Assessment and management of preterm

labour

Queensland Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

Document title:

Assessment and management of preterm labour

Publication date:

September 2009

Document number:

MN09.6-V4-R14

Replaces document:

MN09.6-V3-R11

Author:
Audience:

Queensland Maternity and Neonatal Clinical Guidelines Program

Health professionals in Queensland public and private maternity services

Exclusions:

Management of premature rupture of membranes

Review date:

September 2014

Endorsed by:

Statewide Maternity and Neonatal Clinical Network

QH Patient Safety and Quality Executive Committee

Contact:

Queensland Maternity and Neonatal Clinical Guidelines Program

Email: MN-Guidelines@health.qld.gov.au
URL: www.health.qld.gov.au/qcg

Disclaimer
These guidelines have been prepared to promote and facilitate standardisation and consistency of
practice, using a multidisciplinary approach.
Information in this guideline is current at time of publication.
Queensland Health does not accept liability to any person for loss or damage incurred as a result of
reliance upon the material contained in this guideline.
Clinical material offered in this guideline does not replace or remove clinical judgement or the
professional care and duty necessary for each specific patient case.
Clinical care carried out in accordance with this guideline should be provided within the context of
locally available resources and expertise.
This Guideline does not address all elements of standard practice and assumes that individual
clinicians are responsible to:
Discuss care with consumers in an environment that is culturally appropriate and which
enables respectful confidential discussion. This includes the use of interpreter services
where necessary
Advise consumers of their choice and ensure informed consent is obtained.
Provide care within scope of practice, meet all legislative requirements and maintain
standards of professional conduct
Apply standard precautions and additional precautions as necessary, when delivering care
Document all care in accordance with mandatory and local requirements

This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 2.5 Australia licence. To view a copy of this
licence, visit http://creativecommons.org/licenses/by-nc-nd/2.5/au/
State of Queensland (Queensland Health) 2010
In essence you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute the authors
and abide by the licence terms. You may not alter or adapt the work in any way.
For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001,
email ip_officer@health.qld.gov.au , phone (07) 3234 1479. For further information contact Queensland Maternity and Neonatal Clinical
Guidelines Program, RBWH Post Office, Herston Qld 4029, email MN-Guidelines@health.qld.gov.au phone (07) 3131 6777.

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Queensland Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

Flowchart: Assessment and management of preterm labour

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Queensland Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

Abbreviations
BP
cm
CTG
FBC
fFN
g
GBS
IM
IV
M/C/S
mg
min
mm
mmHg
MSU
PPROM
PROM
PTL
RSQ
stat
TVCL
VE
O
C

Blood pressure
Centimetres
Cardiotocograph
Full blood count
Fetal fibronectin
Grams
Group B streptococcus
Intramuscular
Intravenous
Microscopy / culture / sensitivity
Milligram
Minutes
Millimetres
Millimetres of mercury
Mid stream urine
Preterm premature rupture of membranes
Premature rupture of membranes
Preterm labour
Retrieval Services Queensland
Statim (immediately)
Transvaginal cervical length
Vaginal examination
Degrees Celsius

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Queensland Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

Table of Contents
Introduction.....................................................................................................................................6
1.1
Definition ................................................................................................................................6
1.2
Risk factors ............................................................................................................................6
2 Assessment ....................................................................................................................................6
2.1
Review history........................................................................................................................6
2.2
Assess for signs and symptoms of preterm labour ...............................................................6
2.3
Physical examination and initial Investigations......................................................................6
2.4
Fetal fibronectin testing..........................................................................................................7
2.5
Transvaginal ultrasound of cervical length ............................................................................7
2.5.1 Interpreting TVCL results...................................................................................................7
3 Management of preterm labour ......................................................................................................8
3.1
Negative fFN and no evidence of cervical change / TVCL > 20 mm.....................................8
3.2
Positive fFN and / or evidence of cervical change / TVCL < 20 mm .....................................8
4 Tocolysis.........................................................................................................................................8
4.1
Contraindications ...................................................................................................................8
4.2
Relative contraindications......................................................................................................8
4.3
Nifedipine ...............................................................................................................................9
4.3.1 Contraindications ...............................................................................................................9
4.3.2 Dosage and administration ................................................................................................9
5 Corticosteroids..............................................................................................................................10
5.1
Dosage and administration ..................................................................................................10
6 Antibiotics .....................................................................................................................................10
6.1
Dosage and administration ..................................................................................................10
7 Transfer ........................................................................................................................................10
References ..........................................................................................................................................11
Appendix A: Drug Table.......................................................................................................................13
Appendix B: Acknowledgements .........................................................................................................14
1

List of Tables
Table 1. Fetal fibronectin testing ........................................................................................................... 7
Table 2. Nifedipine dosage and administration ..................................................................................... 9
Table 3. Betamethasone dosage and administration .......................................................................... 10
Table 4. Antibiotics dosage and administration................................................................................... 10

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Queensland Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

Introduction

Fourteen percent of Australian perinatal deaths in 2005 were as a result of preterm delivery,1
however most women that present with symptoms of preterm labour will deliver at term with a small
minority delivering within seven days of onset of symptoms.2,3

1.1

Definition

Delivery occurring before 37 completed weeks gestation.

1.2

Risk factors

Previous preterm birth

Preterm premature rupture of membranes (PPROM)
Cervical incompetence
Cervical surgical procedures
Uterine anomalies
Multiple gestation
Polyhydramnios
Placental abruption
Vaginal bleeding
Smoking
Illicit drug use

Assessment

The aim of assessment is to determine the risk of delivery within the next seven days and to assess
fetal and maternal wellbeing.

2.1

Review history
Medical
Surgical
Obstetric

2.2

Assess for signs and symptoms of preterm labour

2.3

Lower abdominal cramping

Pelvic pressure
Lower back pain
Vaginal spotting or show
Regular uterine activity
Cervical effacement / dilatation

Physical examination and initial Investigations

Vital signs
Mid-stream urinalysis and consider microscopy/culture/sensitivity
Maternal abdominal examination
Fetal heart rate +/- cardiotocograph (CTG)
Sterile speculum examination
Exclude premature rupture of membranes (PROM)
Obtain fFN test if not contraindicated [refer section 2.4]
High vaginal swab with M/C/S
Low vaginal/anorectal swab for Group B streptococcus
Assess cervical dilatation by sterile digital vaginal examination unless contraindicated by
o Ruptured membranes
o Suspected placenta praevia

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Queensland Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

2.4

Fetal fibronectin testing

Fetal fibronectin (fFN) is a screening test used to assess the risk of preterm delivery within the next
seven days. Point of care fFN testing should be utilised in the assessment of preterm labour.
Table 1. Fetal fibronectin testing

Indications4

Contraindications

Relative
Contraindications
Procedure

Positive Result

Negative Result

2.5

Symptomatic preterm labour between 24 and 36 weeks gestation and

Intact membranes and
Cervical dilatation less than 3 cm
Ruptured membranes
Visual evidence of moderate or gross bleeding
Cervical cerclage insitu
After the use of lubricants or disinfectants
Within 24 hours of coitus
Within 24 hours of vaginal examination
Performed during sterile speculum examination prior to any examination
or manipulation of the cervix or vagina
Use only sterile water as a lubricant
Obtain the sample for testing from the posterior fornix of the vagina
As per test kit instructions
Consider transvaginal ultrasound of cervical length if available (see 2.5)
Admit for tocolysis and steroids
Consider transfer to appropriate level facility
False positive result may occur as a result of recent4,5
o Coitus
o Digital vaginal examination
o Transvaginal ultrasound
Low risk of delivery within seven days
False negative result may occur due to4,5
o Use of lubricant with speculum examination
o Intravaginal disinfectants.

Transvaginal ultrasound of cervical length

Transvaginal ultrasound of cervical length (TVCL) is an additional screening test that can aid in
assessing the risk of preterm delivery. TVCL must be performed by a credentialed clinician. Lack of
local capability to perform this test is not a reason for transfer.
2.5.1 Interpreting TVCL results
A cervical length less than 15 mm is associated with an increased risk of spontaneous preterm birth.3
Due to the distances required for transfer from Queensland regional centres, a TVCL cut-off of 20
mm is appropriate.

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Queensland Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

Management of preterm labour

Tocolysis and steroids are the main strategies to manage preterm labour [see section 4, 5]. Transfer
may also be necessary, dependent on the acuity level of the facility and nursery requirements.
Management options will depend on the services available at each facility, such as:
screening test availability
equipment (eg CTG) availability
acuity level of the nursery
If necessary, contact an obstetrician for further advice.

3.1

Negative fFN and no evidence of cervical change / TVCL > 20 mm

There is a low risk of delivery within the next 7 days therefore:

if contractions are infrequent / irregular
o offer discharge home with follow-up as an outpatient within 7 days
if contractions are regular and painful:
o admit for observation
o offer analgesia
o reassess in 2 hours
if contractions are persistent and painful
o consider steroids
o tocolysis and
o transfer if necessary

3.2

Positive fFN and / or evidence of cervical change / TVCL < 20 mm

There is an increased risk of delivery within the next 7 days therefore:

admit and offer analgesia
administer steroids and commence tocolysis (if no contraindications)
continuous fetal monitoring with CTG
transfer if necessary

Tocolysis

The aim of tocolysis is to suppress uterine contractions and delay preterm delivery6,7 to:
allow in-utero transfer to an appropriate level facility
allow for the administration of corticosteroids

4.1

Contraindications

4.2

Gestation > 34 weeks

Labour is too advanced
In utero fetal death
Lethal fetal anomalies
Suspected fetal compromise
Placental abruption
Suspected intra-uterine infection
Maternal hypotension: BP < 90 mmHg systolic

Relative contraindications

Cautiously give tocolysis if:

pre-eclampsia
placenta praevia (if not bleeding)

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Queensland Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

4.3

Nifedipine

Nifedipine is the tocolytic of choice. Nifedipine is a calcium channel blocker that relaxes smooth
muscle.8 It is an effective tocolytic with fewer side effects than other tocolytics available.6
4.3.1 Contraindications
If there are contraindications to Nifedipine, liaise with an Obstetrician to determine alternate
tocolysis.9
Contraindications include8:
previous adverse reaction to calcium channel blockers
maternal cardiac disease
hypotension
hepatic dysfunction
concurrent use with salbutamol or other beta-sympathomimetics
concurrent use of nitrates or antihypertensive medication
4.3.2

Dosage and administration

Table 2. Nifedipine dosage and administration

Nifedipine
Route
Dose

Maintenance Dose
Comments

Side Effects

Observations6,10

Oral
20 mg stat
If contractions persist after 30 minutes: Repeat 20 mg
If contractions persist after a further 30 minutes: Repeat 20 mg
If blood pressure is stable, 20 mg every 6 hours for 48 hours. Further
maintenance therapy is ineffective6
Maximum dose is 160 mg/day8
Do not use sustained release formulation
Use cautiously with magnesium sulphate8
Hypotension
Headache
Facial flushing
Cardiac failure
Tachycardia, palpitations
Nausea
Dizziness
Cardiotocograph monitoring until contractions cease
Pulse rate, respiratory rate and blood pressure monitoring
o every thirty minutes for first hour, then
o second hourly for 24 hours, then
o four hourly
Measure and record temperature every four hours

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Queensland Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

Corticosteroids

Administration of corticosteroids can reduce fetal mortality and morbidity.11 Antenatal corticosteroid
therapy should be initiated in women between 24 and 34 weeks gestation.12

5.1

Dosage and administration

Table 3. Betamethasone dosage and administration

Betamethasone
Route
Dose

Comments

IM
11.4 mg
Repeat 24 hours after initial dose12-14
Where delivery is not imminent, routine prophylactic administration of
steroids is not recommended15,16
If delivery is imminent and it is more than 10 days since the initial dose,
subsequent steroid dose may be administered. Careful clinical
assessment is required, including fFN testing

Antibiotics

Prophylactic antibiotics for GBS are not recommended in threatened preterm labour.17
Prophylactic antibiotics for GBS should be administered in established preterm labour.18

6.1

Dosage and administration

Table 4. Antibiotics dosage and administration

Penicillin
Route
Dose

Comments

IV
1.2 g stat then 600 mg every 4-6 hours19
If there is penicillin hypersensitivity give
o Lincomycin 600 mg IV every 8 hours (on the QH List of
Approved Medications) or
o Clindamycin 900 mg IV every 8 hours19 (not on the QH List of
Approved Medications)
Erythromycin should be avoided17
If GBS screening tests are negative - cease antibiotics

Transfer
Neonatal outcome is improved with appropriate in-utero transfer
If transfer is indicated the relevant obstetric medical coordinator should be contacted via
Retrieval Services Queensland (RSQ) on 1300 799 127
If after discussion with the obstetric coordinator it is thought there may be a risk of
delivery during transfer, in-utero transfer should not be attempted

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Queensland Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

References
1. Australian Bureau of Statistics. Causes of death. [online]. 2005 [cited 2009 March 3]; 2009.
Available from:
http://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/3FFF8096D9500CA9CA25729D001C0B05
/$File/33030_2005.pdf.
2. Giles W, Bisits A, Knox M, Madsen G, Smith R. The effect of fetal fibronectin testing on
admissions to a tertiary maternal-fetal unit and cost savings. Am J Obstet Gynecol. 2000; 182(2):43942.
3. Tsoi E, Akmal S, Geerts L, Jeffery B, Nicolaides K. Sonographic measurement of cervical length
and fetal fibronectin testing in threatened preterm labour. Ultrasound Obstet Gynecol. 2006; 27:36872.
4. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Use of
cervical fetal fibronectin as a screening test for preterm birth. College Statement C-Obs 26. 2008
[cited 2009 March 3]. Available from: www.ranzcog.edu.au/publications/statements/C-obs26.pdf.
5. Anderson HF. Use of fetal fibronectin in women at risk for preterm delivery. Clin Obstet Gynecol.
2000; 43(4):746-58.
6. King J, Flenady V, Papatsonis D, Dekker G, Carbonne B. Calcium channel blockers for inhibiting
preterm labour. Cochrane Database Syst Rev. 2003; Issue1.Art, No.: CD002255.
DOI10.1002/14651858.CD002255.
7. Department of Health New South Wales. Tocolytic agents - protocols for administration for
threatened preterm labour. Circular No 2002/49. 2002.
8. Australian Medicines Handbook. Nifedipine [online]2009 [cited 2009 May 25]. Available from:
https://www-amh-netau.cknservices.dotsec.com/online/view.php?page=chapter17/monographnifedipine02.html#nifedipine-02.
9. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. The use of
nifedipine in obstetrics. College Statement C-Obs 15. 2008.
10. King JF, Flenady V, Papatsonis D, Dekker G, Carbonne B. Calcium channel blockers for
inhibiting preterm labour; a systematic review of the evidence and a protocol for administration of
nifedipine. Aust N Z J Obstet Gynaecol. 2003; 43(3):192-8.
11. Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women
at risk of preterm birth. Cochrane Database Syst Rev. 2006; Issue 3. Art. No.: CD004454. DOI:
10.1002/14651858.CD004454.pub2.
12. Royal College of Obstetricians and Gynaecologists. Antenatal corticosteroids to prevent RDS.
Guideline No.7 [online]. 2004 [cited 2009 March 25]. Available from: http://www.rcog.org.uk/files/rcogcorp/uploaded-files/GT7AntenatalCorticosteroids2004.pdf.
13. Australian Medicines Handbook. Betamethasone [online]2009 [cited 2009 May 25]. Available
from: https://www-amh-netau.cknservices.dotsec.com/online/view.php?page=chapter14/monographbetamethasone.html#betam
ethasone.
14. Antenatal corticosteroids revisited: repeat courses. National Institute of Health Consensus
Statement [online]. 2000 [cited 2009, June 25]; 17(2):1-10. Available from:
http://consensus.nih.gov/2000/2000AntenatalCorticosteroidsRevisted112html.htm.
15. Murphy K, Hannah M, Willan A, Hewson S, Ohlsson A, Kelly E. Multiple courses of antenatal
corticosteroids for preterm birth. Lancet. 2008; 372:2143-51.

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Queensland Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

16. Newnham JP, Jobe AH. Should we be prescribing repeated courses of antenatal
corticosteroids? Semin Fetal Neonatal Med. 2009; 14(3):157-63.
17. Kenyon SL. Broad spectrum antibiotics for spontaneous preterm labour: the ORACLE II trial.
Lancet. 2001; 357:1319-27.
18. Flenady V, Jenkins-Manning, S. Prevention of neonatal early onset Group B streptococcal
disease (EOGBSD). Queensland Clinical Practice Guidelines Working Party 2007.
19. Australasian Society for Infectious Diseases. Management of perinatal infections. [online]. 2002
[cited 2009 May 25]. Available from:
http://www.asid.net.au/downloads/Management%20of%20Perinatal%20Infections%20ASID%202002
%20rev%202007.pdf.

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Queensland Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

Appendix A: Drug Table

Drug Name
Tocolysis

Nifedipine

Dose

Route

Comments

20 mg stat
Repeat 20 mg (if still contracting at
30 minutes)
Final 20 mg (if still contracting after
further 30 minutes)
Maintenance 20 mg every 6 hours
for 48 hours

oral

Do not use sustained

release
CTG whilst
administering
Monitor vital signs
Maximum dose of 160
mg/day

11.4 mg stat, then

Repeat 11.4 mg 24 hours after
initial dose

IM

Repeat doses after

initial course not
recommended

Corticosteroids
Betamethasone

Antibiotics
IV
1.2 g stat, then
Group B streptococcus
prophylaxis
600 mg every 4 6 hours
If the patient has Penicillin hypersensitivity give either Lincomycin or Clindamycin
IV
600 mg every 8 hours
On the QH List of
Lincomycin
Approved Medications
IV
Clindamycin
900 mg every 8 hours
Not on the QH List of
Approved Medications
Penicillin

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Queensland Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour

Appendix B: Acknowledgements
The Maternity and Neonatal Clinical Guidelines Program gratefully acknowledge the contribution of
Queensland clinicians and other stakeholders who participated throughout the guideline development
process particularly:

Working Party Clinical Lead

Dr Liana Tanda, Obstetrician, Caboolture Hospital
Working Party Members
Ms Karen Baker, Midwife, Mackay Base Hospital
Dr Kathleen Braniff, Obstetrician, Mackay Base Hospital
Ms Penelope Dale, Midwife, Royal Brisbane and Womens Hospital
Professor Ian Jones, Obstetrician, Royal Brisbane and Womens Hospital
Dr Christopher King, Obstetrician, Mt Isa Hospital
Ms Mary Hindmarsh, Midwife, Weipa
Professor Michael Humphrey, Obstetrician, Office of Rural and Remote Health
Associate Professor Rebecca Kimble, Obstetrician, Royal Brisbane and Womens Hospital
Dr David Moore, Obstetric Registrar, Gold Coast Hospital
Ms Vivienne Rybarczyk, Midwife, Rockhampton Base
Dr Renukar Sekar, Obstetrician, Royal Brisbane and Womens Hospital
Ms Mary Tredinnick, Pharmacist, Royal Brisbane and Womens Hospital

Program Team
Associate Professor Rebecca Kimble, Director, Queensland Maternity and Neonatal Clinical
Guidelines Program
Ms Joan Kennedy, Principal Program Officer, Queensland Maternity and Neonatal Clinical Guidelines
Program
Mr Stephen Aitchison, Program Officer, Queensland Maternity and Neonatal Clinical Guidelines
Program
Ms Jacinta Lee, Program Officer, Queensland Maternity and Neonatal Clinical Guidelines Program
Mrs Catherine van den Berg, Program Officer, Queensland Maternity and Neonatal Clinical
Guidelines Program
Steering Committee Queensland Maternity and Neonatal Clinical Guidelines Program

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