3.1 PPROM & Prem Labour

Question 1

Preterm labour

Answer 1

Delivery between 20-37 weeks estimated gestational age
Preterm labour is characterised by uterine contractions and cervical dilation/effacement

Question 2

Preterm labour - risk factors & causes

Answer 2

Risk factors:
Hx of preterm birth
Cervical surgery
Vaginal bleeding, UTI, genital tract infections
Behavioural factors (substance abuse, low maternal BMI, smoking)
Short interpregnancy interval
<18 or >35 years old
Ethnicity (Indigenous are 70% increased risk)

Causes:
Short cervical length (<25mm before 25 weeks gestation)
Multiple gestation
Uterine anomalies
Polyhydramnios/Oligohydramnios
Medical conditions - preeclampsia

Question 3

Preterm labour - signs/symptoms & complications

Answer 3

Signs & Symptoms:
Irregular uterine activity / contractions
Lower abdominal cramping
Vaginal loss - mucous, blood, fluid, meconium
Lower back pain
Pelvic pressure
Presenting part fixed or engaged, cervical dilation
Increased urinary frequency

Complications:
fFN - US, FBE, CTG, medications (corticosteroids & tocolytics), antibiotics (especially if GBS+)

Question 4

Preterm labour - assessments

Answer 4

Vitals
Abdominal palpation - look for engagement of heart
Contractions 4:10 (palp, CTG & FHR at >38)
GBS swab @ 36
Vaginal examination
Foetal fibronectin test - a protein that the foetus produces, tells us if labour is imminent, positive means the amniotic sac is not attaching to the uterus. Speculum swab (medical procedure)
Blood & urine test

Question 5

Preterm labour medical management - Tocolytic therapy (CCBs)

Answer 5

Indication:
Short-term, prolongation of pregnancy within 24-34 weeks

Dose:
Reassess after 30 minutes if still contracting after initial dose, maintenance every 6 hours

Action:

Contraindication:
Hypotension
Preload dependent cardiac lesions (e.g., aortic insufficiency)

Question 6

Preterm labour medical management - tocolytic therapy (NSAIDS)

Answer 6

Indication:
Short-term, prolongation of pregnancy within 24-34 weeks

Dose:

Action:

Contraindication:
Platelet dysfunction or bleeding disorder
Hepatic dysfunction
GI ulcerative disease
Renal dysfunction
Asthma

Question 7

Preterm labour medical management - Tocolytic therapy (Beta-adrenergic receptor agonists)

Answer 7

Indication:
Short-term, prolongation of pregnancy within 24-34 weeks

Dose:

Action:

Contraindication:
Tachycardia sensitive maternal cardiac disease
Poorly controlled diabetes mellitus

Question 8

Preterm labour medical management - Tocolytic therapy (mag sulph)

Answer 8

Indication:
Short-term, prolongation of pregnancy within 24-34 weeks
Neuroprotection of <30 week gestation

Dose:

Action:

Contraindication:
Myasthenia gravis

Question 9

Preterm labour medical management - progesterone therapy

Answer 9

Indication:
Reduce risk / prevention of preterm delivery. For women with previous preterm birth or short cervical length

Dose:

Action:
Inhibition of cervical ripening, reduction of myometrial contractility, modulator of inflammation

Contraindication:
No evidence of improvement for women with shortened cervix at multiple gestation (can be effective for singletons)

Question 10

Preterm labour medical management - Cervical clercage

Answer 10

Indication:
Hx of spont preterm birth, short cervix

Dose:

Action:

Contraindication:
Not recommended for hx of cervical surgeries or anomalies, multiple pregnancy

Question 11

Preterm labour medical management - Corticosteroids

Answer 11

Indication:
Helps mature the foetal lungs to avoid respiratory distress

Dose:

Action:

Contraindication:
>36 weeks

Question 12

Midwifery care for preterm labour - 24-34 weeks

Answer 12

• Corticosteroids (reduces respiratory distress syndrome, intracranial haemorrhage, death
• Short-term tocolytic therapy (prolongation of pregnancy)
• Magnesium sulphate

Question 13

Midwifery care for preterm labour - >34 weeks

Answer 13

• Prepare for birth - consult with OB
• Anticipate vaginal birth
• Prepare resus equipment appropriate for gestation
• Counsel woman about what to expect in terms of baby’s condition and care
• Follow up care - counselling, debrief

Question 14

PPROM - definition & risk factors

Answer 14

The spontaneous rupture of membranes before 37 weeks gestation, without the onset of labour.

Risk factors:
Previous hx of PPROM
Previous hx of preterm birth
Cervical insufficiency
Placental abruption
Uterine distention
Infection - chorioamnionitis
Multiple gestation

Question 15

PPROM - complications & assessments

Answer 15

Complications:
Preterm birth (respiratory distress, infection)
Cord prolapse
Infection (maternal sepsis)
Placental abruption
Oligohydramnios (limb deformities, cord compression)

Assessments:
Assess liquor - blood, meconium, amount
Don’t drive - call an ambulance if needed
Amnisure - determines if membranes are actually ruptured. Like a covid test swab.
Pack bags - potentially for multiple nights
Chorioamnionitis - purulent or foul smelling amniotic fluid (mec looking), fever, tachycardia. Needs antibiotics (benpen), potentially expedite delivery
Shower and don’t bathe - reduce risk of infection
Monitor for foetal movements
Avoid intercourse
FBE
Send home if: negative fFN, cephalic presentation, low symptoms, weekly scans and CTG monitoring if at home, FBE

Question 16

PPROM management - <23 weeks

Answer 16

Antibiotic prophylaxis (benzyl penicillin or clindamycin)

Established labour:
Prepare for birth
Provide counselling for woman & family

Not established labour:
Suspected sepsis/chorioamnionitis? Significant antepartum haemorrhage?
Yes - active management IOL
No - continue antibiotics, US examination for FG & wellbeing, weekly high vaginal swab, biweekly FBE & CRP, daily FHR auscultation

Question 17

PPROM management - 23-34 weeks

Answer 17

Antibiotic prophylaxis (benzyl penicillin or clindamycin)

Established labour:
Aim for in utero transfer when possible - contact PIPER
Tocolysis, corticosteroids, MgSO4 if <30 weeks
Prepare for birth or transfer

Not established labour:
Suspected sepsis/chorioamnionitis? Significant antepartum haemorrhage?
Yes - active management IOL or c-section
No - US examination for FG & wellbeing, continue antibiotics, daily mat observations, weekly HVS, FBE 7 CRP 3x daily then bi-weekly, <28 daily auscultation of FHR, >28 daily CTG

Question 18

PPROM management - 34-37 weeks

Answer 18

Antibiotic prophylaxis (benzyl penicillin or clindamycin)

Established labour:
Aim for in utero transfer when possible - contact PIPER
Corticosteroids if 37+
Prepare for birth or transfer

Not established labour:
Suspected sepsis/chorioamnionitis? Significant antepartum haemorrhage? GBS+ & >37?
Yes - active management IOL or c-section
No - US examination for FG & wellbeing, await spont labour until 37 weeks, antibiotic prophylaxis during labour, daily CTG

Question 19

PPROM Maternal & Fetal monitoring

Answer 19

Maternal:
Chorioamnionitis - lower abdominal pain, abdominal vaginal discharge, fever, reduced fetal movements (Lab CRP and FBE)
Antibiotics - reduce chorioamnionitis, prolong latency, improve neonatal outcome
Offer expectant management until 37 weeks - if there are no contraindications
Intrapartum antibiotic prophylaxis for GBS

Fetal:
Non-stress test daily
CTG continuous in labour/delivery