There are 4 maternity-led strategies that should be offered/considered dependent on gestation to reduce mortality and morbidity in cases of preterm labour and planned preterm birth. See below sections for detailed guidance on each. These form part of the Scottish patient Safety Programme (SPSP) perinatal optimisation package.

1. Delivery at unit with level 3 NICU service when appropriate.
2. Antenatal corticosteroids.
3. Magnesium sulphate.
4. Deferred cord clamping.

In addition:

Tocolysis may be considered to facilitate in-utero transfer and administration of steroids.

Intrapartum antibiotics for group B strep prophylaxis reduce the rate of neonatal sepsis.

Thermal care of the neonate.

Optimisation 1. Delivery unit

See GGC in utero transfer (IUT) guideline no 469

• Aim to transfer the following to a maternity unit with NICU level 3 care:  singleton pregnancies under 28 weeks, multiple pregnancies under 29 weeks, babies with an estimated fetal weight (EFW) <800g.

• The In Utero Coordination Service (formerly known as PAS) should be contacted on 03333 990 210.  MDT discussion from consultant obstetricians and neonatologists should follow re safety and feasibility of transfer.

• Delivery in a NICU significantly improves survival and neurodevelopmental outcomes and should be accommodated if safe to do so.

• Factors to consider when considering IUT:

  • Gestation
  • Maternal condition
  • Current fetal condition including background risk factors and fetal monitoring.
  • Active labour/progress of labour.
  • Neonatal and obstetric unit activity and cot/bed status.
  • Be aware that transfer takes time. It is appropriate to commence both steroids and magnesium prior to transfer. Magnesium bolus can be given +/- infusion can be started, discontinued for transfer and restarted in receiving hospital. This approach can ensure babies get the best chance of full optimisation.
  • Perform a pretransfer pause. See appendix for transfer form in GGC IUT guideline.
  • Prior to transfer, reassess the patient clinically to ensure remains appropriate for transfer. Ensure observations are up to date and this may also warrant repeat vaginal examination (digital vaginal examination (VE) or speculum) to assess for possible progress in labour if there has been delay since last assessment.

Optimisation 2. Antenatal corticosteroids

Antenatal corticosteroids reduce perinatal mortality and morbidity for premature babies.  

Administration:

Betamethasone: two doses of 12 mg IM given 24 hours apart (or 12 hours apart if delivery anticipated within the 24 hours)

Or Dexamethasone: Four doses of 6mg IM given at 12 hourly intervals

Maximal benefit occurs in pregnancies that deliver 24 hours after and up to 7 days after administration of the second dose of antenatal corticosteroids.

There is no/very limited benefit if birth occurs >7 days following steroid administration (RCOG 2022).

Maternal corticosteroid therapy has been shown to reduce the risk of neonatal death and morbidity even if delivery occurs within the first 24 hours. A steroid course should be commenced even if delivery is anticipated with 24 hours.

See Diabetes guidelines regarding use in diabetic pregnancies as steroids cause maternal hyperglycaemia. Women treated with insulin are likely to need additional insulin therapy.

There is no evidence of other significant maternal harm caused by steroid administration. Steroids do not increase maternal infection rate but may worsen already present systemic infection therefore caution and individualised plan should be used in this scenario.  

Recommendations per gestation 

There is some variation in national and international guidance regarding the use of steroids per gestation. Benefits and risks in late preterm birth remain controversial.

GGC recommendations for steroid administration per gestation

22+0- 23+6: individualised discussion. See also section on extreme preterm birth

Individualised discussion involving senior obstetrician, neonatologist and the pregnant person/parents. Steroids may be offered after individualised discussion and shared decision-making. There is evidence of benefit at extreme preterm gestation (RCOG, BAPM).

Babies born at this gestation have the highest risk of mortality and severe morbidity (BAPM). Discussion should be had regarding the decision for either survival focused care (active obstetric and neonatal management) or comfort focused care (palliative obstetric and neonatal management). This will take into account factors such as singleton or multiple pregnancy, fetal sex, EFW/growth restriction, location of birth. See section on extreme preterm gestation.

24+0- 33+6: Offer steroids

Offer steroids to all women in preterm labour or having a planned preterm birth.

34+0 – 36+6: Consider steroids

Consider steroids. This should involve shared decision-making with the birthing person. Risks and benefits of steroids at late preterm gestations should be discussed. Take into account other risk factors such as caesarean birth, known underlying neonatal conditions, fetal growth restriction.

Repeated course of steroids

 Repeat courses of steroids are not routinely recommended but may be considered in certain circumstances. This would be a consultant decision taking into account timing of steroids and likelihood of imminent birth.  There is poor evidence of benefit from steroids when birth is > 7 days from administration.

NICE (2022) and WHO advises to consider a single repeat course if <34+0, steroids >7 days ago and are at very high risk of giving birth in the next 48 hours.

GGC Recommendation:

Consider a second course (2 x 12mg betamethasone 12-24hours apart (WHO)) of steroids when:

• Previous course >7 days ago,
• Particularly in earlier gestations. Do not give from 34+0 onwards.
• Only if birth is clearly imminent (i.e. progressive cervical dilatation or decision has been made to deliver)
• Do not give more than 2 courses of steroids for preterm birth.
• This should be a consultant decision.

Optimisation 3. Magnesium sulphate for fetal neuroprotection

Preterm delivery is a known risk factor for cerebral palsy. Magnesium Sulphate reduces this risk.

Magnesium sulphate should be offered to all women <30 weeks’ gestation (individualised decision 22+0-23+6) where delivery is planned or expected within 24 hours.

Offer magnesium sulphate to those who are in established preterm labour of having planned preterm birth within 24 hours. Ideally it should be given in the 24 hours prior to birth for maximum efficacy.

Bolus +/- infusion can be commenced prior to in utero transfer, discontinued for transfer and restarted in receiving unit.

Guidance per gestation

22+0- 23+6:  Consider magnesium sulphate following individualised discussion involving senior obstetrician, neonatologist, and the birthing person/parents when a decision has been made to offer active/survival focused care.

24+0- 29+6:  Offer magnesium sulphate

30- 33+6 Do not routinely offer.  May occasionally be considered in certain circumstances

Administration and dosage of magnesium sulphate

Magnesium sulphate should be offered to all women < 30 weeks’ gestation where delivery is planned or expected within 24 hours.

A 4g bolus dose should be given followed by an infusion of 1g/hour until birth or for 24 hours whichever is sooner.

If magnesium sulphate use is for preterm optimisation only (i.e. not PET), discontinue at delivery.

For planned delivery commence infusion as close to 4 hours before delivery as practical. For unplanned situations, ideally at least 4 hours of magnesium should be given but treatment should not be withheld if delivery is anticipated before this.

If tocolysis has been commenced but onward progression of labour continues discontinue tocolysis and consider the use of Magnesium Sulphate.

Careful assessment of maternal BP should be observed if nifedipine has been given recently but there is some evidence that such practice does not compromise maternal safety (we commonly use both in severe PET). Contraindications to both drugs must be observed.

If there is maternal and/or fetal compromise delivery should not be delayed to allow administration of magnesium. Multiple pregnancies should receive the same dose and treatment. The resident anaesthetic and neonatal medical staff should be aware of the decision to give magnesium sulphate.

Contraindications: allergy, severe aortic stenosis, cardiogenic shock. Caution: oliguria, renal impairment: see below

The dosing and monitoring regime are the same as given in severe pre-eclampsia and eclampsia.

Loading Dose (by hand):                      

• 4 grams IV over 5 minutes
  (Add 4 grams (8 mls of 50%) Magnesium Sulphate to 12 mls Normal Saline)          

Maintenance Infusion Dose:

• IV infusion 1 gram Magnesium Sulphate per hour                 

Maintenance Infusion Preparation:

• 10 grams (20 mls of 50%) Magnesium Sulphate made up to 50 mls by adding to 30 mls normal saline in a 60 ml luer lock syringe
• Infusion rate is 1 gram (5 mls) per hour via an syringe driver

Infusion is maintained at 1 gram/hr for 24 hours provided:

• Respiratory rate > 14 per minute
• Urine output > 25mls/hour, and
• Patellar reflexes are present

Magnesium Sulphate – Patient Monitoring:

One to One care is required

Reflexes

• Patellar reflexes after completion of loading dose and hourly whilst on maintenance dose (use arm reflexes if functional regional anaesthesia).
• If reflexes are absent stop infusion until reflexes return and check Magnesium level.

Oxygen saturation/ respiratory rate

• Continuous O2 saturation should be assessed.
• Perform respiratory rate every 15 minutes
• If O2 saturation < 94% or respiratory rate < 14 / min, administer O2 (4 L/min via Hudson mask), stop Magnesium Sulphate infusion and call anaesthetist. Check Magnesium level. Consider antidote

Urine Output

Monitor hourly.

If >20 ml/h - continue Magnesium Sulphate infusion.

If 10 - 20 ml/h & creatinine <150mmol/l - continue as protocol and recheck Magnesium level every 2 hours.

If 10 - 20 ml/h & creatinine > 150mmol/l (or urea >10) - recheck Magnesium levels immediately and every 2 hours. Decrease infusion rate to 0.5gram/hour.

If < 10 ml/h - stop infusion and check Magnesium level.

Biochemical monitoring (magnesium levels): this is not routine. If required then see below

Therapeutic range is 2-4 mmol/l.

Low If < 2 mmol/l - Maintain infusion at current rate.  Recheck in 2 hours.

Therapeutic If 2 -3.5 mmol/l - Continue infusion at current rate. Recheck in 2 hours if clinical indication remains. 

High If  >3.5- 5 mmol/l - STOP INFUSION for 15 min and then recommence at half previous infusion rate and recheck in 1 hour.

Very High If > 5mmol/l - STOP INFUSION and consider antidote. See below for further details.

Magnesium Sulphate toxicity and management:

Optimisation 4. Deferred Cord clamping (DCC)/optimal cord management

See also GGC neonatal guideline Delayed Cord Clamping (DCC) WoS MCN, Obstetrics

DCC results in a significant (32%) reduction in mortality in preterm babies.

When survival focused care is being offered, all babies <34 weeks should receive deferred cord clamping for a minimum of 60 seconds.

Practicalities

• We now routinely offer DCC to all babies in our units, however the impact on preterm babies is significant and we should ensure preterm babies in particular receive this.
• When birth is expected or planned, there should be discussion with neonatal team regarding attendance. Initial stabilisation of the baby can be offered with the cord intact and may involve use of devices such as “LifeStart” to facilitate this. This may also involve placing the baby in plastic bag as part of thermal management.
• Neonatal attendance at safety briefs prior to planned preterm caesarean births is of benefit for planning of this and should be part of routine practice.
• Whenever possible timing of cord clamping should be guided by the neonatal team in conjunction with the obstetric team.
• Decision to perform earlier cord clamping due to concerns regarding the condition of the baby should be a shared decision with the neonatal team.
• take care to assess cord length to prevent disruption of cord from traction.
• Administration of active 3^rd stage drugs (oxytocin/syntometrine) should be administered as normal at normal time.
• DCC should be passive with the baby ideally at the level of the placenta or below. The cord should not be routinely milked. 

DCC special circumstances

• General anaesthesia is not a contraindication to DCC.
• Initial management of caesarean related traumatic bleeding may be able to be managed whilst the cord is intact. This is for a relatively short time and given DCC results in a significant reduction in neonatal mortality, every effort should be made to provide this. This may involve e.g. the use of Green Armitage clamps on bleeding vessels.
• If the placenta delivers with the baby ie en caul delivery, BAPM recommend that DCC can still continue for 60 seconds (the beneficial effects are not in relation to oxygenation from the placenta but in relation to blood volume) and the placenta can be held at a level above the baby.
• At caesarean birth for DCDA twins, if possible delivery of second twin should continue whilst dcc being performed for first twin.

Contraindications to DCC:

• The need for maternal resuscitation for massive, acute haemorrhage
• Ruptured vasa praevia, snapped cord or other trauma to the cord vessels which will result in haemorrhage from the baby,
• transection of placenta during caesarean.
• Hydrops
• abruption:
  Individualise. Limited safety evidence. BAPM recommends considering.
  
  Where the placenta is delivered at the same time as the baby, it could be held above the baby, with gentle application of pressure to the placenta, and then clamped at 60 seconds before the placenta is lowered. Consideration should be given however to the management of maternal haemorrhage during this time.

Individualised decision:

• FGR with abnormal umbilical artery Doppler.
• Monochorionicity
  BAPM suggests Monochorionicity alone is not necessarily a contraindication. There is some limited evidence showing the safety of its use. There remains some concern re the theoretical risk of acute transfusion between the babies during delayed clamping and many guidelines continue to advise against.
  
  If there is suspicion of twin to twin transfusion syndrome/TAPS DCC should definitely be avoided. DCC can be considered in pregnancies where TTTS has been successfully treated with Laser.

There is no clear evidence that tocolytic drugs improve neonatal outcomes and therefore it is reasonable not to use them.

Tocolysis can be considered <33+6 to allow administration of steroids and or transfer to an appropriate unit for neonatal care dependent on gestation.

Tocolytic drugs are contraindicated when delayed delivery may have adverse effects on maternal health or may keep the fetus in a potentially hostile environment. (E.g. known chorioamnionitis)

Contraindications include:

Following discussion with the on call obstetric consultant, if tocolysis is deemed necessary then the agent of choice is Nifedipine.

Dose: Nifedipine Retard 20 mg TID x 48 hrs.

Side effects: hypotension, tachycardia, headache, nausea, flushes

Contraindications: allergy, severe aortic stenosis, cardiogenic shock.

Caution:  concurrent administration of Magnesium Sulphate. May cause maternal hypotension.

If Tocolysis has been commenced but labour is progressing: Stop Nifedipine and start Magnesium Sulphate for fetal neuroprotection.

Maintenance of normothermia also forms part of the SPSP preterm perinatal package.

Please see GGC Thermal care of the neonate Guidance which includes sections on the preterm infant and preparation for birth.

Ensure room temperatures are appropriate

Consider delivery into plastic bag dependent on gestation and neonatal advice. This should routinely happen <32 weeks.

• Symptoms of preterm labour/history
• Diagnosis of established preterm labour
• Suspected/threatened preterm labour
• Adjuncts to the diagnosis of preterm labour
• Management when assessment is not in keeping with preterm labour/suspected preterm labour

Those with symptoms of preterm labour should be invited for assessment via maternity assessment.

Symptoms of preterm labour/history

It is important to note that symptoms and signs of preterm labour may be subtle and preterm labour should be considered in people with the below symptoms. Delay in diagnosis could lead to missed opportunities for perinatal optimisation interventions (steroids, magnesium, transfer) and timely counselling.

See also GGC Early signs and symptoms of preterm labour (1037)

Symptoms may include:

• Abdominal Cramps- with or without diarrhoea
• Backache- low, dull constant
• Contractions/ cramping/tightenings
• Vaginal Discharge (increase in the amount of discharge) or bleeding
• un-Easiness- feeling “not right”
• Fetal movements /urinary Frequency– changed
• Gush of fluid loss - preterm rupture of membranes
• Heaviness or pelvic pressure—the feeling that the baby is pushing down

Differential diagnosis

Have a low threshold for suspicion of preterm labour

Alternative diagnoses may include:

Assessment

This should involve:

• Detailed history
• Observations
• Maternal examination including abdominal palpation
• +/- sterile speculum +/- digital vaginal examination
• Fetal assessment (auscultation or CTG dependent on gestation and scenario)
• (+/- Actim Partus testing)
• (+/- cervical length assessment using transvaginal ultrasound)

History

• Establish patient’s background including risk factors for preterm labour including:
  Previous PPROM/preterm birth, uterine anomaly, LLETZ, full dilatation caesarean birth, Ashermans, smoking.
  Multiple pregnancy, PPROM or cervical suture in this pregnancy
• determine if any of above symptoms of preterm labour. If uterine activity/cramping enquire re frequency, duration, pattern.
• determine if any symptoms of infection
• enquire re urinary or gastrointestinal symptoms
• enquire re PV loss (bleeding, discharge, liquor)

Examination/initial Investigation

• Maternal observations
• Perform urinalysis
• Abdominal examination and palpation. Assess for uterine activity but also abdominal tenderness, peritonism, uterine tenderness as part of consideration of differential diagnoses
• Fetal heart rate assessment by doptone or CTG
• Sterile speculum examination to assess for cervical dilation + High vaginal swab
• If unable to assess cervical dilatation adequately, offer digital vaginal examination to assess cervical length, dilatation and effacement
• MSSU if suggestion of UTI
• Blood tests. FBC, CRP should be taken when preterm labour is diagnosed, along with group and save. FBC and CRP (along with others) may also be appropriate in the assessment of PTL and when considering alternative diagnoses.

Diagnosis of established preterm labour:  

If cervix is effaced and 2 or more cms dilated, treat as preterm labour.

Initial management:

• IV access, FBC, G+S, CRP
• Ultrasound for presentation
• MSSU, LVS if HVS not already taken
• admit to labour ward
• steroids based on above guidance
• MgSo4 based on above guidance
• in utero transfer is less likely to be appropriate if > 4cm with ongoing uterine activity but may occasionally be considered depending on gestation, dilatation, uterine activity, maternal and fetal assessment. Regular reassessment of the clinical situation should take place particularly prior to transfer.
• inform neonatal team. Ideally neonatal medical review and counselling for patient.
• inform consultant obstetrician as per Consultant attendance guidance.

Suspected/threatened preterm labour:

Symptoms of preterm labour where assessment confirms the possibility of preterm labour but rules out established labour. This could include regular palpable uterine activity, other strong features in history, patient at high risk of preterm labour or some cervical change but <2cm dilated.

Management of suspected preterm labour

• Consider use of Actim Partus (see below)
• Consider the use of cervical length ultrasound assessment.
• Admission for observation is likely to be appropriate if <30 weeks and should be considered in all patients with ongoing symptoms or signs of preterm labour.
• FBC, CRP, +/- consider G+S
• Ultrasound for presentation
• MSSU, LVS if HVS not taken
• consider in utero transfer
• Repeat cervical assessment in 2- 4 hours if ongoing symptoms.
• treat as preterm labour if cervical change (effacement/dilatation ≥ 2cm)

Adjuncts to the diagnosis of preterm labour

Fetal Fibronectin testing (NICE: 30+0 – 33+6 weeks’ gestation)

Hologic are discontinuing production of fibronectin testing kits nationally, therefore fFN testing has been removed from GGC Guidance.

Actim Partus testing

Actim Partus involves a cervical swab sample.

The rapid test is based on highly specific monoclonal antibodies that bind to the phosphorylated form of insulin-like growth factor binding protein-1 (phIGFBP-1). PhIGFBP-1 is produced in the decidua, but leaks into the cervix when the decidua and chorion detach.

A negative Actim Partus result indicates a very low chance of labour in the next 1-2 weeks.

Recommendation for use of Actim Partus

< 30 weeks: base management on history and examination and manage as established/suspected preterm labour as above.

30+0 -36+6 weeks

Consider use in women with symptoms of preterm labour without cervical dilatation and effacement. Do not use in PPROM or PV bleeding.

Negative result

As Actim Partus has a high negative predictive value, if no ongoing regular uterine activity or other clinical concerns consider discharging patient with advice to return if ongoing or new symptoms of preterm labour.

In some situations where there is a significantly high risk of preterm labour or the patient may find it difficult to return quickly, admission for observation may still be considered but perinatal optimisation/transfer does not need to be started.

Positive Actim Partus result

Be aware that Actim Partus has a lower and highly variable positive predictive value in studies. This means that a large number of women with positive result will not go on to labour.

• admit for observation
• Transvaginal ultrasound could be added to assessment and if 15mm or less treat as preterm labour. See section below
• Do not give steroids/magnesium/ arrange in utero transfer based on positive result alone.
• If ongoing uterine activity, repeat clinical assessment of patient in 2- 4hours including repeat cervical assessment (speculum +/- digital VE).
• If cervical change: steroids +/- Magnesium sulphate/transfer to LW/ in utero transfer dependent on change/dilatation

Performing Actim Partus testing

Collect a cervical secretion sample using a speculum. Lubrication gel CAN be used.

Cervical swab. Hold the swab in for 10-15 seconds.

Extract the specimen

Insert the swab into the extraction buffer. Swirl around vigorously for 10-15 seconds, and discard the swab.

Activate the test

Insert the yellow dip area into the extracted specimen.

Wait until you see the liquid front enter the result area.

Remove the dipstick from the buffer and place it in a horizontal position.

Interpret the test result

• A positive result can be read as soon as it becomes visible.
  Two blue lines (including faint) = positive
• A negative result should be confirmed at 5 minutes.
  One blue line = preterm or imminent delivery is highly unlikely
• No lines= invalid

Actim Partus can be used:

• With lubricating gel
• Following intercourse

Contraindications:

• Ruptured membranes
• Vaginal bleeding. (manufacturer advises against use in moderate/severe and to only perform when no blood present)

Cervical length assessment by transvaginal ultrasound

Cervical length scanning (transvaginal scan by appropriately trained clinician) can be considered between 30+0 - 33+6 weeks in cases of suspected preterm labour. The guidance and evidence for this is not entirely clear. A cervical length < 15mm should be treated as preterm labour.

Management when assessment is not in keeping with preterm labour/suspected preterm labour

Discharge may be appropriate where:

• History and examination findings are not in keeping with preterm labour and are normal.
• There is no palpable uterine activity
• The cervix is not effaced and is <2cm dilated
• Actim Partus testing is negative (if used as per above guidance)
• Observations are normal and clinical assessment is otherwise reassuring
• Differential diagnoses have been considered
• Consideration has been given to the woman’s social circumstances/ability to recognise ongoing symptoms and return.

Advice should be given to return if ongoing or new symptoms.

• Principles (personalise depending on gestation)
• Maternal monitoring
• Fetal monitoring in preterm labour
• Fetal blood sampling (FBS)
• Use of Fetal scalp electrode (FSE)
• Progression in labour
• Antibiotics in labour
• Mode of birth
• Extreme preterm birth 22+0- 26+6

Principles (personalise depending on gestation):

• Inform obstetric consultant if <30 weeks per GGC consultant attendance in labour ward
• Discuss with senior neonatal medical staff and patient should ideally have a neonatal consultation
• Update neonatal team re progress and to ensure able to be present prior to birth
• Provide one to one midwifery care
• Provide perinatal optimisation with steroids, magnesium , deferred cord clamping at birth
• Recommend intrapartum antibiotic prophylaxis
• Ensure room temperature appropriate
• Check Resuscitaire
• Provide regular maternal monitoring. Be alert for developing chorioamnionitis.
• Consider method of fetal monitoring.
• Aim to provide deferred cord clamping in majority of situations.

The on call obstetric consultant should be notified when a patient is admitted in preterm labour <30 weeks. They should be in attendance for all caesarean births <30 weeks.

They should attend in person or should be immediately available (i.e. present on labour ward) for caesarean births 30-34 weeks gestation, unless the trainee on duty is an ST7 and has been assessed by the unit and signed off, by OSATS where these are available, as competent.

Maternal monitoring

Perform baseline observations of HR, BP, temperature, RR.

Take bloods for FBC, CRP, G+S, MSSU and LVS if not already taken.

Regularly assess maternal observations and uterine activity. This should be performed as per standard care in the first and second stage of labour.

Fetal monitoring in preterm labour

Options will be continuous CTG, intermittent auscultation and no fetal monitoring/occasional auscultation/ultrasound to assess presence or absence of fetal heart activity (e.g. < 24 weeks gestation).

There is an absence of evidence to show that CTG improves outcomes in preterm labour vs intermittent auscultation. There is limited evidence regarding features of hypoxia and acidosis in preterm babies although NICE states that available evidence is broadly consistent with that for babies at term. A normal CTG is reassuring but abnormal does not necessarily indicate hypoxia or acidosis.

NICE recommends offering those in established preterm labour the option of continuous CTG monitoring or intermittent auscultation.

BAPM recommend continuous CTG from 26+0.

In practice it is reasonable to offer CTG to those ≥ 26+0 weeks gestation.

Fetal monitoring <26+0 weeks gestation

Decisions around fetal monitoring should involve consultant obstetrician input and will be an individualised discussion and decision with the patient.  Consideration should be given to:

• Difficulties of continuous CTG monitoring and interpretation at this gestation.
• Whether or not it would be appropriate to intervene (with caesarean birth) if CTG or intermittent auscultation was abnormal.
• In most cases intermittent auscultation will be used.

Less than 24 weeks gestation: The option of fetal monitoring for viability but not intervention during labour by intermittent auscultation is a suitable option. Intermittent auscultation may help guide the neonatal team’s resuscitation.

The option of no fetal monitoring is an appropriate option as caesarean birth in the case of abnormalities has significant maternal risk and babies at this gestation have the highest mortality and morbidity rates.

Fetal blood sampling (FBS)

Consideration should be given to the risks and benefits of FBS in all labours per NICE guideline (NG229) Fetal monitoring in labour 

< 34+0 weeks: FBS should not be used

34+0 -36+6: FBS may be occasionally considered in certain circumstances with consultant discussion. Consideration should be given to potential impact of delay in birth.

Use of Fetal scalp electrode (FSE)

FSE should not be routinely used in preterm labour.

<34 weeks: FSE should usually be avoided. It may be considered with consultant discussion if unable to monitor and benefits felt to outweigh risks. Alternatives of birth, intermittent ultrasound and no monitoring (at extreme premature gestations) should be discussed

34+0- 36+6 weeks: FSE may be considered if unable to monitor by alternative methods.

Progression in labour

Preterm labour may progress more slowly than term labour. This may allow time for administration of steroids/magnesium.

Intervention to augment labour would not normally be recommended unless there are maternal or fetal concerns. This should involve discussion with the on call obstetric consultant.

The neonatal team should be contacted when the patient is in the second stage.

Antibiotics in labour

Offer all women in establish preterm labour antibiotics for group B streptococcus prophylaxis. Follow the GGC guideline Group B Streptococcal Prophylaxis (570)

Be vigilant for signs and symptoms of chorioamnionitis and if suspected change the antibiotic regime in keeping with the GGC antibiotic policy in obstetric patients guideline.

Mode of birth

There are no known benefits or harms to the baby from caesarean birth in preterm labour.

Caesarean birth should be considered for breech presentation between 26+0- 36+6. There is an increased risk of head entrapment during vaginal birth particularly at earlier gestations.

Caesarean birth may be the most appropriate mode of birth in planned preterm birth particularly < 34 weeks e.g. severe growth restriction/pre-eclampsia or where there is maternal or fetal comprise in labour.

Extreme preterm caesarean birth can be challenging where the possibility of a difficult delivery of the baby remains. There is an increased risk of non-lower segment caesarean with potential increased risk of haemorrhage, extensions, visceral injury and the implications of a non-lower segment caesarean for future deliveries (increased uterine rupture and placenta accreta spectrum). Risks and benefits should be discussed with the woman.

Extreme preterm birth 22+0- 26+6

Babies born at these gestations have the highest risk of mortality and morbidity. The British association of perinatal medicine (BAPM) have published guidance on the management of this situation.

When preterm birth is planned or women present in preterm labour they should have a consultation with senior neonatologist and obstetrician. This should involve discussion around outcomes including mortality and severe morbidity. Clearly these consultations are difficult and emotive, and therefore senior MDT involvement is crucial.

Discussion should be had around management options of survival focused care (active obstetric and neonatal care) and comfort focused care (palliative obstetric and neonatal care). This will involve assessment of risk factors including gestation, fetal sex, single/multiple pregnancy, fetal growth restriction, congenital anomaly, clinical factors e.g. extreme PPROM, chorioamnionitis. This is particularly relevant between 22+0 and 23+6 weeks gestation.

After discussion and risk assessment, the majority of babies 24+0 and over are likely to be offered survival focused care, along with some 23+0-23+6 with favourable risk factors.

Those at 22+0-22+6 with unfavourable risk factors have a >90% chance of dying. Those that survive have a 1:3 risk of surviving with severe impairment (severe cognitive impairment, severe cerebral palsy, blindness or profound hearing impairment) (BAPM) and comfort focused care may be the most appropriate option. Babies 22+0-22+6 with favourable risk factors are likely to have 50-90% chance of dying (BAPM). Discussion and shared decision-making is needed regarding the most appropriate management plan. In some cases there will be a shared decision to offer survival focused care.

Survival focused /active care

When a shared decision has been made for survival focused care, this should involve

• Transfer to a unit with NICU capacity
• Maternal corticosteroids
• Consideration of tocolysis to allow the above
• Magnesium sulphate for fetal neuroprotection
• Delayed cord clamping for a minimum of 60 seconds
• Consideration and discussion about the most appropriate mode of fetal monitoring and delivery (see sections above on fetal monitoring and mode of birth)
• Neonatal team attendance at delivery

Comfort focused /palliative care

This should be person centred care. Obstetric intervention would not be offered in the fetal interest.

Steroids/tocolysis/magnesium/delayed cord clamping are not recommended.

Fetal monitoring could be none or occasional assessment for presence/absence of fetal heart rate activity to aid patient expectations about the baby’s condition at birth. Frequency should be individualised.

Neonatal attendance at delivery may be of benefit to provide brief assessment of the baby and support staff and family. Babies born <24 weeks, receiving comfort care may live for an average of 1 hour with a range of few minutes to several hours. Parents should have the opportunity to hold and spend time with their baby during this time.

It is unlikely, however, if a baby was born in much better condition than expected, it would be appropriate to ask for senior neonatology review.

Overall outcomes at extreme preterm gestations

The 2019 published BAPM guidance includes overall outcomes using data from MBRRACE-UK 2016, along with cohort studies from USA, Sweden and Germany:

Note this guidance is currently being revised to include most recent data but is not yet published.

• Definition and background
• Diagnosis of PPROM
• Management if PPROM confirmed
• During admission
• Timing of birth if no preterm labour
• Outpatient Management of PPROM
• Evidence regarding outcomes in extreme PPROM

Definition and background

Rupture of membranes prior to 37+0 with no evidence of labour.

3% pregnancies are affected

Occurs in 30-40% preterm births

Complications:

Neonatal morbidity and mortality from prematurity, pulmonary hypoplasia, sepsis, and cord prolapse. Maternal sepsis (chorioamnionitis), abruption.

Diagnosis of PPROM

• History and examination including observations, abdominal palpation, and fetal heart rate assessment (CTG from 26+0 weeks).
• Perform sterile speculum examination and high vaginal swab. Consider performing after the mother has adopted the left lateral position for 20 -30 minutes (limited evidence). If a pool of liquor is seen diagnose PPROM.
• HVS may grow group B streptococcus (GBS) colonisation which is relevant to recommendations re timing of birth. In the absence of PPROM it may point to other causes of vaginal discharge (e.g. candida, bacterial vaginosis)
• Based on clinical evaluation, the diagnosis of PPROM can be equivocal in 10–20% of cases. When a pool of amniotic fluid is not clearly observed, consideration should be given to testing for insulin-like growth factor binding protein-1 (IGFBP1) (Actim PROM/ ROM plus) or placental alpha microglobulin-1 (PAMG-1) (Amnisure) if these tests are available (NICE guidance 25).
• Actim PROM test detects IGFBP-1: sensitivity 97%, specificity 97%. Results are not affected by semen, blood, urine or infection. ROM plus also tests IGFBP-1 and AFP: sensitivity 92-99%, specificity 90-99%.
• Amnisure detects PAMG-1: sensitivity 99%, specificity 98%. AmniSure can be used in the presence of semen, minimal amounts of blood, vaginal infection, after intercourse, after a vaginal examination, and in the presence of a minimal amount of water-based lubricant. DO NOT USE with active vaginal bleeding.
• If the results of the IGFBP1 or PAMG-1 test are negative and no amniotic fluid is observed, do not offer antibiotics and explain PPROM is unlikely but that the woman should return for re-assessment if symptoms persist.
• If results are positive, NICE and RCOG recommendation is not to use the test results alone to decide what care to offer the woman, but also to take into account her clinical condition, medical and pregnancy history and gestational age, and either offer care consistent with PPROM or re-evaluate at a later stage.
• A sensible approach would be if history is consistent with PPROM or the woman is at high risk of preterm labour/PPROM and biomarker testing is positive treat as PPROM in first instance. It may be that in the longer term the ongoing clinical picture does not continue to suggest PPROM and consideration should be given to altering diagnosis.

Management if PPROM confirmed

• Obtain MSSU, LVS if HVS was not taken at time of speculum.
• Do not routinely perform digital examination of cervix. Assess if there is cervical dilation during speculum examination. Digital examination should be considered if unable to visualise a long closed cervix (as this may be due to cervical dilatation) use sterile pack and gloves.
• Take blood tests for WCC (FBC) and CRP.
• There is a high risk of preterm labour in the next 48 hours. Recommend admission for observation for 48 hours.
• Offer steroids dependent on gestation, see below.
• Discuss admission with neonatal staff. Ideally women should have the opportunity for neonatal counselling regarding expectations should their baby deliver.
• In utero transfer should be considered dependent on gestation/known underlying fetal issues.
• Medical review if suggestion of preterm labour. Aim for timely diagnosis to allow transfer to labour ward, magnesium sulphate if <30 weeks gestation, neonatal review and neonatal attendance at delivery
• Perform bedside ultrasound scan for presentation (>22 weeks)
• There is no evidence of benefit from the use of tocolytics following preterm premature rupture of membranes, therefore withhold.
• If there is no evidence of chorioamnionitis, commence antibiotics.
  • Oral Erythromycin 250mg QDS for 10 days, or until labour is established (whichever is sooner).
  • [Antibiotic treatment following PPROM is effective at prolonging pregnancy and reducing maternal morbidity. There is however, no statistically proven benefit that their use improves neonatal morbidity or mortality in the long term.]
  • NICE recommends an oral penicillin if the woman is allergic to erythromycin

Subsequent management will also depend on gestational age:

1. <22+0 weeks

• • Arrange formal ultrasound to assess amniotic fluid volume and fetus. Doppler auscultation to confirm FH should be performed if not already.
  • Consultant obstetrician review and discussion regarding maternal and fetal outcomes. The options of conservative management or termination of pregnancy should be discussed.
  • See evidence summary box below
  • Ongoing management will be individualised
  • There is no definitive guidance as to when steroids should be administered if continuing pregnancy. This should be shared decision making including consultant obstetrician.
  • Options are:
  • Planned course at 23/24 weeks (22 weeks could also be considered) given high risk of preterm labour and risk of perinatal mortality and morbidity. However if then labours/births >7 days later there is no ongoing benefit of steroids and consideration would have to be given to a second course.
  • Delay steroids until clinical picture changes i.e. planned delivery or signs of preterm labour. This does have the risk of missing the opportunity for steroids should labour happen rapidly.

2. 22+0 – 23+6 weeks

• • Consultant obstetrician review
  • Discussion with neonatal team.
  • Arrange formal ultrasound for fetal growth and wellbeing.
  • Consider steroids

Discuss with the woman and the multidisciplinary team the use of maternal corticosteroids in the context of her individual circumstances.

See below re evidence of outcomes <22+6. 22+0-23+6 has been included for consideration of steroids in this guideline to align with BAPM care in extreme preterm birth when steroids may be considered from 22+0.

3. 24+0 – 37 weeks

• • Recommend a course of steroids if 24+0 – 33+6 weeks gestation.
  • If 34+0 – 36+6 weeks, discuss the risks and benefits of antenatal steroids at late preterm gestation.
  • Arrange ultrasound for growth, LV and umbilical artery Doppler.
  • Discuss with neonatal team

If there is evidence of infection or fetal compromise seek senior obstetric opinion and consider delivery.

In cases of suspected chorioamnionitis:

• Sepsis 6 bundle.
• Commence intravenous antibiotics in accordance with Antibiotic Policy for Obstetric Patients.
• Delivery will need to be planned.
• Mode of birth will depend on gestation, presentation, obstetric history, if in active labour, and maternal wishes. For pregnancies at the limits of viability there should be shared decision making regarding survival or comfort focused care for the fetus and obstetric intervention planned as appropriate.

During admission

• Regular maternal observations 4 hourly.
• Fetal monitoring method and frequency will depend on gestation.
• Medical review if suggestion preterm labour, infection or new clinical concerns. Aim for timely diagnosis to allow transfer to labour ward, magnesium sulphate if <30 weeks gestation, neonatal review and neonatal attendance at delivery.

If preterm labour occurs: treat as per preterm labour guidance. 

If there is no evidence of infection or fetal compromise and preterm labour does not develop after 48 hours:

Assess for discharge home

Arrange follow-up through Daycare and own consultant ANC. See below.

Timing of birth if no preterm labour

Timing of birth is should be discussed with the woman and usually decision made through own ANC/with consultant involvement.

 In women with PPROM and no contraindication to continuing the pregnancy birth should be planned at 37 weeks gestation. Intrapartum GBS prophylaxis should be offered irrespective of GBS status (RCOG GBS prevention).

If GBS present.

For those at more than 34+0 weeks gestation it may be beneficial to expedite delivery if a woman is a known GBS carrier.

For those with evidence of GBS colonisation in the current pregnancy or in previous pregnancies, the perinatal risks associated with preterm delivery at less than 34+0 weeks of gestation are likely to outweigh the risk of perinatal infection.

Intrapartum GBS antibiotic prophylaxis should be offered in labour.

Outpatient Management of PPROM

(After a period of minimum 48 hours as an inpatient)

Prior to discharge, women should be advised of the signs and symptoms of chorioamnionitis and under what circumstances they should seek specialist advice. Give them the patient information leaflet.

The following women may not be suitable for outpatient management:

Non-cephalic presentation

Living somewhere far from the unit

SNIPS issues that may prevent compliance

Difficulties with transportation

Woman should be reviewed twice per week in Day Care. The following should be reviewed:

• Well-being of woman, colour of liquor, any pain, fetal movements
• Checks observations, including temperature (if HR >100bpm, temperature < 36°c or > 38°c, RR>20 or O2 saturation <94% on/air then registrar review required).
• Examine abdomen
• Check WCC/CRP
• Check fetal heart (110-160bpm) – if any concerns and ≥26 +0 weeks, commence CTG
• Perform fortnightly ultrasound scans for growth, LV and umbilical Doppler (unless concerns prompt more frequent monitoring)
• CTG monitoring is not routinely required unless there are concerns regarding fetal movement, maternal wellbeing, infection, uterine activity, fetal growth or umbilical artery Doppler.
• Ensure follow up is also in place with woman’s consultant (likely via antenatal clinic) for consultant oversight and delivery planning.
• If there are concerns regarding the above or there is suspicion of chorioamnionitis, then senior obstetric opinion should be sought

Download poster as pdf

Steroids

Betamethasone: two doses of 12 mg IM given 24 hours apart (or 12 hours apart if delivery anticipated within the 24 hours)

or Dexamethasone: Four doses of 6mg IM given at 12 hourly intervals

22+0- 23+6: Consider Individualised discussion. Would usually be offered if planning survival focused care.

24+0- 33+6: Offer steroids

34+0 – 36+6: Consider steroids.  Individualised discussion

Magnesium Sulphate

4g bolus dose should be given followed by an infusion of 1g/hour until birth or for 24 hours whichever is sooner.

22+0- 23+6:  Consider magnesium sulphate. Would usually offer when a decision has been made to offer active/survival focused care

24+0- 29+6:  Offer magnesium sulphate

30- 33+6 Do not routinely offer.  May occasionally be considered in certain circumstances

Maternal monitoring

• Perform baseline observations of HR, BP, temperature, RR.
• Take bloods for FBC, CRP, G+S, MSSU and LVS if not already taken.
• Regularly assess maternal observations and uterine activity per first and second stage normal guidance.

Fetal monitoring

≥ 26 weeks

Offer continuous CTG

<26+0 weeks

Individualised discussion and decision with the patient.  In most cases intermittent auscultation will be used.

Less than 24 weeks gestation:

Intermittent auscultation/ no monitoring/ occasional assessment with IA or USS to confirm presence/absence FH

Fetal blood sampling (FBS)

< 34+0 weeks: FBS should not be used

34+0 -36+6: FBS may be occasionally considered in certain circumstances with consultant discussion. Consideration should be given to potential impact of delay in birth.

Use of Fetal scalp electrode (FSE)

Should not be used routinely

<34 weeks: FSE should usually be avoided. 

34+0- 36+6 weeks: FSE may be considered if unable to monitor by alternative methods.

Progression in labour

• Intervention to augment labour would not normally be recommended unless there are maternal or fetal concerns. This should involve discussion with the on call obstetric consultant.
• The neonatal team should be contacted when the patient is in the second stage.

Antibiotics in labour

• Offer all women in establish preterm labour antibiotics for group B streptococcus prophylaxis. Follow the GGC guideline Group B Streptococcal Prophylaxis (570)
• Be vigilant for signs and symptoms of chorioamnionitis. Change antibiotic regime per GGC antibiotic guidance if suspected. Antibiotic Policy, Obstetric patients, treatment (320)

Mode of birth

• Individualised.
• Consider caesarean birth for breech presentation between 26+0- 36+6.
• Caesarean birth may be the most appropriate mode of birth in planned preterm birth particularly < 34 weeks or where there is maternal or fetal comprise in labour.

Preterm Caesarean birth

• Consultant presence < 30 weeks.  Should attend in person or should be immediately available (i.e. present on labour ward) for caesarean births 30-34 weeks gestation unless ST7 and competent.
• Ensure PPH risk assessment performed for planning of 3^rd stage.
• Aim to have neonatal team attendance at pre-operative brief
• Neonatal team opportunity to discuss any management plan during pause in theatre
• Ensure theatre temperature appropriate
• Resuscitaire on and checked
• LifeStart may be used. MDT planning re positioning
• MDT discussion re cord management, aiming differed cord clamping in most situations
• Discussion re placing baby into plastic bag dependent on gestation
• Increased risk of haemorrhage, extensions, visceral injury and non-lower uterine segment caesarean

Management of suspected preterm labour

• Consider use of Actim Partus (see flow chart)
• Consider the use of cervical length ultrasound assessment.
• Admission for observation is likely to be appropriate if <30 weeks and should be considered in all patients with ongoing symptoms or signs of preterm labour.
• FBC, CRP, +/- consider G+S
• Ultrasound for presentation
• MSSU, LVS if HVS not taken
• Consider in utero transfer
• Repeat cervical assessment in 2- 4 hours if ongoing symptoms.

Treat as preterm labour if cervical change (effacement/dilatation ≥ 2cm)

Assessment is not in keeping with preterm labour/suspected preterm labour

Discharge may be appropriate where:

• History and examination findings are not in keeping with preterm labour and are normal.
• There is no palpable uterine activity
• The cervix is not effaced and is <2cm dilated
• Actim Partus testing is negative (if used as per below guidance)
• Observations are normal and clinical assessment is otherwise reassuring
• Differential diagnoses have been considered
• Consideration has been given to the woman’s social circumstances/ability to recognise ongoing symptoms and return.

Advice should be given to return if ongoing or new symptoms.

Cervical length assessment by transvaginal ultrasound

• Cervical length scanning can be considered between 30+0 - 33+6 weeks in cases of suspected preterm labour.
• A cervical length < 15mm should be treated as preterm labour.