Premature Labour

Question 1

What is the definition of premature labour?

Answer 1

labour at less than 37 completed weeks confirmed by contractions causing dilatation of the cervix

Question 2

If a woman comes in with prem labour what are the midwifes aims?

Answer 2

• To diagnose preterm labour
• To establish a cause, if possible, of preterm labour, which may allow treatment of the primary cause of the preterm labour e.g. urinary tract infection.
• To assess the maternal and fetal condition in the situation of preterm labour.
• To establish effective suppression of labour (unless contra-indicated) prior to 34 weeks gestation without undue delay.

Question 3

What is a tocolytic that can be used to supress preterm labour

Answer 3

Nifedipine Tocolytic Therapy

Question 4

What are the contraindications for the use of nifedipine as a tocolytic?

Answer 4

 Cardiogenic shock
 Cardiac disease
 Hypotension
 Intrauterine infection
 Intrauterine death
 Antepartum haemorrhage
 Pre-eclampsia
 Use with betamimetics, such as Salbutamol
 Contra-indications to any suppression of labour
 Concurrent use of rifampicin

Question 5

What are the precautions for the use of nifedipine as a tocolytic?

Answer 5

congestive heart failure - may exacerbate
mag sulphate use - may induce hypotension
Enzyme producing epileptic medications - may increase metabolism of nifedipine

Question 6

What should be done Prior to commencement of Nifedipine tocolytic Regimen

Answer 6

IV access

Bloods - Us & Es, creatnine and LFTs

Question 7

What are the 2 negative predictors of premature labour within 7 days?

Answer 7

The absence of fetal fibronectin (fFN) in the cervical secretions is a very useful negative predictor of imminent birth (negative predictive value for birth within 7 days 97-98%).
- Like fFN, a cervical length is a good negative predictor, but not a good positive predictor i.e. greater than or equal to 30mm is highly reassuring

Question 8

What is the Admission and investigation for a women in suspected preterm labour?

Answer 8

History - ROM, contractions, APH, EDA by LMP and ultrasound.

Examination - temp, uterine tone and tenderness, amniotic fluid volume, fetal size and presentation

VE- Speculum - bacterial swabs, presentation of cervix, FFN, No dirty digits!

MSU - mid stream

Ultrasound - fetal presentation, gestation, fetal weight, fetal normality, possibility of amniocentesis, transvaginal for assessment of contractions

Electronic fetal heart monitoring (EFM) - if fetus is viable

Amniocentesis - to assess for sepsis/ lung maturity

On call paediatrician to be notified of preterm labour in labour and birth suite

Question 9

What are the indications for Fetal fibronectin (fFN) test?

Answer 9

• symptomatic preterm labour between 24 and 36 weeks of pregnancy
• intact membranes
• Less than 3cm cervical dilatation

Question 10

What are the contra-indications for Fetal fibronectin (fFN) test?

Answer 10

• ruptured membranes
• Cervical cerclage insitu
• Cervical dilation more than 3cm
• Presence of soaps, gels, lubricants or disinfectants
• bleeding
• recent intercourse although reading of less than 10ng/ml after intercourse is negative

Question 11

What is a positive fFN result and what may cause a false positive?

Answer 11

fFN < 50ng/mL

• Use of lubricant with speculum examination.
• Intravaginal disinfectants

Question 12

What is a negative fFN result and what may cause a false negative?

Answer 12

fFN > 50ng/mL

o Coitus
o Digital vaginal examination
o Transvaginal ultrasound
o Bleeding

Question 13

What are the two main stratergies to manage preterm labour

Answer 13

Tocolysis and steroids

Question 14

What would be the management of someone in preterm labour with a negative fFN and no evidence of cervical change.

Answer 14

• if contractions are infrequent/irregular discharge home with 7 day follow up and advise to return if anything changes
• if contractions are regular and painful admit to the ward for observation and consider Tocolysis and steroids

Question 15

What is the management in a woman that presents with suspected premature rupture of membranes?

Answer 15

• History of rupture- smell colour amount
• Obs TPR BP FHR movments
• Palpate - height, lie, presentation, uterine tenderness and irritibility
• If over 24 weeks CTG
• If contractons 1:10 notify obs
• Provide woman with Al-sense liner and encourage mobilisation for 5-10 mins
• If liner blue green confirmed
• Alternitively could perform amnisure test with dry speculum.
• If positive result - low vaginal swab and rectal swab, high vaginal swab if purulent discharge, FBP, CRP, etc
• Bethamethasone
• commenced on a ten-day course of erythromycin 250mg QID
• Obs 4 hourly
• Ultrasound for AFI

Question 16

Define pre-term premature rupture of membranes?

Answer 16

PPROM is defined as spontaneous rupture of the membranes before the onset of labour prior to 37 weeks gestation. It complicates 2 - 4% of all singleton and 7 - 20% of twin pregnancies and is associated with over 60% of preterm births.

Question 17

What is the history that should be taken from a woman presenting with PPROM

Answer 17

 Time of PPROM.
 Type and colour of fluid loss.
 Amount of fluid loss.
 Signs of infection including ‘offensive smelling’ vaginal discharge, uterine tenderness, maternal fever, and fetal tachycardia.

Assess for a differential diagnosis:
 Leakage of urine (incontinence)2.
 Physiological vaginal discharge2.
 Bacterial infection e.g. bacterial vaginosis2.
 Cervical mucous (show) which may be a sign of impending labour2

Question 18

What is the maternal education required around PPROM?

Answer 18

• personal hygiene - pad changes no tampons
• Awareness of colour changes of PV loss
• TEDS to prevent DVT regular movement
• Arrange Paed consultant review if under 32 weeks
• Discuss management of preterm birth - feeding, incubator CPAP
• Arrange tour of Neonatal Intensive Care
• Inform the woman about the Health Information Resource Services (HIRS).
• Advise women that sexual intercourse should be avoided with PPROM
• Have showers rather than baths, and avoid swimming.
• Notify and return to the hospital if any signs of threatened premature labour, vaginal bleeding, or abdominal pain / tenderness.