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MRCOG PART 2 SBAs and EMQs

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ESSAY 223 - PREM LABOUR

Posted by Freha Z.
Risk associated in this pregnancy is prematurity leading to perinatal mortality and morbidity. History should be taken regarding duration of uterine contractions, ruptured membranes and any associated bleeding. As uterine contractions accompanied with bleeding increases the chances of delivery in 7 days. Abdomial examination should be done to palpate the uterine contractions. Fetal hearts should be recorded by doppler. Spaculum examination performed to see pooling of liqour, any blood and visual assessment of dilatation. Digital examination should be limited to where cervical dilataion is in doubt on spaculum examination as it introduces infection and stimulate release of prostaglandins thus further stimulating labour.
Bed side fibronectin can provide rapid assessment of chances of delivery. Combining this with cervical length measurement improves diagnostic accuracy of women delivering within 7 days.
Fetal presentation should be assessed by scan. Estimated fetal weight should also be assessed which may help in parental counselling.
She should be given single course of maternal steroids
(betamethasone12mg 2doses 12 hours apart). It markedly improves neonatal outcome, reduces rate of respiratory distress syndrome, neonatal death and intraventricular haemorrhage.
Use of tocolysis is limited in preterm labour as it doesnt reduce perinatal mortality or prolong pregnancy to term. Although it can be used for short term to complete steroid course or in utero transfer. Atosiban is as effective as ritodrine with lower side effect profile.
Uk Oracle study showed no benefit for antibiotc cover in uncoplicated preterm labour. Women should have meeting with neonatologist to discuss neonatal survival rates. Women should be provided support and adequate counselling.
If the women goes into active labour in utero transfer should be considered if facilities for preterm infant unavailable, according to unit guidelines. Epidural analgesia is preferred because it will avoid expulsive efforts before dilatation. Choice of continuous fetal monitering should be discussed with mother. Breech presentation can be delivered by caesarean but there is not clear evidence to support improved outcome in preterm breech. Neonatologist should be present at time of delivery.
Postnatally risk of recurrence in next pregnancies should be discussed. Breast feeding should be encouraged and suitable contraception offered.
Posted by Fahima A.
This is a case of preterm labor.
A history should be taken whether it is associated with watery vaginal discharge to exclude spontaneous rupture of membrane( SROM). Her case note also should be reviewed to detect any polyhydramnios, multiple pregnancy as these are often associated with preterm labor.
During examination pulse, BP, temperature is important as tachycardia , raised temperature is associated with chorioamnionitis. Abdominal examination should be done for uterine contractions & for lie presentation, position of fetus to exclude any malposition. If chorioamnionitis develops there will be abdominal tenderness. Speculum examination is important to exclude SROM.
Her blood should be taken for FBC as leucocytosis raised ESR & CRP may present in chorioamnionitis. If SROM present high vaginal swab should be sent to exclude infection. In any doubt about SROM nitrazine test can be done but it has low sensitivity. Ultrasound scan can help to detect liquor volume in case of SROM. Cardiotocography should be done to see fetal well being.
Patient should be admitted in a unit where SCBU facilities available. Injection Betamethasone 12 mg IM 24 hours apart should be given to prevent RDS, intracranial haemorrhage of neonate. Repeat dose is not necessary as it did not show any benefit. Tocolytics is not indicated as trial did not show any improvement of outcome of neonate except to buy time for steroid to work or in utero transfer . If tocolytic is to given Atosiban & Nifedipine is the drug of choice, not Ritrodine because of the side effects. Atosiban is licensed for use but nifedipine is not.
If SROM present prophylactic antibiotics ( Tab Erythromycin) should be given to prevent infection. If chorioamninitis develops early delivery is indicated.
Mother should be reassured that at this gestation outcome of the baby is generally good. If she is anxious a meeting with neonatologist can be arranged.



Posted by Srivas  P.
The goal of management would be identifying the cause of premature labor, treatment of cause if possible, if she is going to establish labor use of tocolytics to delay delivery so as to let corticosteroid have effect, use of corticosteroids and management of neonate in a unit equipped to handle premature baby.

History of over distension of uterus suggesting hydramnios, history of vaginal discharge with possible colonization with GBS, bacterial vaginosis, any watery vaginal discharge suggesting preterm PROM, H/O vaginal bleeding with possible placental abruption, repeated vaginal bleeding in early pregnancy may result in preterm labor. History of smoking should be taken. DES exposure in utero may suggest uterine abnormalities.

Exam should include temp, pulse, B.P. and more frequently if evidence of PROM to detect onset of IU infection. Abdominal exam may reveal abnormal contour of uterus, uterine tenderness or irritability and fetal tachycardia as sign of infection. P/S exam to see pool of fluid if post fornix and to see evidence of infection and to collect swabs. Pelvic examination should be avoided unless she goes into regular contractions and progress need to be assessed or if she is to be assessed for any in-utero transfer to tertiary centre.

Investigations should include complete blood with TLC and CRP to detect asymptomatic chorioamnionitis and also as baseline to watch for development of signs of intra uterine infection. Urine M/E and C/S for asymptomatic bacteuria as cause for PTL, High vaginal swab to look for any vaginal infection especially GBS which can cause PTL and intrapartum antibiotics would be necessary. +ve Nitrazine test and fern tests are simple tests to detect PROM with good sensitivity and may be done if PROM is in doubt even after P/S and USG. On USG a finding of oligohydramnios may suggest PROM. USG should be done to see cervical length, fetal presentation and amount of liquor--hydramnios, Breech, footling breech, face presentation and intra uterine fibroids and fetal abnormalities?all these may be the cause for PTL. CTG for fetal tachycardia or any distress.

Management should involve a Neonatologist, Obstetrician, mid wife and GP. Couple should be told about good chances of survival at this gestation and management plan discussed. Treatment of Asymptomatic bacteuria if present may prevent her going into established labor.

The nursery should be informed about possibility of a preterm labor and if they have beds ready. If beds are not present woman should given tocolytics to delay delivery for up to 48 hrs. If asymptomatic bacteriuria is detected it should be treated.

Tocolytics do not improve neonatal income and do not decrease RDS, IVH but helps only in delaying delivery so that in utero transfer and corticostroids can take effect. Atosiban is drug of choice with minimal maternal and fetal side effects like nausea and vomiting and is licensed in UK. Nifedipine is another possibility with minimal side effects, though not yet licensed in UK pending study.

Prophylactic corticosteroids in the form of betamethasone in two doses is useful as it decreases incidence of RDS, IVH and Necrotising enterocolitis but does not increase maternal or fetal infection. No role for prophylactic antibiotics in routine preterm labor with intact membranes unless there is evidence of PROM or intra uterine infection. If vag swab / urine show GBS she must receive intravenous prophylaxis with antibiotics. If labor is sufficiently delayed for her not to have received GBS antibiotic prophylaxis, baby should be watched for signs of early onset GBS and given antibiotics.

At the time of delivery neonatolist should be present. Aim for vaginal delivery. There is no role for prophylactic forceps or episiotomy to prevent intra cranial injuries to baby. Vacuum should be avoided. Postnatally the couple would need psychological support while baby is in nursery. Breast feeding should be encouraged. She should be counseled about increased risk of recurrence in next pregnancy (20%). The causes if possible should be identified and treated.
Posted by sandra B.
This is threatened preterm labour and carries a significant risk of perinatal morbidity and mortality secondary to prematurity. In the initial assessment I would inquire as to whether her membranes had ruptured, as this would indicate a need for antibiotics. I would also ask about symptoms of a urinary tract infection as this can sometimes mimic preterm labour and is easily treated with antibiotics. Details of her antenatal history are also important, for example if there were any significant fetal anomaliues which can also contribute to an increase in the perinatal mortality and morbidity especially in conjunction with preterm labour.

Abdominal palpation is performed to establish lie and presentation. Once the fetus is in a cephalic presentation a vaginal delivery is allowed.

Urinanalysis and an MSU is sent off to rule out a urinary tract infection. An Ultrasound scan is performed to confirm presentation as palpation can be unreliable. Fetal fibronectin test can be peformed and a positive test increases the likelihood of preterm delivery. The patient is placed on the CTG to assess the baby\'s well-being.

I would start tocolysis; even though it has not been shown to improve outcome, it allows time to administer steroids and allow for an in-utero transfer if needed. I would use nifedipine as opposed to ritodrine or atosiban because it is just as efficatious but has less side effects than the former and is less expensive than the latter.Steroids in the form of betamethasone should be administered 12mg IM 24 hours apart. Steroids have been shown to decrease the risk of respiratory distress syndrome, intraventricular haemorrhage and neonatal death. Should a urinary tract infection be suspected I would commence antibitics. Special care baby unit needs to be notified to see whether there is a cot available and the paediatric registrar should be asked to see the patient to discuss prognosis.

Should the contractions settled the patient can be discharged after a period of observation. Should the contractions continue and the baby is cephalic, the woman should be allowed to labour with continuous CTG monitoring. Breech presentation is not necessarily an indication for a cesarean section as she is preterm and the Term Breech Trial should not be extrapolated to a preterm breech. There is still uncertainty around the mode of delivery of a preterm breech and this decision should be made along with the mother. Paediatricians should be present at delivery.
Posted by TAIWO NURENI Y.
History of onset of pains and the frequency of the pains is taken.Presence or absence of associated rupture of membrane is important as well because if present it immensely influence management and outcome.History of vagina bleeding and urinary syptoms is also important because abruptio placenta could lead to premaure labor.History of past or present history of urinary tract infection is taken as UTI could cause preterm labor in a significant number of pregnant women.The hospital note is reviewed to confirm her date from either Lmp or early scan.
She will then be examined starting from her vital signs.Pyrexia or tachycardia might be suggestive of infection which is a common cause of preterm labor.Contraction may be palpable per abdomen and also generalised tenderness and hard uterus might be signs of abruption. Sterile Speculum examination is done to confirm SROM if history is suggestive.
Full blood count is taken and of use in suspected infection or baseline in SROM.It is of limited value in interpretation of white cell count as this is also raised in normal pregnancy.CTG is performed to assess fetal well being at the time.Though,the interpretation at this stage is of concern with regards to control of the fetal heart rate.However,obvious abnormal CTG should prompt a reaction.Ultrasound examination of abdomen is done to confirm presentation and get estimated fetal weight.The urine is also sent for analysis,culture and sensitivity to confirm or rule out UTI.
Treatment is tailored towards the finding as per possible aetiology.The special care baby unit informed of admission and chance of survival or morbidity associated needs to be discussed with the mother and neonatologist is involved to highlight this.Steroid injection(Betamethazone) is given 12mg by 2 doses 24hrs apart as metat trials have confirmed benefit in reducing morbidity from RDS,Intraventricular hamorrhage and NEC.Tocolysis might be neccessary to facilitate the steroid to be given and in case of transfer to a tertiary centre with special care baby unit.However,this will not be indicated in obvious need for urgent delivery like in abruption.
If the labor subsides ,which is a possibility,the pregnancy is allowed to continue provided it is safe for the fetus.On the contrary if labor progresses,vagina delivery is the aim with cephalic presentation.There is no need for propyhlactic forcep and ventuose is an obvious contraindication at this gestation.Experience paediatrician should be present at delivery for rescucitation of the baby.Postnatally breastfeeding should be encouraged and risk of recurrence of preterm labor in subsequent pregnancy is discussed prior to discharge.
Posted by Randa E.
Preterm labour occurs in around 6-10% of all pregnancies. 54% is associated with preterm rupture of the membranes or idiopathic preterm labour. Obstetric management is focussed around measures to prevent spontaneous premature delivery and if delivery is thought to be inevitable, to optimize neonatal outcome. Premature labour is associated with neurodevelopmental and other disabilities e.g. cerebral palsy,blindness and chronic oxygen dependency. However survival rate at 28wks exceeds 80%due to improvement on neonatal intensive care.
Maternal and fetal evaluation after admission are important to maximize the chances of normal survival after birth. Preterm labour appears to be higher among smokers and high alcohol intake groups so this should be elicited in the history. It also appears to be high amongst low socioeconomic status and the non-white race. Rupture of the membranes should also be excluded by speculum examination and if present then colour of the liquor should be noted. The relationship between lower genital tract infections and preterm labour is well established and screening for asymptomatic bacturia including GBS is important. HVS ,LVS, Urethral and rectal swaps should be obtained. Baseline investigations like FBC / CRP should also be done and could point to presence of early infection. Abdominal u/s should be done to ascertain the presentation, weight and detect any congenital anomalies/IUGR. CTG should be done to detect any early fetal compromise.
Cervical incompetence might be a possible cause so measuring cervical length using TVS, if possible may be a useful method in predicting preterm labour in next pregnancies.
Betamethasone should be administered to promote lung maturity in 2 doses 24 hrs apart if possible They reduces the incidence of RDS, IVH and NEC at this gestation. They also help in reducing the costs and duration of neonatal intensive care. There is no evidence to show benefit of multiple doses of corticosteroids. In the case of regular contractions then the needs for tocolytics should be considered. Although tocolysis does not reduce fetal mortality and morbidity it might be helpful in prolonging delivery for up to 48hrs until SCABU is arranged or in utero transfer to a tertiary centre is possible. This also gives time for the steroids to take effect. Atisoban has shown to delay labour by up to 7 days with less sideeffects compared to other drugs. This should be contemplated depending on individual circumstances, and no fetal compromise and with prior discussion with a senior colleague. There is no evidence to support maintenance of tocolytic therapy therefore it is not recommended. If there is association with rupture of membranes then erythromycin therapy is initiated.
A multidisciplinary approach should be undertaken during labour involving a senior obstetrician and a neonatologist and experienced nursery staff. The indication and the timing of the delivery including the mode of delivery should be discussed with the parents in conjunction with the neonatal team . The parents should comprehend the full extent of the problems associated with premature delivery and their wishes respected. Maintaining good communication with neonatal team is vital.
If labour is inevitable, neonatologist should be present and vaginal delivery should be the aim.C/S reserved for obstetrical causes. Continuous ctg monitoring undertaken. SCABU should be informed. There is no role for forceps in delivery and vacuum should be avoided. After delivery breastfeeding should be encouraged if possible. The patient should counselled about recurrence rate (about 20%) and postnatal screening offered for possible detectable causes. Contraception should be discussed before discharge.

Posted by neera  B.
I shall take history of foul smelling vaginal discharge and fever because infection can be associated with preterm labour . History of bleeding and leaking from vagina will be asked as antepartum hemorrhage and PROM predispose to preterm labour. History of smoking will be asked due to association of preterm labour with smoking. Temperature and BMI will be recorded because infection and low BMI predispose to preterm labour. I shall palpate the abdomen for intensity , duration and frequency of contractions , and fetal heart will be auscultated.
FBC will be sent as leucocytosis can be assciated with infection , though physiological leucocytosis can occur in pregnancy. Midstream urine sample will be sent for culture and sensitivity as UTI and asymptomatic bacteriuria are associated with preterm labour. Vaginal swabs for GBS and bacterial vaginosis , endocervical swab for chlamydia will be sent because these are associated with preterm labour . Base line ultrasound TVS for cervical length, funneling and internal os diameter , lie and presentation of fetus and to check fetal heart will be done . CTG is difficult to interpret at 28 wks. I shall admit the patient for observation . Bed rest will not be advised because it may increase the incidence of preterm labour. Smoking cessation would be advised and she would be enrolled in smoking cessation programme . Two doses of steroids 12 hrs apart will be advised as it decreases the chance of respiratory distress syndrome, periventricular leucomalacia, intraventricular hemorrhage, neonatal death, cost and duration of NICU stay.
Repeated doses of steroids will not be advised as they are found to decrease brain growth and cause adrenal supression. NICU beds will be arranged and the neonatal team will be intimated . Long term tocolysis will not be advised because it does not help to prolong pregnancy. Short term tocolysis for 48 hrs. with nifedipine or atosiban will be advised as this allows steroids to have their effect and in-utero transfer to take place. If asymptomatic bacteriurea is detected I shall treat with antibiotics based on sensitivity results because this helps to stop preterm labour pains. If chlamydia swabs are positive I shall give appropriate antibiotics and refer to GUM clinic. If GBS is positive intrapartum antibiotics will be given. Routine antibiotics with intact membranes will not be given as they do not improve maternal or fetal outcome. I shall advise weekly TVS for cervical length and internal os diameter and fibronectin in cervicovaginal secretions because this helps to monitor progression of preterm labour . Repeated digital examinations will not be done as it may precipitate preterm labour.
I shall counsel her about the risk of premature birth , prolonged NICU stay , neonatal complications like RDS and neonatal death. A meeting with neonatologists will be arranged . Cervical cercilage will not be offered as it has not been found useful in primies with preterm labour. If contractions settle I shall send her home with 24 hr help line numbers and a followup visit will be arranged . If she goes upto 34 weeks the risks of prematurity are markedly decreased. delivery should be in a tertiary care centre wiyh NICU beds available and neonatologist should be present at delivery.
Malpresentations are more common at 28 wks. In case of breech or transverse lie a caesarian will be offered , consultant obstetrician will be called for caesarian section as the lower segment may not be well formed and a classical caesarian or a De lee incision may be required. At the post natal visit , chances of recurrence of preterm labor in 20% cases with one previous preterm labour will be discussed.


Posted by Zaharuddin R.
The most likely diagnosis is premature labour. However placenta abruptio, urinary tract infection and other possible surgical condition such as appendicitis need to be excluded.

Further detailed history should be taken including leaking liquor, vaginal bleeding, vaginal discharge,show, frequency,dysuria, trauma and fetal movement. Antenatal notes should be reviewed especially regarding detailed scan and fetal anomaly.

Physical examination should be done to assess uterine size, fetal lie and presentation. Contraction must be timed. Continuous uterine contraction may suggest placenta abruptio and uterine irritable may suggest infection.

Speculum examination should be done to look for pooling of liquor, vaginal discharge,high vaginal swab and progression of labour by cervical effacement and dilatation.

Ultrasound should be done to determine placenta localization, fetal lie, presentation, anomaly and estimated fetal weight. Liquor volume should be assessed. Cardiotocogram should be done to assess fetal well being.

Other investigations should be done such as FBC, urea and electrolytes, random blood sugar and ECG as possible tocolysis of labour. Blood pressure, pulse rate and temperature should be taken.

The aim of management is to prevent progression of labour,prolongation of pregnancy and to reduce perinatal morbidity and mortality.

However, indication to allow labour to progress and delivery include chorioamnionitis, lethal fetal anomalies and fetal compromise.

After excluding the above conditions, tocolysis should be done as local hospital protocol either by nifedipine, terbutaline or atosiban. A course of corticosteroid should be given to reduce risk of RDS, NEC and IVH of the fetus. Tocolysis could allow \'to buy time\' for effect of steroid and in-utero transportation to tertiary centre with ventilator.

SCBU should be informed for standby ventilator and the patient should be counselled by neonatologist regarding prognosis of the fetus if delivered prematurely.

If labour is still progressing in spite of tocolysis, membrane should be intact as long as possible until spontanous rupture to reduce risk of infection. Paediatrician should be standby upon delivery for resuscitation.

If fetal in breech presentation and labour is progressing, role of caesarean section (CS) is uncertain to reduce perinatal morbidity and mortality. CS is associated with increased maternal mortality and morbidity and increased risk in subsequent pregnancy.

If labour is progressing, fetal is not in logitudinal lie or present of placenta praevia, emergency CS should be done to reduce maternal and perinatal morbidity and mortality. Decision of delivery should be done at consultant level.

The patient and her spouse should be informed regarding current problems, options available and plan so that they can make an informed choice. All discussion and action made should be clearly documented in the patient notes.
Posted by Abi T.
Preterm birth carries a high risk of perinatal mortality and morbidity and the aim of management should be to reduce these risks and improve outcome. A good history should be obtained to exclude infection ie, chest or urinary symptoms and possible SROM. Associated vaginal bleeding may indicate abruption. Chorioamnionitis and abruption with fetal and maternal compromise are an indication to expedite delivery and contraindication for tocolysis.
Antenatal notes should be reviewed to identify if there are any fetal problems which would influence management ie, in utero transfer is not necessary if there is lethal fetal anomaly.
Maternal pulse, blood pressure and temperature should be taken. Abdominal examination is done to identify a tender uterus which may suggest chorioamnionitis or abruption. Speculum examination is done to identify pooling of liquor or vaginal bleeding. An HVS should be taken. Fetal fibronectin test may be done if available, however a negative test is more useful as it predicts delay of delivery for at least 7 days. This would ensure time for corticosteroid to be effective and avoids need for in-utero transfer.
FBC and CRP should be done as a raised WCC and CRP indicate infection. Renal and liver function tests should also be done as they may be deranged if maternal sepsis is present. Clotting factors, group and save or cross match should be done if abruption is suspected . urinalysis should be done to exclude a UTI. If there is a suspicion of infection, antibiotics should not be delayed while waiting for definitive microbiological diagnosis.
An USS should be done to assess fetal lie, presentation and placental localization. A transverse lie or placenta previa necessitate a Caesarean section if contractions do not stop.
Administration of corticosteroids improves fetal outcome by reducing RDS, intraventricular hemorrhage and neonatal death.
Betamethasone is the recommended choice; 12mg IM given 12 hours apart as it has decresed risk of periventricular leucomalacia in preterm infants ,compared to dexamethasone.
There is no clear evidence that tocolysis improves perinatal outcome but should be considered if few days gained can be used to administer course of steroids or for in utero transfer. The choice should be based on local unit protocols. Ritodrine is no longer best choice because of adverse maternal side effects. Atosiban and nifedipine are better choices with few side effects and comparable results in delaying delivery for a few days. Nifedipine can be used orally and is cheaper than atosiban but not licensed for tocolysis, so risks and benefits must be discussed with patient before use.
Atosiban is licensed for this use but is more expensive and need to be administered intravenously. Maintenace treatment of tocolysis is not recommended as routine practice.
Antibiotic prophylaxis is of no benefit if membranes are intact.
The patient should be given the opportunity to discuss survival rates and neonatal outcomes with a neonatologist.
Efforts must be made for in utero transfer if the local SCBU is closed or unequipped to care for a 28 week fetus, provided there are no contraindications eg, established labour, maternal or fetal compromise.
If labour is progressing, continuous fetal CTG monitoring is indicated. The aim is for vaginal delivery if cephalic presentation. Breech presentation at this gestation is not an indication for C/section as there is insufficient evidence that it confers better outcomes.
Effective analgesia should be offered. A neonatologist should be present at delivery.
Posted by Yasser S.
This is a case of threatened preterm labor and prompt attendance is important because preterm delivery is a major cause of perinatal morbidity and mortality. It is also a leading source of economic burden on the health services. This fetus is in danger of moderately preterm birth and is at increased risk of neurodevelopmental impairements, disability and handicaps in later life if born at this gestational age.
A meticulous history is mandatory as it helps to track the further management. Her dates should be rechecked to reconfirm the gestational age. History of onset of symptoms and the duration of pain, associated vaginal leaking of amniotic fluid to rule out ruptured membranes and any associated bleeding is important. If she has associated bleeding with 1 cm dilatation, the risk of delivery is higher within the next 7 days as compared to if she has no bleeding. Associated history of urinary tract infection symptoms is very important as UTI is proven to be a cause of preterm labor and prompt treatment with IV antibiotics can alleviate her current symptoms. History of vaginal discharges and associated itching is also important as vaginal infections are also a known cause of preterm labor and potentially treatable at this stage for her. History of pyrexia, unwell being and abdominal pain before the onset of contractions is important as it gives the clue of chorioamnionitis. The perception of fetal movements should be ascertained.
On examination pulse, temperature and BP should be recorded. A high pulse rate with or without high temp. may be an indicator of chorioamnionitis. General appearance of the patient can give a clue to how much pain she is in and how sick does she feel. Abdominal palpation should be performed to assess the fetal size and to rule out overdistension of the abdomen which could be due to multiple gestation or polyhydramnios, both of which are known risk factors of preterm delivery. Fetal lie and presentation should be assessed along with placental localization. If the assessment is difficult due to small fetal size or maternal obesity, then a bedside scan should be used to confirm fetal presentation. This is extremely important to decide the mode of delivery if the patient progresses in labor.
A speculum examination should then be performed. A vaginal swab should be taken as most of the vagnal infections precipitating preterm labor are asymptomatic. Any leaking of amniotic fluid should be noted along with any abnormal vaginal discharges and/or presence of meconium. A nitrazine test should be performed though it has an appreciable false positive and negative rates. Other option is to perform fibronectin testing if available. Digital examination should ideally be avoided but in a patient with contractions, an initial examination is reqired to assess the length and dilaltion of the cervix.
Patient should be started on CTG monitoring. Baseline investigations required are Full blood counts, urea and electrolytes, blood grouping and urinalysis and culture and sensitivity. If the patient is stabilized, the later a detailed scan can be perfomed to assess fetal well being, assessment of fetal weight , placental localization and to rule out any structural anomalies.
The immediate managment required to start the patient on tocolysis and to start steroids for fetal lung maturity. The use of tocolysis is debateable but in the situation where she is just 1 cm dilated with no active bleeding, it should be started to get the benefit of steroids and inutero transfer if required. The use of ritrodine is no longer recommended. Terbutaline, nifedipine and atosiban can be used. Nifedipine is cheap and effective as compared to atosiban but atosiban is licenced for use as a tocolytic. Tocolysis should be stopped once the steroid course is completed or if the patient have persistant contractions. Tocolysis should not be used if the patient has chorioamnionitis and vaignal bleeding. Steroids used are either Dexamathasone 12 mg 12 hrly for 2 doses or Betamethasone in same doses. Steroids are associated with significant reduction in rates of RDS, neonatal death and intraventricular hemorrhage. Single course doesnot appear to have any significant maternal or fetal adverse effects.
IV antibiotics should be commenced if there\'s evidence of urinary tract infection, vaginitis or ruptured membranes according to unit protocol.
This patient needs a multidisciplinary care. The neonatologist should be informed and the couple should be councelled by him for the outcome of this pregnancy. Senior obstetrician should be informed. If the patient stops contacting and there is no progression in cervical dilatation, she can be discharged home after 24 hours of observation. If she has ruptured membranes, then she should be hospitalized and should be kept on the pathway for preterm ruptured membranes as per unit protocol. Planned delivery should at 34 weeks unless indicated otherwise. If she has to be discharged, the decision should be made at consultant level after 48-72 hours of observation. If she progresses in labor, the mode of delivery should be decided according to fetal presentation. A tranverse or oblique lie requires a C section where as breech is not a contraindication to vaginal delivery. A consultant\'s opinion is however required to make a decision for assisted vaginal delivery. Women should be fully informed about the risks of vaginal breech delivery. Decision should be made with her informed consent. Neonatologist should attend the delivery.
Posted by SWATI M.
The diagnosis in this case is most likely threatened Preterm labour.Prematurity is associated with increased risk of perinatal morbidity and mortality due to respiratory distress syndrome, infections, exaggerated physiological jaundice and difficulties with neonatal feeding.Maternal risks are increased risk of operative deliveries due to malpresentations and psychological stress.
History about duration, frequency and interval of uterine contractions should be enquired. Enquire about any per-vaginal loss of fluid or bleeding as its presence may alter management and chance of preterm delivery will be high. Fetal movements should be enquired to assess fetal well being.
Clinical examination includes general examination with abdominal examination in details.Note uterine height ,fetal lie and presentation as abnormal lie and malpresentation are common at this gestation. Auscultate fetal heart, note frequency and duration of uterine contractions which help further management and counselling.

Investigations include CTG for fetal well being.Ultrasound examination should be preformed especially if malpresentation is suspected.

Treatment should aim to prolong the pregnancy, to enhance fetal lung maturity. Tocolytics such as oral nifedipine or injectable atosiban should be given as per hospital protocol. Tocolytics help prolong pregnancy from 48 hours upto 7 days which is useful to establish action of corticosteroids & / transfer in-utero to the unit with SCBU fascilities. Betamethasone should be given 12mg ,2 doses 24 hours apart .It improves perinatal outcome by reducing incidence of RDS , IVH and also reduces cost of care. Discuss with neonatologist about the prognosis ,available SCBU fascilities and beds .Counsel parents about the perinatal outcome with neonatologist.If the fascilities are not available locally , arrangements should be made for in-utero transfer with appropriate communication with the referring centre.
Continue tocolytics for 48 hours if the woman responds.If contactions continue ,allow vaginal delivery for cephalic presentation.If breech presentation, decide route of delivery after conselling parents that perinatal outcome depends upon fetal maturity than route of delivery and caesarean section does not provide additional advantage.
Neonatologist should be present at delivery. At this gestation baby most likely will need admission to SCBU and woman will need psychological support . Breast feeding should be encouraged and she may need additional support for it and for baby care which should be provided by SCBU nurses.At discharge counsel about the increased risk of recurrence in future pregnancy and methods of contraception.Provide a letter to her GP with further care and management plan for future pregnancy.


Posted by Parveen  Q.
Preterm labour is associated with increase risk of perinatal morbidity and mortality. Management of this patient involves proper diagnosis , identifying any risk factors , and preventing the complications. History of smoking, family history of twins, and any history of rupture of membranes determined. If she is a booked patient, her antenatal record reviewed to note for any previous history of threatened preterm labour, urinary tract infection , as they are likely factors for recurrence. Her previous USS scan will give us an idea about the exact gestational age, number of foetus, placental localisation, any abnormality of the uterus or the foetus. this will guide us to make a treatment plan, to weigh the benefits against risk of continuing the pregnancy in case of gross foetal abnormality, or IUGR.

General examination will be performed , as tachycardia, and pyrexia will point towards infection. Abdominal examintion to feel for uterine contractions, presenting part, and symphsio fundal height, as large for dates and tense abdomen give a clue of polyhydramnios which is a risk factor for preterm labour . Speculam examniation done next, to look for any liquor ,and swabs taken for culture and sensitivity. Investigations include FBC, CRP, and urine analysis for microscopy and culture and sensitivity. If patient gives history of rupture of membranes, and if she is febrile, , with leucocytosis, point towards chorioamnionitis, and clearly delivery outweighs the risk of prematurity to reduce maternal morbidity and mortality. TVUS to measure for cervical length, and cervical testing for foetal fironectin has no benefit, but in the presence of negative value of the latter, patient can be reassured. USS for the estimated foetal weight, foetal growth , and amount of liquor performed, as IUGR , with polyhydramnios can point towards intrauterine infection. CTG for basal heart rate and uterine contractions done.

After the intial assessment, corticosteriods in the form of betamethsone 12mg 2doses 24 hours apart given. Dehydration if any should be corrected. steriods reduce the incidence of respiratory distress syndrome, neonatal death, and intraventricular haemorrhage. It increases the efficacy of neonatal surfactant therapy and reduces the cost and duration of neonatal intestive care unit. It does not increase the maternal or foetal infection. Any infection should be treated. Neonatal intensive care unit informed for the availability of beds, and paediatrician should be informed. There is no improved outcome in giving tocolytics, except to complete the course of steriods, or to facilitate inutero transfer. If tocolytics are used, ritodrine is no longer seems to be the best chioce. Atosiban, and nifedipine has equal efficiency. But the advandage of atosiban is lesser side effect profile and it is licensed for use in U.K where as nifidepine is not. There is no role for maintainence tocolytic therapy . With intact membranes there is no role for routine antibiotic therapy. but is given in the presence of PPROM. If the pain has subsided and if there is no progress of labour, patient can be discharged. There is lack of evidence to show significant benefits of repeated courses of corticosteriods. However if the labour progresses, allow vaginal delivery in case of cephalic presentation. There is no clear evidence about the mode of delivery in case of preterm breech presentation. The patients views should be considered. Paediatrician will be present to attend the baby.

The risk of recurrence is high, so upon discharge patient should be advised to avoid risk factors like smoking, and given leaflets to recognise the condition, and seek early treatment with steriods.







Posted by M M A.
Appropriate history should first establish whether uterine activity is regular or irregular. Regular, painful contractions that progressively become longer, more painful and more frequent are typically labour pain.
The lack of pain free intervals would suggest the possibility of abrubtio placenta which may be the precipitating cause, therefore; we should ask her also about other symptoms like vaginal bleeding which will support the diagnosis. Also history of abdominal trauma can be suggestive of occult abruption.
Presence of leaking liquor can support the diagnosis of rupture membrane and possibility of chorioamnionitis, therefore; we should ask also if she develop fever or not.
History of symptoms like frequency and dysuria are also required to exclude urinary tract infection which can lead to premature contraction
Although she appears healthy, we should ask her about other medical disease like thyroid disease or heart disease and other risk factors like smoking, drug addiction, all these can influence further management.

A general examination, including pulse, temperature and blood pressure is required.
Abdomen should be examined to determine uterine contractility and the duration of contractions. Uterine tenderness may be associated with placental abruption or chorioamnionitis.
Symphysio-fundal height should be measured to rule out IUGR, fetal lie and presentation should be assessed also to decide mode of delivery if labour progress.
Liquor volume can be clinically assessed to detect oligohydramnios or rupture membrane.
FHR is also required to detect any abnormality.

The patient will need FBC to detect anaemia and / or neutrophilia, also urine analysis and culture to exclude urinary tract infection
Admission CTG will be required to assess fetal wellbeing and also it can records frequency of contractions.
Ultrasonography will check also fetal well being and can assess amniotic fluid volume; also it can exclude placenta previa and sometimes shows if there is retroplacental haemorrhage.
Blood group and Rh-status is also required.
High vaginal swab can be done to detect infection especially if there is vaginal discharge.

The aim of management in this patient is to suppress uterine activity and prolongation of pregnancy as far as possible because preterm labour is associated with increased incidence of perinatal morbidity and mortality.

Tocolysis should be prescribed unless there are contraindications like placental abruption or rupture membrane or other medical disease or presence of fetal distress or anomaly.
Tocolysis can prolong pregnancy 24-48 hours and this gives time for administration of corticosteroid and also in utero transfer if there are no neonatal intensive care facilities available.
Tocolytic drugs are all equally effective , Beta agonist like ritodrine , turbutaline and solbutamol are available and cost effective but has some side effects like palpitation and tremor, Nifedipine is a better alternative with less side effect, however, it is still not licensed for this use therefore patient counseling is required.
Atosiban which is oxytocin antagonist can be used also but it is expensive.
Sometimes a combination of tocolytics can be used and this should be under close monitoring.
Progesterone can be used as tocolytic also like Dydrogesterone.

Corticosteroid administration will accelerate fetal lung maturation and decrease incidence of neonatal respiratory distress if administered 24 hour to 7 days before delivery.

Antibiotics can also be prescribed for her because there is evidence that sub-clinical or occult infection can precipitate preterm labour, it also prescribed to treat associated urinary tract infection or vaginal infection.

If the contraction cease, the Tocolytic should continue for 18-48 hours with re-evaluation of risks and benefits for both the fetus and the mother, prolong use has not been shown to effective in preventing preterm labour

If labour progress, a partogram should be used, also continuous fetal heart monitoring is required because preterm fetuses are more liable for hypoxia, a neonatologist should be involved.
Caesarean section is done for obstetrical causes only.
The patient should be counseled that there is an increased risk of recurrence of preterm labour in subsequent pregnancies of 15 %.
Home visiting nurses and enrollment of social workers may be required for care and support.


Posted by sailaja devi K.
Women is in preterm labour. Preterm labour is associated with increased neonatal mortality(three -quarters of neonatal mortality) & long term neurological impairement ,chronic lung problems & visual abnormalities.Manage the women to optimize neonatal birth condition thus minimizing risk & sequeale of preterm birth.

Exclude PPROM by history & clinical examination. Evaluate the fetal condition by cardiotocography & ultrasound scan.Scan for estimated fetal weight ,presentation, amount of amniotic fluid,& assess fetal wellbeing.This findings help in management and counseling the women.Test for infective etiology this includes urine analysis, urine for culture sensitivity ,vaginal &cervical secretions for culture complete blood picture & c-reactive protein.

Preterm birth causes significant mortality & morbidity due to respiratory problems.RCOG recommends Inj betnesol 12 mg intramuscular 2 doses 24 hours apart.This reduces respiratory distress ,intraventricular haemorrhage & neonatal sepsis.Single course of steroids is not associated with risk of maternal /fetal infection.The optimal treatment ? delivery interval for administration of steroid is more than 24 hours but less than 7 days after start of treatment.Tocolytics are used only to complete course of steroids or for in utero transfer . There is no evidence that tocolytics alone improve the outcome.Tocolytic of choice is atosiban or nifidepine . Both have comparable effectiveness with minimum side effects.Atosiban is expensive,licensed for use.Nifidepine is cheap, easy to use &easily available.The results of Oracle study suggest to discourage routine use of antibiotic in preterm lobour unless there is maternal infection.If the women is in peripheral unit transfer to teritiary centre if possible.Discuss with the women about the above plan ,provide with written information & document in case notes.

If the preterm delivery is inevitable ,discuss with women about mode of delivery & the neonatal outcome.Quote the hospital figures about out come & complications.Make arrangement for discussion with neonatologist & obstetric anaesthetist.Midwife should be included be included in discussion concerning the management of labour & delivery.If suspecting intrauterine infection start antibiotics.Management of labour should not differ significantly from that beyond 34 wks .Use of continous electronic fetal monitoring & epidural analgesia are of unproven benefit but commonly used in preterm labour.Prophylactic outlet forceps & elective episiotomy should only be performed for obstetric indications.Randomised controlled trails suggest that prophylactic outlet forceps ,electective episiotomy does not significantly contribute to neonatal outcome . Caesarean section for obstetric indications .Early cord clamping is not recommended as it has not proven to confer any advantage.Standard third stage management in preterm birth.

Important aspect in postnatal management is to encourage parent ?infant bonding.Encourage breast feeding.Continous psychological support if important ,utilize the services of domiciliary mid wife ,social worker.Evaluate the possible etiologic factor of preterm labour by perinatal team, this help to plan treatment for further pregnancies.Neonate should be evaluated by neonatologist.

Posted by GBENGA O.
THis is a case of threatened preterm labour and its consequence-prematurity is associated with increased perinatal morbidity and mortality.Therefore,onset of the pains,frequency and progressive intensity should be sought.History of vaginal bleeding and or trauma to the abdomen to outrule placenta abruption which is a recognised cause of preterm labour is important.Symptoms of UTI-dysuria,frequency,fever must be excluded.Any history of liquor leakage must be sought.Patient\'s notes should be reviewed to confirm the dates from LMP or early scan.
Patient should be examned to rule out fever and dehydration which could point to infection.Pulse rate and blood pressure are measured.Abdominal examination to determine the SFH,the fetal lie and presentation is carried out.A large for date with shining abdomen may be indicative of polyhydramnios which is another cause of preterm labour.Mid-stream urine sample should be collected for analysis,culture and sensitivity.If there is history of liquor leakeage,sterile speculum examination should be performed and LVS,ECS taken to rule out genital tract infection such as GBS.
Ultrasound examination is performed to confirm fetal viability,presentation and to estimate fetal weight asess liquor volume and other biophysical profile.Admission GTG is also perfomed,though its senstivity at this gestation age is limited.Blood sample is also taken for FBC and CRP.
Findings are exaplained to the patient and the plans are discussed.Steriods in form of bethametazone 12mg IM is administered,2 doses 24 hours apart as this has been proven to reduce RDS and IVH in neonates.The neonatologists are informed of the admission so they can counsel the woman on the outcome.They may also influence the decision to transfer to a bigger unit where better facilities are available.Tocoloysis is also administer to either allow the course of steroids or in-utero transfer.Atosbian-an oxytocin antagonist is used in the UK.Antibiotics-erythromycin is commenced if SROM is confirmed.
If the contractions are aborted,the woman could be discharged home,otherwise vaginal delivery is aimed for if presentation is cephalic and there is no obstetric contraindication to this.Continous fetal monitoring in labour is advised and neonatologist must attend the delivery.While ventouse is contraindicated at this gestational age,prophylatic forceps is not recomended.If presentation is non-cephalic,then patient\'s view and the unit protocol are essential to determine mode of delivery.
Post-natal counselling which should include the planned care for subsequent counselling should be undertaken.Contraception and smear test if due, should be advised.
Posted by Shyamaly S.
This woman has prevented with threatened preterm labour at extreme prematurity. Delivery at this gestation is associated with significant perinatal mortality and morbidyty so managment will aim to minimise the risk of delivery and also its associated morbidity.
Any history of vaginal loss should be noted, which maybe suggestive of rupture or membranes or bleeding- this increase the liklihood of delivery. Any history of Group B Strep positive swabs or MSU in pregnancy should be noted- this increases the risk of preterm delivery. A bowel and urinary history should be taken. GI upsets and UTI can precipitate preterm labour and both should be treated. A history of polyhydramnios, diabetes or multiple pregnancy also predisposes to multiple pregnancy.

On examination, presentation should be determined. Speculum examination will enable High Vaginal and rectovaginal swabs for GBS to be taken. GBS and vaginal infections predispose preterm labour. Also pooling of liquor will confirm rupture of membranes.

A CTG should be performed to ensure that the fetal heart is present and the pattern is normal. USS will confirm presentation and enable fetal weight to be estimated to facilitate counselling regarding neonatal survival. An MSU should be performed to exclude UTI, and treat as appropriate. Blood should be taken for full blood count and CRP and maternal temperature should be measured to assess for evidence of infection, which may precipitate preterm labour.

Steroids ( Betamethasone 12mg in 2 doses given 24hours apart) should be given. This significantly reduces the risk of neonatal morbidity by reducing respiratory distress syndrome, intraventricular haemorrhages and reduces SCBU admission length. Tocolysis should also be given (atosiban iv regimen over 48hours, licensed) to prevent delivery before steroids have been given. There is no improvement in neonatal outcomes if steroids are given beyond this period, so there is no indication for a maintenance dose.
SCBU should be liased with. If neonatal cots are not available, in-utero transfer should be arranged to a unit that does with tocolysis cover to prevent delivery en route. The neonatal registrar should be asked to counsel the mother regarding rates of survival and prognosis using the estimated fetal weight as added information.
If the membranes are ruptured, prophylactic antibiotics should be given (erythromycin 250mg three times daily). The ORACLE study has shown that Augmentin should not be given in this situation as it is associated with NEC, and that antibiotics do not improve outcome when the membranes are not ruptured.
If the contractions settle for 24hours, a rescue suture maybe considered to prolong the pregnancy. The evidence for a long-term benefit of this approach is not yet clear. The woman maybe discharged after 48hours if the contractions settle.
If there is evidence of chorioamnionitis- raised temperature, positive cultures on swabs and raised inflammatory markers, induction of labour should be considered, to minimise the risks of maternal systemic overwhelming sepsis and neonatal brain injury.
If the contractions continue, a cephalic fetus should deliver vaginally. If the fetus is breech, the mode of delivery needs to be discussed on an individual basis- the results of the term breech study cannot be extrapolated to preterm infants).
The fetal heart should be monitored in labour- there is controversy whether this should be continuous or intermittent.
Rupture of membranes should be avoided, as there is a risk of cord prolapse, infection and a shrinking cervix. Epidural analgesia should also be avoided, as there is a risk of the contractions ceasing.
A senior paediatrician should be attendant at delivery with full neonatal support (i.e. resuscitaire, neonatal nurse, drugs, UVC).
Post delivery the woman should be counselled about her increased risk of future preterm delivery-she should book under a consultant early and should be offered early pregnancy screening for BV and cervical length scanning or prophylactic suture.