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									Assessment and management of preterm
labour
Statewide Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour



 Document title:             Assessment and management of preterm labour

 Publication date:           September 2009

 Document number:            MT0909.6-V1-R11

 Replaces document:          New document

 Author:                     Statewide Maternity and Neonatal Clinical Guidelines Program
                             Medical, midwifery and nursing staff in Queensland public and private
 Audience:                   maternity services

 Exclusions:                 Management of premature rupture of membranes

 Review date:                September 2011
                             Statewide Maternity and Neonatal Clinical Network
 Endorsed by:
                             Patient Safety and Quality Executive Committee
                             Statewide Maternity and Neonatal Clinical Guidelines Program
 Contact:                    Email: MN-Guidelines@health.qld.gov.au
                             URL: http://www.health.qld.gov.au/cpic/resources/mat_guidelines.asp




Disclaimer

These guidelines have been prepared to promote and facilitate standardisation and
consistency of practice, using a multidisciplinary approach.

Information in this guideline is current at time of publication.

Queensland Health does not accept liability to any person for loss or damage incurred as a
result of reliance upon the material contained in this guideline.

Clinical material offered in this guideline does not replace or remove clinical judgement or the
professional care and duty necessary for each specific patient case.

Clinical care carried out in accordance with this guideline should be provided within the
context of locally available resources and expertise.

This Guideline does not address all elements of standard practice and assumes that
individual clinicians are responsible to:
    • Discuss care with consumers in an environment that is culturally appropriate and
        which enables respectful confidential discussion. This includes the use of interpreter
        services where necessary
    • Advise consumers of their choice and ensure informed consent is obtained.
    • Provide care within scope of practice, meet all legislative requirements and maintain
        standards of professional conduct
    • Apply standard precautions and additional precautions as necessary, when delivering
        care
    • Document all care in accordance with mandatory and local requirements




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Statewide Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

Flowchart: Assessment and management of preterm labour




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Statewide Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

Abbreviations
 BP                   Blood pressure
 cm                   Centimetres
 CTG                  Cardiotocograph
 FBC                  Full blood count
 fFN                  Fetal fibronectin
 g                    Grams
 GBS                  Group B streptococcus
 IM                   Intramuscular
 IV                   Intravenous
 M/C/S                Microscopy / culture / sensitivity
 mg                   Milligram
 min                  Minutes
 mm                   Millimetres
 mmHg                 Millimetres of mercury
 MSU                  Mid stream urine
 PPROM                Preterm premature rupture of membranes
 PROM                 Premature rupture of membranes
 PTL                  Preterm labour
 RSQ                  Retrieval Services Queensland
 stat                 Statim (immediately)
 TVCL                 Transvaginal cervical length
 VE                   Vaginal examination
  O
   C                  Degrees Celsius




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Statewide Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

Table of Contents
1   Introduction .....................................................................................................................................6
  1.1     Definition ................................................................................................................................6
  1.2     Risk factors ............................................................................................................................6
2 Assessment ....................................................................................................................................6
  2.1     Review history........................................................................................................................6
  2.2     Assess for signs and symptoms of preterm labour ...............................................................6
  2.3     Physical examination and initial Investigations......................................................................6
  2.4     Fetal fibronectin testing..........................................................................................................7
  2.5     Transvaginal ultrasound of cervical length ............................................................................7
    2.5.1 Interpreting TVCL results ...................................................................................................7
3 Management of preterm labour ......................................................................................................8
  3.1     Negative fFN and no evidence of cervical change / TVCL > 20 mm .....................................8
  3.2     Positive fFN and / or evidence of cervical change / TVCL < 20 mm .....................................8
4 Tocolysis .........................................................................................................................................8
  4.1     Contraindications ...................................................................................................................8
  4.2     Relative contraindications ......................................................................................................8
  4.3     Nifedipine ...............................................................................................................................9
    4.3.1 Contraindications ...............................................................................................................9
    4.3.2 Dosage and administration ................................................................................................9
5 Corticosteroids..............................................................................................................................10
  5.1     Dosage and administration ..................................................................................................10
6 Antibiotics .....................................................................................................................................10
  6.1     Dosage and administration ..................................................................................................10
7 Transfer ........................................................................................................................................10
References ..........................................................................................................................................11
Appendix A: Drug Table.......................................................................................................................13
Appendix B: Acknowledgements .........................................................................................................14


List of Tables
Table 1. Fetal fibronectin testing ........................................................................................................... 7
Table 2. Nifedipine dosage and administration ..................................................................................... 9
Table 3. Betamethasone dosage and administration .......................................................................... 10
Table 4. Antibiotics dosage and administration................................................................................... 10




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Statewide Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour


1       Introduction
Fourteen percent of Australian perinatal deaths in 2005 were as a result of preterm delivery,1
however most women that present with symptoms of preterm labour will deliver at term with a small
minority delivering within seven days of onset of symptoms.2,3

1.1     Definition
Delivery occurring before 37 completed weeks gestation.

1.2     Risk factors
         •   Previous preterm birth
         •   Preterm premature rupture of membranes (PPROM)
         •   Cervical incompetence
         •   Cervical surgical procedures
         •   Uterine anomalies
         •   Multiple gestation
         •   Polyhydramnios
         •   Placental abruption
         •   Vaginal bleeding
         •   Smoking
         •   Illicit drug use

2       Assessment
The aim of assessment is to determine the risk of delivery within the next seven days and to assess
fetal and maternal wellbeing.

2.1     Review history
         • Medical
         • Surgical
         • Obstetric

2.2     Assess for signs and symptoms of preterm labour
         •   Lower abdominal cramping
         •   Pelvic pressure
         •   Lower back pain
         •   Vaginal spotting or ‘show’
         •   Regular uterine activity
         •   Cervical effacement / dilatation

2.3     Physical examination and initial Investigations
         •   Vital signs
         •   Mid-stream urinalysis and consider microscopy/culture/sensitivity
         •   Maternal abdominal examination
         •   Fetal heart rate +/- cardiotocograph (CTG)
         •   Sterile speculum examination
         •   Exclude premature rupture of membranes (PROM)
         •   Obtain fFN test if not contraindicated [refer section 2.4]
         •   High vaginal swab with M/C/S
         •   Low vaginal/anorectal swab for Group B streptococcus
         •   Assess cervical dilatation by sterile digital vaginal examination unless contraindicated by
                   o Ruptured membranes
                   o Suspected placenta praevia

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Statewide Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

2.4      Fetal fibronectin testing
Fetal fibronectin (fFN) is a screening test used to assess the risk of preterm delivery within the next
seven days. “Point of care” fFN testing should be utilised in the assessment of preterm labour.

Table 1. Fetal fibronectin testing
 Indications4                •   Symptomatic preterm labour between 24 and 36 weeks gestation and
                             •   Intact membranes and
                             •   Cervical dilatation less than 3 cm
 Contraindications           •   Ruptured membranes
                             •   Visual evidence of moderate or gross bleeding
                             •   Cervical cerclage insitu
 Relative                    •   After the use of lubricants or disinfectants
 Contraindications           •   Within 24 hours of coitus
                             •   Within 24 hours of vaginal examination
 Procedure                   •   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
 Positive Result             •   Consider transvaginal ultrasound of cervical length if available (see 2.5)
                             •   Admit for tocolysis and steroids
                             •   Consider transfer to appropriate level facility
                             •   False positive result may occur as a result of recent4,5
                                     o Coitus
                                     o Digital vaginal examination
                                     o Transvaginal ultrasound
 Negative Result             •   Low risk of delivery within seven days
                             •   False negative result may occur due to4,5
                                     o Use of lubricant with speculum examination
                                     o Intravaginal disinfectants.

2.5      Transvaginal ultrasound of cervical length
Transvaginal ultrasound of cervical length (TVCL) is an additional screening test that can aid in
assessing the risk of preterm delivery. TVCL must be performed by a credentialed clinician. Lack of
local capability to perform this test is not a reason for transfer.

2.5.1 Interpreting TVCL results
A cervical length less than 15 mm is associated with an increased risk of spontaneous preterm birth.3

Due to the distances required for transfer from Queensland regional centres, a TVCL ‘cut-off’ of 20
mm is appropriate.




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Statewide Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour


3       Management of preterm labour
Tocolysis and steroids are the main strategies to manage preterm labour [see section 4, 5]. Transfer
may also be necessary, dependent on the acuity level of the facility and nursery requirements.
Management options will depend on the services available at each facility, such as:
        • screening test availability
        • equipment (eg CTG) availability
        • acuity level of the nursery
If necessary, contact an obstetrician for further advice.

3.1     Negative fFN and no evidence of cervical change / TVCL > 20 mm
There is a low risk of delivery within the next 7 days therefore:
        • if contractions are infrequent / irregular
                 o offer discharge home with follow-up as an outpatient within 7 days
        • if contractions are regular and painful:
                 o admit for observation
                 o offer analgesia
                 o reassess in 2 hours
        • if contractions are persistent and painful
                 o consider steroids
                 o tocolysis and
                 o transfer if necessary

3.2     Positive fFN and / or evidence of cervical change / TVCL < 20 mm
There is an increased risk of delivery within the next 7 days therefore:
        • admit and offer analgesia
        • administer steroids and commence tocolysis (if no contraindications)
        • continuous fetal monitoring with CTG
        • transfer if necessary


4       Tocolysis
The aim of tocolysis is to suppress uterine contractions and delay preterm delivery6,7 to:
       • allow in-utero transfer to an appropriate level facility
       • allow for the administration of corticosteroids

4.1     Contraindications
         •   Gestation > 34 weeks
         •   Labour is too advanced
         •   In utero fetal death
         •   Lethal fetal anomalies
         •   Suspected fetal compromise
         •   Placental abruption
         •   Suspected intra-uterine infection
         •   Maternal hypotension: BP < 90 mmHg systolic

4.2     Relative contraindications
Cautiously give tocolysis if:
       • pre-eclampsia
       • placenta praevia (if not bleeding)




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Statewide Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour


4.3     Nifedipine
Nifedipine is the tocolytic of choice. Nifedipine is a calcium channel blocker that relaxes smooth
muscle.8 It is an effective tocolytic with fewer side effects than other tocolytics available.6

4.3.1 Contraindications
If there are contraindications to Nifedipine, liaise with an Obstetrician to determine alternate
tocolysis.9
Contraindications include8:
          • previous adverse reaction to calcium channel blockers
          • maternal cardiac disease
          • hypotension
          • hepatic dysfunction
          • concurrent use with salbutamol or other beta-sympathomimetics
          • concurrent use of nitrates or antihypertensive medication

4.3.2   Dosage and administration

Table 2. Nifedipine dosage and administration
 Nifedipine
 Route                       Oral
                             • 20 mg stat
 Dose                        • If contractions persist after 30 minutes: Repeat 20 mg
                             • If contractions persist after a further 30 minutes: Repeat 20 mg
                             • If blood pressure is stable, 20 mg every 6 hours for 48 hours. Further
 Maintenance Dose              maintenance therapy is ineffective6
                             • Maximum dose is 160 mg/day8
                             • Do not use sustained release formulation
 Comments
                             • Use cautiously with magnesium sulphate8
                             • Hypotension
                             • Headache
                             • Facial flushing
 Side Effects                • Cardiac failure
                             • Tachycardia, palpitations
                             • Nausea
                             • Dizziness
                             • Cardiotocograph monitoring until contractions cease
                             • Pulse rate, respiratory rate and blood pressure monitoring
                                     o every thirty minutes for first hour, then
 Observations6,10
                                     o second hourly for 24 hours, then
                                     o four hourly
                             • Measure and record temperature every four hours




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Statewide Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour


5       Corticosteroids
Administration of corticosteroids can reduce fetal mortality and morbidity.11 Antenatal corticosteroid
therapy should be initiated in women between 24 and 34 weeks gestation.12

5.1     Dosage and administration
Table 3. Betamethasone dosage and administration
 Betamethasone
 Route                       IM
                              • 11.4 mg
 Dose
                              • Repeat 24 hours after initial dose12-14
                              • Where delivery is not imminent, routine prophylactic administration of
                                steroids is not recommended15,16
 Comments                     • If delivery is imminent and it is more than 10 days since the initial dose,
                                subsequent steroid dose may be administered. Careful clinical
                                assessment is required, including fFN testing


6       Antibiotics
Prophylactic antibiotics for GBS are not recommended in threatened preterm labour.17
Prophylactic antibiotics for GBS should be administered in established preterm labour.18

6.1     Dosage and administration
Table 4. Antibiotics dosage and administration
Penicillin
Route                        IV
Dose                          • 1.2 g stat then 600 mg every 4-6 hours19
                              • If there is penicillin hypersensitivity give
                                    o Lincomycin 600 mg IV every 8 hours (on the QH List of
                                        Approved Medications) or
Comments                            o Clindamycin 900 mg IV every 8 hours19 (not on the QH List of
                                        Approved Medications)
                              • Erythromycin should be avoided17
                              • If GBS screening tests are negative - cease antibiotics

7       Transfer
         • Neonatal outcome is improved with appropriate in-utero transfer
         • If transfer is indicated the relevant obstetric medical coordinator should be contacted via
           Retrieval Services Queensland (RSQ) on 1300 799 127
         • If after discussion with the obstetric coordinator it is thought there may be a risk of
           delivery during transfer, in-utero transfer should not be attempted




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Statewide Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour


References
1. Australian Bureau of Statistics. Causes of death. [online]. 2005 [cited 2009 March 3]; 2009.
Available from:
http://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/3FFF8096D9500CA9CA25729D001C0B05
/$File/33030_2005.pdf.

2. Giles W, Bisits A, Knox M, Madsen G, Smith R. The effect of fetal fibronectin testing on
admissions to a tertiary maternal-fetal unit and cost savings. Am J Obstet Gynecol. 2000; 182(2):439-
42.

3. Tsoi E, Akmal S, Geerts L, Jeffery B, Nicolaides K. Sonographic measurement of cervical length
and fetal fibronectin testing in threatened preterm labour. Ultrasound Obstet Gynecol. 2006; 27:368-
72.

4. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Use of
cervical fetal fibronectin as a screening test for preterm birth. College Statement C-Obs 26. 2008
[cited 2009 March 3]. Available from: www.ranzcog.edu.au/publications/statements/C-obs26.pdf.

5. Anderson HF. Use of fetal fibronectin in women at risk for preterm delivery. Clin Obstet Gynecol.
2000; 43(4):746-58.

6. King J, Flenady V, Papatsonis D, Dekker G, Carbonne B. Calcium channel blockers for inhibiting
preterm labour. Cochrane Database Syst Rev. 2003; Issue1.Art, No.: CD002255.
DOI10.1002/14651858.CD002255.

7. Department of Health New South Wales. Tocolytic agents - protocols for administration for
threatened preterm labour. Circular No 2002/49. 2002.

8. Australian Medicines Handbook. Nifedipine [online]2009 [cited 2009 May 25]. Available from:
https://www-amh-net-
au.cknservices.dotsec.com/online/view.php?page=chapter17/monographnifedipine-
02.html#nifedipine-02.

9. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. The use of
nifedipine in obstetrics. College Statement C-Obs 15. 2008.

10. King JF, Flenady V, Papatsonis D, Dekker G, Carbonne B. Calcium channel blockers for
inhibiting preterm labour; a systematic review of the evidence and a protocol for administration of
nifedipine. Aust N Z J Obstet Gynaecol. 2003; 43(3):192-8.

11. Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women
at risk of preterm birth. Cochrane Database Syst Rev. 2006; Issue 3. Art. No.: CD004454. DOI:
10.1002/14651858.CD004454.pub2.

12. Royal College of Obstetricians and Gynaecologists. Antenatal corticosteroids to prevent RDS.
Guideline No.7 [online]. 2004 [cited 2009 March 25]. Available from: http://www.rcog.org.uk/files/rcog-
corp/uploaded-files/GT7AntenatalCorticosteroids2004.pdf.

13. Australian Medicines Handbook. Betamethasone [online]2009 [cited 2009 May 25]. Available
from: https://www-amh-net-
au.cknservices.dotsec.com/online/view.php?page=chapter14/monographbetamethasone.html#betam
ethasone.

14. Antenatal corticosteroids revisited: repeat courses. National Institute of Health Consensus
Statement [online]. 2000 [cited 2009, June 25]; 17(2):1-10. Available from:
http://consensus.nih.gov/2000/2000AntenatalCorticosteroidsRevisted112html.htm.

15. Murphy K, Hannah M, Willan A, Hewson S, Ohlsson A, Kelly E. Multiple courses of antenatal
corticosteroids for preterm birth. Lancet. 2008; 372:2143-51.



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Statewide Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

16. Newnham JP, Jobe AH. Should we be prescribing repeated courses of antenatal
corticosteroids? Semin Fetal Neonatal Med. 2009; 14(3):157-63.

17. Kenyon SL. Broad spectrum antibiotics for spontaneous preterm labour: the ORACLE II trial.
Lancet. 2001; 357:1319-27.

18. Flenady V, Jenkins-Manning, S. Prevention of neonatal early onset Group B streptococcal
disease (EOGBSD). Queensland Clinical Practice Guidelines Working Party 2007.

19. Australasian Society for Infectious Diseases. Management of perinatal infections. [online]. 2002
[cited 2009 May 25]. Available from:
http://www.asid.net.au/downloads/Management%20of%20Perinatal%20Infections%20ASID%202002
%20rev%202007.pdf.




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Statewide Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour


Appendix A: Drug Table

  Drug Name                                 Dose                      Route          Comments
Tocolysis
                          • 20 mg stat                                oral    • Do not use sustained
                          • Repeat 20 mg (if still contracting at               release
                            30 minutes)                                       • CTG whilst
Nifedipine                • Final 20 mg (if still contracting after             administering
                            further 30 minutes)                               • Monitor vital signs
                          • Maintenance 20 mg every 6 hours                   • Maximum dose of 160
                            for 48 hours                                        mg/day
Corticosteroids
                          • 11.4 mg stat, then                        IM      • Repeat doses after
Betamethasone             • Repeat 11.4 mg 24 hours after                       initial course not
                            initial dose                                        recommended
Antibiotics
                       • 1.2 g stat, then                     IV        • Group B streptococcus
Penicillin
                       • 600 mg every 4 – 6 hours                         prophylaxis
      If the patient has Penicillin hypersensitivity give either Lincomycin or Clindamycin
                       • 600 mg every 8 hours                 IV        • On the QH List of
Lincomycin
                                                                          Approved Medications
Clindamycin            • 900 mg every 8 hours                 IV        • Not on the QH List of
                                                                          Approved Medications




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Statewide Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour


Appendix B: Acknowledgements

Working Party Clinical Lead
Dr Liana Tanda, Obstetrician, Caboolture Hospital
Working Party Members
Ms Karen Baker, Midwife, Mackay Base Hospital
Dr Kathleen Braniff, Obstetrician, Mackay Base Hospital
Ms Penelope Dale, Midwife, Royal Brisbane and Women’s Hospital
Professor Ian Jones, Obstetrician, Royal Brisbane and Women’s Hospital
Dr Christopher King, Obstetrician, Mt Isa Hospital
Ms Mary Hindmarsh, Midwife, Weipa
Professor Michael Humphrey, Obstetrician, Office of Rural and Remote Health
Associate Professor Rebecca Kimble, Obstetrician, Royal Brisbane and Women’s Hospital
Dr David Moore, Obstetric Registrar, Gold Coast Hospital
Ms Vivienne Rybarczyk, Midwife, Rockhampton Base
Dr Renukar Sekar, Obstetrician, Royal Brisbane and Women’s Hospital
Ms Mary Tredinnick, Pharmacist, Royal Brisbane and Women’s Hospital


Program Team
Associate Professor Rebecca Kimble, Program Chair, Statewide Maternity and Neonatal Clinical
Guidelines Program
Ms Joan Kennedy, Principal Project Officer, Statewide Maternity and Neonatal Clinical Guidelines
Program
Mr Stephen Aitchison, Project Officer, Statewide Maternity and Neonatal Clinical Guidelines Program
Ms Jacinta Lee, Project Officer, Statewide Maternity and Neonatal Clinical Guidelines Program
Mrs Catherine van den Berg, Project Officer, Statewide Maternity and Neonatal Clinical Guidelines
Program
Steering Committee 08_09, Statewide Maternity and Neonatal Clinical Guidelines Program




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