Preterm labour

Labour (regular contractions) before 37 weeks pregnant

  • Be aware
    • Birth may be difficult or happen very fast
    • Membranes and amniotic fluid may be infected (intrauterine infection)
    • Baby may be breech or other abnormal presentation
    • Baby may have breathing problems and/or low BGL when born

Do first — if birth about to happen

  • Urgent medical consult  — don’t leave the woman alone
    • Get midwife/doctor/obstetrician on speaker phone if none at the clinic 
    • Arrange to send to hospital if there is time
  • See — Getting ready to birth baby and Newborn resuscitation
  • If baby’s bottom or foot coming first — see Breech birth

Check notes for

  • Cerclage (cervical stitch)
  • Expected date of birth (current gestation)
  • Obstetric and medical history including medications
  • Date of most recent previous pregnancy

Ask

  • Vaginal discharge or bleeding — currently or during pregnancy
  • Any fluid loss — using pad or pants wet, how long, colour, quantity
  • Baby movements
  • Describe abdominal pain
  • Any urine problems — burning, passing urine often

Check

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • Before sending to toilet check
    • Pad or pants for vaginal fluid loss — quantity, color, blood
    • Vulva for cord prolapse. If cord seen — see Cord prolapse
  • U/A, send urine for MC&S +/- PCR — see Urine infections in pregnancy
  • Check pads after 10–15 minutes for any fluid leakage

Do

Sterile speculum exam (if skilled) after woman has been lying down for 10 minutes (not flat on back) — use sterile gloves and sterile speculum

  • Wash vulva with sterile normal saline. Do not use lubricant
  • Gently put in sterile speculum and look for
    • Pooling of fluid at back of vagina
    • Ulcers on inside or outside of vagina — may be herpes
    • Cervical dilatation
    • Membranes, cord, hair or other part of baby in cervix. If cord seen — see cord prolapse straight away
    • Discharge from cervix
  • Ask woman to cough or perform Valsalva manoeuvre — look for fluid coming out of cervix
    • If fluid present — do test (eg AmniSure) for amniotic fluid to confirm ruptured membranes, if available 
    • Take high vaginal swabs for MC&S, and endocervical swabs for MC&S and gonorrhoea, chlamydia, trichomonas NAAT
  • If not able to do speculum exam — take low vaginal swabs for MC&S and gonorrhoea, chlamydia, trichomonas NAAT

If woman bleeding — see Bleeding in pregnancy

  • Do not do vaginal examination
  • Medical consult —Doctor should talk with obstetrician about
    • Sending to hospital
    • Stopping labour
    • Antibiotics — may need treatment for GBS or intra-uterine infection
    • Pain relief
    • Magnesium sulphate if gestational age 24–33 weeks and birth imminent within 24 hours — obstetrician to advise on dosing regime
    • If less than 35 weeks pregnant — help mature baby’s lungs by giving betamethasone ​IM — 11.4mg — 2 doses 24 hours apart OR dexamethasone IM — 6mg — 4 doses 12 hours apart
  • See — Labour and birth
  • If contractions stop and does not progress to birth AND the woman remains in community — make sure clear management plan is provided by obstetrician for the rest of the pregnancy

Preterm labour with cerclage (cervical stitch)

If woman with suture or tape around cervix has PROM or preterm labour in community

  • Urgent medical/obstetrician consult about sending to hospital and immediate management
  • Do not remove suture or tape unless advised to by doctor
    • Only need to remove if woman is in established labour and will give birth before she can be sent to hospital
    • If doctor not in community — they need to stay on phone and talk you through the procedure

Stopping labour (tocolysis)

  • Tocolysis is the use of medicines to stop labour — may not work if labour is advanced
  • Check medical history especially for RHD, thyroid problems, diabetes, kidney disease, high BP, asthma

Do not

  • Do not use controlled-release nifedipine tablet (SR, CR, OROS)

Do first

  • Always do medical consult before starting treatment
    • Decide whether to stop labour and which medicine to use
    • Doctor arranging evacuation needs to talk with obstetrician at receiving hospital

Nifedipine — Immediate Release tablets

  • Nifedipine comes in a number of different formulations
  • Generally nifedipine is very well tolerated. Side effects can include headache, fast pulse, flushing
  • Medical consult before using nifedipine for woman with significant heart disease — RHD is common in Aboriginal communities
  • Do not use controlled-release tablets (CR, OROS) — only Immediate Release (IR) tablets can be used for stopping labour
  • Immediate Release tablets may only be available through the Special Access Scheme. If nifedipine IR tablets are not available — contact obstetrician OR pharmacist for access and guidance

Check

  • Before giving nifedipine IR — monitor contractions — how often they are felt, how long they last, how strong
  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • Repeat REWS and contractions observations every 15 minutes — see Labour and birth

Do

  • POC Test — Hb
  • Put in IV cannula — largest possible, insert 2 if time
    • Give normal saline 1L — 500mL as quickly as possible THEN 125mL/hour
  • Give nifedipine IR oral — 20mg/dose every 30 minutes for up to 3 doses. Total 60mg
    • Crush or chew first 2 doses to make it work faster
    • If woman vomits in first hour — medical consult
    • If contractions persist 30 minutes after first dose — give second dose AND if contractions persist after 60 minutes — give third dose
  • If contractions still persist — give further nifedipine IR — 20mg/dose every 3–6 hours up to 48 hours. Maximum dose — 160mg in 24 hours
    • If systolic BP less than 90mmHg or short of breath — medical consult — may need to stop nifedipine
  • If contractions do not stop — doctor may suggest different treatment
  • If high dose of nifedipine given and prophylaxis needed to prevent fitting - only give magnesium sulfate as maintenance infusion. Do not give usual loading dose 
  • High dose nifedipine and high dose magnesium sulfate together can interact and cause serious low BP and/or breathing difficulties

Supporting resources