Preterm labor is defined as the

onset of labor (regular uterine

contractions associated with
cervical changes) occurring after
24 weeks and before 37
completed weeks of gestation.

In Jordan, accurate statistics

regarding the incidence of
preterm labor and its impact on
maternal and fetal morbidity and
mortality are lacking.

Worldwide, preterm labor occurs in 68% of pregnancies; preterm labor with

intact membranes accounts for 30-40%
of preterm
Labor
Preterm birth accounts for 70% of cases
of neonatal morbidity and mortality.

There are three major etiological factors

that contribute to preterm labor:
Preterm pre-labor rupture of
membranes (PPROM)
Spontaneous preterm labor in
pregnancies with intact membranes
Complications of pregnancy that
severely jeopardize fetal and
sometimes maternal health and
mandate delivery

Previous preterm labor, the recurrence risk of

preterm labor varies from 15% to 40%
after one prior preterm birth and significantly
increases with two or more preterm labors.
Uterine overdistension, e.g., multiple
pregnancy, hydramnios
Vaginal infection, bacterial vaginosis has been
shown to be associated with preterm labor.
In recent years, the most popular theory for
one cause of preterm labor has been
intrauterine infection.

Uterine abnormalities (septum, fibroid,

etc.)
History of incompetence of the cervix
Urinary tract infections
Poor nutrition, smoking and poor
weight gain during pregnancy
Young maternal age

History taking
Follow the history taking in the booking
procedure in the Antenatal Care
chapter and keep in mind the following
important data:

Date of the last menstrual period

History of previous pregnancy with
occurrence of preterm labor
History of risk factors, e.g., multiple
pregnancy
Warning symptoms (vaginal bleeding,
ROM)
History suggestive of vaginal infection:
vaginal discharge, dysuria

* Follow the steps of physical

examination as mentioned in the
Antenatal Care chapter, keeping in
mind the following signs:
- Abdominal examination
Uterine contractions, frequency and
duration
Palpate renal angle for tenderness

Perform a sterile vaginal examination

provided there are no contraindications
(e.g.,bleeding) to assess:
Cervical effacement and dilation
Station and nature of the presenting
part

Documented uterine contractions, 4

per 20 minutes
Documented cervical changes: cervical
effacement or cervical dilatation of 2
cm or more

* Laboratory investigations
CBC
ABO grouping and Rh type
Urine analysis and culture
Swab of the lower vagina for culture

- Ultrasound
Asses fetal gestational age and weight
Document presentation
Assess amniotic fluid
Assess placenta site and grade
Assess cervical length
Rule out the presence of any
congenital malformations

Once the diagnosis has been

made, the clinician must identify
women who need delivery and
women who need tocolysis and
steroids to enhance lung maturity

Cervix is dilated 4 cm.

Membranes are ruptured.
The woman has an acute medical or
surgical condition such as
thyrotoxicosis, heart disease or PIH.
The woman has a temperature 38C
or clinical evidence of chorioamnionitis.
Fetal demise

Fetal congenital anomalies

incompatible with life
Severe fetal distress
Severe IUGR
Bleeding suggestive of abruptio
placentae
Severe pre-eclampsia

Membranes are intact, AND

Gestational age is < 34 weeks, AND
There is no overt maternal or fetal
infection, AND
Cervix is dilated < 4 cm, AND
There is no evidence of placental
insufficiency or maternal disease to
justify delivery.

* Prophylactic measures
Identify women at risk for preterm labor:
Treat vaginal infections.
Provide education to the woman to
identify early symptoms and signs, so
that women are admitted early to allow
initiation of tocolytic therapy.

- First aid management

Admit the woman to the labor ward
and put her on complete bed rest.
Insert an IV cannula.
Give steroids if the gestational age is <
34 weeks.

If the gestational age is > 34 weeks:

Allow delivery
- If the gestational age is < 34 weeks
Tocolysis, Uterine tocolytic agents
- sympathomimetic agents, e.g., ritodrine
(Yutopar)
Calcium channel blockers (nifedipine)
Oxytocin receptors antagonist (Atosiban)
MgSO4
Prostaglandin synthetase inhibitors
-Antibiotics
-Corticosteroids

If a tocolytic drug is used, nifedipine

appears preferable over ritodrine as it
has fewer adverse effects and seems
to have comparable effectiveness.
(Recommendation grade:A)

* Calcium channel blockers (nifedipine)

A growing body of evidence suggests that
nifedipine as an oral agent is very effective
in suppressing preterm labor with minimal
side effects. The only side effects are
headache, cutaneous flushing, hypotension
and tachycardia. The latter two side effects
can be partially avoided by making certain
the woman is well hydrated.

How to use?
Put the woman on complete bed rest.
Give nothing by mouth for at least the
first 46 hours.
Start IV tocolysis as follows:

Dissolve 3 ampules (150 mg) of ritodrine

(Yutopar) in 500 mL D5W or Ringers lactate
Start the IV infusion at a rate of 0.050.1
mg/min (1020 drops/min and
increase by 0.05 mg (10 drops) each 10
minutes until: Contractions stop
Infusion reaches a maximum of 0.35
mg/min (70 drops/min)
Pulse rate reaches or exceeds 130/bpm
Toxicity appears, e.g., tachycardia, nausea,
vomiting and/or irritability

Once an adequate dose is reached,

continue for 12 hours from the last
contraction.
There is no evidence to support the use
of oral tocolysis after the cessation of
uterine contractions; i.e., the
maintenance treatment is not
recommended for routine practice.
(Recommendation grade: A)


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Do not begin tocolysis using -sympathomimetics if

the woman presents with:
Symptomatic maternal cardiac disease, especially
outflow obstruction
Arrhythmia
Hyperthyroidism
Severe bleeding
Severe anemia
Eclampsia and severe pre-eclampsia
Uncontrolled insulin dependent diabetes
Taking monoamine oxidase inhibitors
Asthma and is already taking -sympathomimetics

*Complications of - sympathomimetics
(ritodrine)
Pulmonary edema
Heart failure
- A strong diuretic such as Furesamide 40
mg ampoule should be available when
using ritodrine as a tocolytic agent.

In the above situations, it is

highly recommended that the case
be referred to a higher level.

Begin MgSO4 tocolysis by an intravenous bolus

of 6 gm in 100150 mL of a standard IV solution
over 2030 minutes.
Maintain MgSO4 infusion at 13 gm/hour to
titrate cessation of contractions for
approximately 24 hours.
Monitor woman for muscle weakness (absent
reflexes), double vision, and
respiratory insufficiency in addition to the
monitoring advised below.
Calcium gluconate (1 gm IV push over a few
minutes) may be administered to reverse
MgSO4 toxicity if it occurs and must be
available if MgSO4 is used.

Agents that inhibit prostaglandin

synthetase are quite effective tocolytic
agents.
Indomethacin is the most commonly
used. Its use can result in
oligohydramnios and premature
closure of the ductus arterious.
However, short term use may be
acceptable.

Indomethacin dose: A loading dose of

50100 mg is followed by a total 24hourdose not greater than 200 mg.
Most studies have limited the use of
indomethacin
to 2448 hours duration (rectal
suppository/12 hours).

- Ritodrine hydrochloride (Yutopar)

Solution: 150 mg of ritodrine in 500 mL of
D5W (0.3 mg/mL): IV piggyback
Parenteral administration
Initial dose: 0.050.1 mg/min (10-20
drops/min)
Titrating dose: Increase by 0.05 (10 drops)
every 10 min until contractions cease or
unacceptable side effects occur; maximum
dose, 0.35 mg/min (70 drops/min) or
maternal pulse of 130 bpm
Maintenance dose: 12 hrs at maximum dose

Nifedipine
Preparation: Oral gelatin capsules of 10 or 20
mg
Loading dose: 30 mg; if contractions persist
after 90 min, give an additional 20 mg
(second dose); if labor is suppressed, a
maintenance dose of 20 mg is given orally
every 6 hrs for 24 hrs and then every 8 hrs for
another 24 hrs
Failure: If contractions persist 60 min after the
second dose, treatment should be considered
a failure

- Atosiban
IV bolus of 0.9 ml of 7.5 mg/ml solution
in the first minute, then (300g/min)
12 ml/hr
of 7.5 mg/ml solution for three hours
then (100g/min) 4 ml/hr of 7.5 mg/ml
for 48

- Magnesium sulfate (MgSO4)

Parenteral administration
Initial dose: 6 gm over 2030 min
Titrating dose: 2 gm/hr until contractions
cease; follow serum levels (57 mg/dL);
maximum dose, 4 gm/hr
Maintenance dose: Maintain dose for 12
hours, then 1 gm/hr for 2428 hrs; may
switch to oral -agonist therapy before
discontinuing

The woman should be observed for the following:

Pulse rate should not exceed 130/bpm. The woman
should be observed every 15 minutes until the
maximum dose is reached, then every 30 minutes for
one hour, and then every hour.
Monitor temperature to guard against pyrexia, every
eight hours
Abdominal tenderness in the absence of contractions,
every eight hours
BP, every hour during IV medication; should not be <
100/60 mmHg
Respiratory rate should not exceed 24/minute.
Pulmonary edema is possible, especially if steroids are
used and it is a multiple pregnancy
Chest auscultation

Fetal heart rate variations: Normal is 120

160 bpm. Use continuous external fetal
monitoring (EFM) when available.
Fetal movements
Excessive vaginal discharge
Vaginal bleeding
Nausea and vomiting
Urinary output; every hour during IV infusion,
at least 30 cc/hour
Total fluid intake should not exceed 125
cc/hour (3000 mL/day) of mixed fluids (IV and
oral).

Transfer the woman to the antenatal

ward.
Require absolute bed rest to start, then
bed rest with bathroom privileges.
Allow normal diet.

Vital signs every 30 minutes for two

hours; if normal, then per routine
BP should not be < 100/60 mmHg
Maternal pulse (should not be higher than
120/bpm)
Vaginal discharge or bleeding
Uterine contractions (should be less than
6 per hour)
Urinary output (should be > 30 cc/hour or
> 100 cc/4 hours)

Ultrasound twice weekly

NST daily
Consultations according to associated
problems
Monitor intake of all medications

Stop tocolytic medication and allow the woman to

progress. The obstetric specialist should attend the
delivery; the pediatric specialist should be advised
and be present for the delivery. Remember to
notify the neonatal service to prepare for a preterm
neonate.
If the woman initially presents with cervical dilation
of 4 cm or more, admit her to the labor ward and
allow her to progress with a vaginal delivery if
there is no contraindication. The obstetric specialist
should attend the delivery; the pediatric specialist
should be advised and be present for the delivery.
If there is any contraindication to a vaginal birth,
perform a cesarean delivery.

- Antibiotic therapy
It is reasonable to use prophylactic
antibiotics in women with preterm
labor in an attempt to
prevent the progression of silent
infection to clinical amnionitis and the
risk of fetal infection.

- Corticosteroid therapy
Dexamethasone IM 4 mg/6 hours for 4
doses or betamethasone IM 12 mg/12
hours for 2
doses promotes fetal lung maturation
for pregnancies less than 34 weeks
gestation

Conditions for Discharge

At least 48 hours have passed since tocolysis
was achieved and labor pains have resolved.
Stable general condition
No associated pathology and not under
treatment (e.g., antibiotics)
Educate the woman to:
Monitor uterine activity
Count fetal movements and watch for
decreased movement
Stop sexual activity

Evaluate vaginal discharge

Evaluate vaginal bleeding
Decrease physical activity
Understand the necessity of delivering
in a hospital
Understand the importance of correctly
complying with medical treatment and
prenatal care

- Care of the Preterm Neonate

Preterm neonates are subjected to
many problems:
Hypothermia
Respiratory distress

Follow steps of neonatal resuscitation according to

guidelines (refer to Normal Labor chapter).
Transport the neonate immediately to the NICU in a
portable incubator.
Provide an appropriate thermal environment.
Provide adequate oxygenation by oxygen mask in
case of respiratory distress, cyanosis or oxygen
saturation less than 88% or by ambu bag in case of
irregular gasping respirations, apnea, persistent
cyanosis despite 100% oxygen supplementation by
oxygen mask or heart rate < 100 bpm.
Flow of oxygen should be 510 L/min. Monitor O2
saturation if pulse oximeter is available (required
O2 saturation 8895%).

Check the neonates glucose level

using a glucose strip within the first
hour after birth to exclude
hypoglycemia. If the neonate is
hypoglycemic, give D10W 2mL/kg IV
over 24 min and transport
immediately to the NICU in a portable
incubator.

Do not wait for symptoms of

hypoglycemia to appear in
preterm babies inorder
to start IV glucose