Pre-term Labour

Question 1

A woman presents at 32wks with uterine contractions. How would you manage her?

Answer 1

Impression
Pre-term labour is onset of labour prior to 37wks GA. Concerned about this being signs of the onset of labour - would want to conduct thorough Hx/Ex/Ix and arrange O&G consult emergently to optimally manage this patient.

Question 2

Pre-term labour - History

Answer 2

History

• sx: pain, pelvic pressure, vaginal loss (fluid, blood), contractions (Braxton-hicks vs labour) - their intensity, regularity, lower back pain
• O&G hx: GTPAL, yellow book, scans, etc
• Review rest of medical history

Question 3

Pre-term Labour - Examination

Answer 3

Examination

• General appearance + vitals
• Abdo palp to assess uterine tone, contractions
• sterile spec exam: confirm/exclude PPROM, if so assess liquor (colour, consistency) ,visualise cervix and membranes
• if PPROM, no digital examination to reduce risk of infection, however if not contraindicated perform digital examination to assess cervical length, ripening,
• GBS swabs, other STI screening if necessary

Question 4

Pre-term labour - Investigations

Answer 4

Investigations

• Bedside: GBS swabs, other STI screening if necessary, urinalysis
• Bloods: Kleihauer, G+H, FBC
• Imaging: Abdo ultrasound to assess for fetal condition, trans-vaginal ultrasound of cervical length
• CTG monitoring (continuous)
• fetal fibronectin analysis (if high levels, indicated increased risk of Pre-term Birth)

Question 5

Pre-term labour - management

Answer 5

Management
Consider admission for further assessment, O&G review and input. Aim is to balance risk of continuing pregnancy depending on results of fetal investigation vs risks of pre-term delivery. Consider transfer to MFU/tertiary referral centre if imminent labour/high risk pregnancy.

Considerations depending on features of presentation

• tocolysis (nifedipine 1st line) to prolong/prevent labour to allow time for optimisation of fetal condition
• corticosteroids (betamethasone), magnesium sulphate (neuro protection)
• mode of delivery dependent on other risk factors associated with the pregnancy (NVD vs Caesarean section)
• consider prophylactic ABx in setting of +ve GBS, or other signs of chorioamnionitis (fevers, tachycardia, etc)

Ongoing
- regular review/F/U if for discharge to home