Please note that all guidance is currently under review and some may be out of date. We recommend that you also refer to more contemporaneous evidence in the interim.
In 2013, 7.2 per cent of babies in Victoria were born preterm - at less than 37 weeks gestation. This rate of preterm birth has been stable since 2000 and in 2013 represented approximately 5,600 babies. The majority of these babies were born between 32 and 36 weeks.
Preterm labour and the care of premature babies present a range of challenges for families and health care services. Most importantly, babies born preterm have higher rates of neonatal morbidity and mortality and are at higher risk of neurodevelopmental disorders than babies born at term.
Appropriate management of preterm labour involves timely assessment, with the aim of ensuring birth occurs in the optimal location for the baby. Optimal location of care will depend on a baby's gestation at birth and the required level of nursery care, as per the Newborn Capability Framework.
For assistance with assessment and management, contact PIPER: 1300 137 650.
|Risk factors associated with preterm labour and birth|
|Medical and pregnancy conditions||
For women with a history of spontaneous preterm birth or an ultrasound diagnosis of shortened cervix, progesterone therapy or cervical cerclage may be appropriate to prevent preterm labour.
|History of spontaneous preterm birth||Commence progesterone 200 mg vaginal suppository daily from 16-24 weeks. Continue until 34 weeks gestation, rupture of membranes or birth, whichever occurs first.|
|Shortened cervix - singleton gestation|
|Shortened cervix - multiple gestation||No evidence for improving outcomes with progesterone therapy.|
|History of spontaneous preterm birth||Offer cervical cerclage|
|History of cerclage for painless cervical dilation in 2nd trimester|
|Cervix <25 mm at <24 weeks gestation, with a history of spontaneous preterm birth - singleton|
|Cervical shortening or painless dilation >24 weeks gestation||Limited data to support rescue cerclage - individualise decisions|
|Cervix <25 mm at <24 weeks gestation, without a history of spontaneous preterm birth - singleton||Cerclage not recommended|
|Funnelling of the cervix in absence of cervical shortening|
|History of cervical surgeries or anomalies|
Full obstetric, medical, surgical and social history.
Assess for signs and symptoms of preterm labour
- Regular uterine activity
- Lower abdominal cramping
- Vaginal loss - mucous, blood, fluid, meconium
- Lower back pain
- Pelvic pressure
- Presenting part fixed or engaged.
- Vital signs - heart rate, blood pressure, respiratory rate, oxygen saturation, temperature
- Abdominal palpation - pain, rigidity, contractions, fetal presentation, size and movement
- Fetal surveillance - Fetal heart rate (FHR) or cardiotocograph (CTG).
- Sterile speculum examination:
- visualise the cervix, looking for changes in length and dilatation
- assess for rupture of membranes.
- During the speculum examination test for fetal fibronectin* (fFN):
- perform a quantitative fFN test, if available
- be aware that the presence of blood or semen in the vagina may affect test reliability but that a negative result is still valid.
* This may not be necessary if in a facility with capability for the gestation. Perform high and low vaginal swabs.
- Abdominal ultrasound (US) for fetal growth and wellbeing
- Transvaginal US for cervical length.
- Midstream urine for MCS
- Full blood examination
- C-Reactive Protein
- High vaginal swab
- Low vaginal/anorectal swab for GBS.
If a woman presents in preterm labour at a gestation outside the service's Newborn Capability Level, aim for in-utero transfer wherever possible.
Within Victoria, consult with PIPER for support with assessment and transfer: 1300 137 650.
- Nifedipine 20 mg oral
- If contractions persist after 30 minutes, repeat nifedipine 20 mg oral
- If contractions persist after a further 30 minutes, repeat nifedipine 20 mg oral
- Maintenance therapy 20 mg every six hours for 48 hours
- IV Benzylpenicillin 3g loading dose
- IV Benzylpenicillin 1.8g every four hours
If the woman has a penicillin hypersensitivity with no history of anaphylaxis
- IV Cephazolin 2g loading dose
- IV Cephazolin 1g every eight hours
If the woman has a penicillin allergy with history of anaphylaxis
- IV Clindamycin 900mg every eight hours
- Loading dose Ampicillin or amoxycillin 2 g IV, then 1 g every six hours
- Gentamicin 5 mg/kg IV daily
- Metronidazole 500 mg IV every 12 hours
- Lincomycin or clindamycin 600 mg IV every eight hours
- Gentamicin 5 mg/kg IV daily
- Metronidazole 500 mg IV every 12 hours
If ≤36+6 weeks:
- Betamethasone 11.4 mg IM
- Betamethasone 11.4 mg IM in 24 hours
- consider second dose at 12 hours if birth likely within 24 hours
- if risk of preterm birth remains ongoing in seven days, repeat a single dose.
Magnesium sulfate (MgSO4)
If <30 weeks:
- loading dose MgSO4 4 g IV bolus over 20 minutes
- maintenance dose MgSO4 1 g/hr IV for 24 hours or until birth - whichever is first.
Prepare for birth
- Consult with obstetric and paediatric clinicians.
- Anticipate vaginal birth unless there are fetal or maternal contraindications (see below).
- Prepare resuscitation equipment appropriate for gestation.
- Notify SCN/NICU.
- Counsel woman and family about what to expect in terms of baby's condition and care.
- Offer tour of SCN/NICU if possible.
- After birth, ensure the placenta is sent for histopathological examination.
Possible contraindications to vaginal birth, subject to individual assessment
- Placenta praevia
- Maternal condition necessitating caesarean section
- Breech and <32 weeks
- Multiple pregnancy and <26 weeks
Discharge and follow-up
A baby's need for follow-up care will be dependent upon their individual clinical presentation, gestation at birth and complications experienced during their inpatient care.
- Offer the woman and her family the opportunity to debrief with clinicians involved in their care.
- If a woman and/or baby has been transferred between services, ensure discharge summaries are sent to the referring service and the woman's GP.
- When organising follow-up care, aim to connect the woman with clinicians and services close to her home wherever possible.
- Ensure the woman is aware of any follow-up appointments that have been organised for her and her baby.
Audit and performance improvement
All maternity services should have processes in place for:
- auditing clinical practice and outcomes
- providing feedback to clinicians on audit results
- addressing risks, if identified
- implementing change, if indicated.
- Documentation of risk factors
- All indicated investigations requested, followed up and acted on
- fFN result and time to delivery
- Follow up planning
For further information or assistance with auditing, please contact us.
- Early onset Group B Streptococcal disease (2010). Queensland Clinical Guideline.
- Measurement of cervical length for prediction of preterm birth (2012). RANZCOG.
- Prelabour rupture of membranes (≥37 weeks) clinical guideline (2015) SA Maternal and Neonatal Clinical Network.
- Preterm labour (2016) KEMH.
- Preterm labour and birth (2014). Queensland Clinical Guidelines.
- The Association Between Pre-pregnancy BMI and Preterm Delivery in a Diverse Southern California Population of Working Women (2011). Maternal & Child Health Journal.
- Antenatal corticosteroids for maturity of term or near term fetuses: systematic review and meta-analysis of randomized controlled trials (2016). BMJ 355 doi.
- Management of Perinatal Infections (2014). Palasanthiran, Starr, Jones & Giles. NSW: Australian Society for Infectious Diseases.
Last updated 11 Mar 2018
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First published: August 2017
Last web update: March 2018
Review by: August 2019
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Page last updated: 02 Feb 2021