.1186/1471-2393-12-79.
36. Romero R, Nicolaides K, Conde-Agudelo A, Tabor A, O'Brien JM, Cetingoz E, et al. Vaginal progesterone in women with an asymptomatic
sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: a systematic review and metaanalysis of
individual patient data. Am J Obstet Gynecol. 2012; 206(2):124 e1-19.
37. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Progesterone: Use in the second and third trimester of
pregnancy for the prevention of preterm birth (C-Obs 29b). 2013 [cited 2014 May 17]. Available from: https://www.ranzcog.edu.au/.
38. The American College of Obstetricians and Gynecologists. Prediction and prevention of preterm birth; Practice Bulletin Number 130. 2012.
39. Alfirevic Z, Stampalija T, Roberts D, Jorgensen AL. Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy. Cochrane
Database of Systematic Reviews 2012, Issue 4. Art. No.: CD008991. DOI: 10.1002/14651858.CD008991.pub2.
40. Shannon G, Sekar R, Kimble RM. Septic shock following cervical cerclage for advanced cervical dilatation. Aust N Z J Obstet Gynaecol.
2011; 51(5):469-70.
41. Berghella V, Rafael TJ, Szychowski JM, Rust OA, Owen J. Cerclage for short cervix on ultrasonography in women with singleton gestations
and previous preterm birth: a meta-analysis. Obstet Gynecol. 2011; 117(3):663-71.
42. Royal College of Obstetricians and Gynaecologists. Cervical cerclage Green-top Guideline No.60. 2011.
43. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Maternal Group B streptococcus in pregnancy:
screening and management (C-Obs 19). 2012 [cited 2014 May 17]. Available from: https://www.ranzcog.edu.au/.
44. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Measurement of cervical length for prediction of
preterm birth (C-Obs 27). 2012 [cited 2014 May 17]. Available from: https://www.ranzcog.edu.au/.

45. 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.
46. Berghella V, Hayes E, Visintine J, Baxter JK. Fetal fibronectin testing for reducing the risk of preterm birth. Cochrane Database of
Systematic Reviews 2008, Issue 4. Art. No.: CD006843. DOI: 10.1002/14651858.CD006843.pub2.
47. Abbott DS, Radford SK, Seed PT, Tribe RM, Shennan AH. Evaluation of a quantitative fetal fibronectin test for spontaneous preterm birth in
symptomatic women. Am J Obstet Gynecol. 2013; 208(2):122 e1-6.
48. Peaceman A. Fetal fibronectin as predictor of preterm birth in patients with symptoms: A multicenter trial. Am J Obstet Gynecol. 1997;
177:13-18.
49. Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database
of Systematic Reviews 2006, Issue 3. Art. No.: CD004454. DOI: 10.1002/14651858.CD004454.pub2.
50. Royal College of Obstetricians and Gynaecologists. Antenatal corticosteroids to reduce neonatal morbidity and mortality. Green-top
Guideline No. 7. 2010.
51. Asztalos EV, Murphy KE, Willan AR, Matthews SG, Ohlsson A, Saigal S, et al. Multiple courses of antenatal corticosteroids for preterm birth
study: outcomes in children at 5 years of age (MACS-5). JAMA Pediatr. 2013; 167(12):1102-10.
52. Crowther CA, McKinlay CJ, Middleton P, Harding J. Repeat doses of prenatal corticosteroids for women at risk of preterm birth for improving
neonatal health outcomes. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD003935. DOI:
10.1002/14651858.CD003935.pub3.
53. Royal College of Obstetricians and Gynaecologists. Tocolysis for women in preterm labour. Green-top Guideline No.1b. 2011.
54. Gaunekar NN, Raman P, Bain E, Crowther CA. Maintenance therapy with calcium channel blockers for preventing preterm birth after
threatened preterm labour. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD004071.
DOI:10.1002/14651858.CD004071.pub3.
55. Mackeen AD, Seibel-Seamon J, Muhammad J, Baxter JK, Berghella V. Tocolytics for preterm premature rupture of membranes. Cochrane
Database of Systematic Reviews 2014, Issue 2. Art. No.: CD007062. DOI: 10.1002/14651858.CD007062.pub3.
56. Australian Medicines Handbook. Drugs for preterm labour. 2014 [cited 2014 May 20]. Available from: https://www-amh-net-au.
57. Flenady V, Wojcieszek AM, Papatsonis DNM, Stock OM, Murray L, Jardine LA, et al. Calcium channel blockers for inhibiting preterm labour
and birth. Cochrane Database Systematic Reviews 2014, Issue 6 Art.No.:CD002255. DOI: 10.1002/14651858.CD002255.pub2.
58. Conde-Agudelo A, Romero R, Kusanovic JP. Nifedipine in the management of preterm labor: a systematic review and metaanalysis. Am J
Obstet Gynecol. 2011; 204(2):134 e1-20.
59. Haas DM, Caldwell DM, Kirkpatrick P, McIntosh JJ, Welton NJ. Tocolytic therapy for preterm delivery: systematic review and network meta-
analysis. BMJ. 2012; 345:e6226.
60. Neilson JP, West HM, Dowswell T. Betamimetics for inhibiting preterm labour. Cochrane Database of Systematic Reviews 2014, Issue 2.
Art. No.: CD004352. DOI: 10.1002/14651858.CD004352.pub3.
61. Dodd JM, Crowther CA, Middleton P. Oral betamimetics for maintenance therapy after threatened preterm labour. Cochrane Database Syst
Rev. 2012; 12:CD003927.
62. King J, Flenady V, Cole S, Thornton S. Cyclo-oxygenase (COX) inhibitors for treating preterm labour. Cochrane Database of Systematic
63. Queensland Clinical Guidelines. Queensland Health [In: Early onset of Group B streptococcus disease. Issue MN16.20-V3-R21, 2016
64. Tita AT, Andrews WW. Diagnosis and management of clinical chorioamnionitis. Clin Perinatol. 2010; 37(2):339-54.
65. Australasian Society for Infectious Diseases. Management of perinatal infections. 2014 [cited 2014 September 02]. Available from:
http://www.asid.net.au/.
66. Flenady V, Hawley G, Stock OM, Kenyon S, Badawi N. Prophylactic antibiotics for inhibiting preterm labour with intact membranes.
CochraneDatabase of Systematic Reviews 2013, Issue 12. Art.No.:CD000246.DOI: 10.1002/14651858.CD000246.pub2.
67. Royal College of Obstetricians and Gynaecologists. Magnesium Sulphate to prevent cerebral palsy following preterm birth. Scientific Impact
Paper No.29. 2011.
68. Doyle LW, Crowther CA, Middleton P, Marret S, Rouse D. Magnesium sulphate for women at risk of preterm birth for neuroprotection of the
fetus. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD004661. DOI:10.1002/14651858.CD004661.pub3.
69. 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.
70. Doyle LW, Anderson PJ, Haslam R, Lee KJ, Crowther C. School-age outcomes of very preterm infants after antenatal treatment with
magnesium sulfate vs placebo. JAMA. 2014; 312(11):1105-13.
71. Alfirevic Z, Milan SJ, Livio S. Caesarean section versus vaginal delivery for preterm birth in singletons. Cochrane Database of Systematic
72. Biswas A, Su LL, Mattar C. Caesarean section for preterm birth and, breech presentation and twin pregnancies. Best Practice & Research
Clinical Obstetrics & Gynaecology. 2013; 27(2):209-219.
73. Skupski DW, Greenough A, Donn SM, Arabin B, Bancalari E, Vladareanu R. Delivery mode for the extremely premature fetus: a statement
of the prematurity working group of the World Association of Perinatal Medicine. Journal of Perinatal Medicine. 2009; 37(6):583-586.

Appendix A: Magnesium Sulfate for fetal neuroprotection

One to one midwifery care in birth suite or high dependency unit for the
duration of therapy
Resources
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
Contraindications Maternal myasthenia gravis use cautiously and monitor closely
Concomitant Nifedipine use cautiously and monitor closely
Reduced renal function monitor plasma magnesium level/urine output
Route IV infusion via controlled infusion device
Loading dose 4 g IV bolus over 20 minutes
Maintenance
1 g/hour for 24 hours or until birth, whichever occurs first
dose
Related to hypermagnesaemia
Side effects Common (> 1%): nausea and vomiting, flushing
Infrequent (0.11%): headache, dizziness
Vital signs: BP, pulse, respiratory rate
Oxygen saturation (SpO2)
Baseline Patellar reflex
observations 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
Monitoring during
o Document reason if CTG not able to be performed
loading dose
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
Monitoring during
o Interpret CTG relevant to gestational age if less than 28 weeks
maintenance
dose 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
Monitoring post Minimum 4 hourly or more frequently as clinically indicated
infusion 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
Discontinuation
Diastolic BP decreases more than 15 mmHg below baseline
and urgent
Absent deep tendon reflexes
medical review
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.

Appendix B: Consumer advice after threatened preterm labour

Aspect Discussion point
It is normal for your uterus to contract now and then during pregnancy
What is preterm Preterm labour is when you have frequent contractions along with the
th
labour? 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
Signs of preterm
The feeling that your baby is pushing down, called pelvic pressure
labour
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
Call your health
You have any bleeding from your vagina
care provider
immediately if: 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
Activity
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
You may resume your normal activities
Having sex or orgasm may cause uterine contractions
Sexual activity
Do not have sex until your health care provider says it is okay
You need to eat well for you and your babys health
Diet 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
Fluids
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
Stool softeners
with fibre
You can also ask your health care provider for help with constipation
Adapted from: March of Dimes Preterm Labour Assessment Toolkit (2013)

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 Innovation and Research
Branch.

G PTL PDF

Încărcat de

Informații document

Titlu original

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

G PTL PDF

Încărcat de

Drepturi de autor:

Formate disponibile

Queensland Health

Maternity and Neonatal Clinical Guideline

Preterm labour and birth

Document title: Preterm labour and birth

Refer to online version, destroy printed copies after use Page 2 of 26

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

Review History In-utero transfer

If established labour (or imminent risk of PTB) give

Queensland Clinical Guidelines: Preterm labour and birth F14.6-1-V8-R19

Refer to online version, destroy printed copies after use Page 3 of 26

Refer to online version, destroy printed copies after use Page 4 of 26

Refer to online version, destroy printed copies after use Page 5 of 26

A multidisciplinary health care approach to care is essential

1.2 Clinical standards

Undertake clinical observations in accordance with the National Consensus Framework

Refer to online version, destroy printed copies after use Page 6 of 26

Table 1. Risk factors associated with preterm birth

Aspect Risk factors associated with preterm birth (PTB)

o Younger than 18 years

High levels of psychological stress

Late or no health care in pregnancy

Low socio-economic status

High or low body mass index (BMI)

Presence of fetal fibronectin in the vaginal secretions

Short cervical length

Previous PTB recurrence risk related to:

Assisted reproduction associated with 2 fold increased risk of PTB

Preterm prelabour rupture of membranes (PPROM)

Surgical procedures involving the cervix

Chronic medical conditions

Refer to online version, destroy printed copies after use Page 7 of 26

Routine screening and treatment for asymptomatic BV not found to prevent

Urinary tract infection is associated with threatened preterm labour

Refer to online version, destroy printed copies after use Page 8 of 26

3.1 Progesterone therapy

and 200 mg Progesterone pessaries for women with a short cervix

3.2 Cervical cerclage

o Prior spontaneous PTB before 34 weeks gestation and

Refer to online version, destroy printed copies after use Page 9 of 26

4 Clinical assessment of preterm labour

Refer to online version, destroy printed copies after use Page 10 of 26

4.1 Cervical length

Table 6. Cervical length assessment

Table 7. Cervical length and risk of preterm birth

Cervical length Likelihood ratio for birth at:

Refer to online version, destroy printed copies after use Page 11 of 26

4.2 Fetal fibronectin testing

Table 8. Fetal fibronectin testing

Refer to online version, destroy printed copies after use Page 12 of 26

4.3 Assess need for admission

Table 9. Assessment of need for admission

Care Assessment (assumes intact membranes)

Refer to online version, destroy printed copies after use Page 13 of 26

5 Management of preterm labour

5.1 Planning care

Table 10. Planning care

Refer to online version, destroy printed copies after use Page 14 of 26

5.2 In-utero transfer

Refer to online version, destroy printed copies after use Page 15 of 26

5.3 Antenatal corticosteroids

Refer to online version, destroy printed copies after use Page 16 of 26

Maternal contraindications to tocolysis (agent specific)

Refer to online version, destroy printed copies after use Page 17 of 26