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SDMS ID: P2010/0498-001 2.

11/09WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Preterm Labour Preterm Labour WACSClinProc2.11/06 Management of threatened preterm labour Midwifery and Medical Staff, Queen Victoria Maternity Unit Preterm labour P2010/0508-001 Tocolysis for Threatened Preterm Labour P2010/0507-001 Preterm Prelabour Rupture of Membranes Purpose: For gestations between 24 to 34 weeks the primary aim is to postpone the birth of the fetus for at least 48 hours whilst steroids are given to accelerate fetal lung maturation. In some clinical situations tocolysis may be indicated to allow transfer to a hospital with appropriate neonatal facilities. The Launceston General Hospital provides care for singleton newborns < 30 weeks or twin newborns < 32 weeks gestation but this is determined on a case by case basis. The best results in postponing birth are obtained in women who have intact membranes and who are less than 5 cm dilated. Fetal factors such as gestational age, chorioamnionitis, known group B Streptococcus carrier status, antepartum haemorrhage and intrauterine growth restriction may dictate that tocolysis is unwise. Definition: Preterm labour is the presence of regular uterine contractions associated with cervical effacement and/or dilation prior to 37 weeks gestation. Assessment Confirm gestational age. Document history to include: o duration/frequency of uterine activity o rupture of membranes o antepartum haemorrhage o urinary symptoms o systemic illness o previous obstetric history eg. preterm birth or caesarean birth o complications of pregnancy eg twins o fetal movement Perform baseline maternal observations. o Palpation of abdomen for o symphysis fundal height o lie o presentation o evidence of uterine activity/tone/tenderness If contracting >1:10 commence CTG and notify registrar
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Auscultate fetal heart rate Perform sterile speculum examination noting any cervical dilation, visible membranes, evidence of PPROM or abnormal PV discharge Consider performing fetal fibronectin if: o Gestation <30 weeks or o Gestation <34 weeks and other complications exist which may warrant transfer to level 3 neonatal nursery o and there is no history of PPROM, bleeding or recent vaginal examination Perform a high vaginal swab for MC&S If any evidence of cervical dilation on speculum examination arrange urgent registrar review If unable to visualise cervix on speculum examination and there is no evidence of spontaneous rupture of membranes a digital vaginal examination maybe considered after performing fetal fibronectin (if < 34 weeks gestation) Obtain urine specimen for urinalysis. Consider MSU if symptoms suggestive of UTI or protein, leucocytes or nitrites on urinalysis Consider IV hydration Hartmanns 3 L over 24 hours.

Tocolysis Consideration should be given for the administration of tocolytics all women experiencing preterm labour when there is a need to delay delivery: to permit in-utero transfer to a tertiary perinatal centre to gain up to 48 hours to allow for the administration of corticosteroids to enhance pulmonary maturity. Corticosteriods Corticosteriods are recommended for lung maturation between 24 weeks and prior to 34 weeks. Two doses of Betamethasone 11.4mg are given intramuscularly 24 hours apart, for prophylaxis against neonatal respiratory distress syndrome. Woman with diabetes mellitus will require additional monitoring if corticosteroids are administered. Antibiotics When Group B Streptococcus status is unknown, women in preterm labour should be treated with antibiotics, as preterm labour is considered a risk factor for Group B Streptococcus and the preterm fetus is more at risk of severe Group B sepsis. Paediatric Consultation When preterm labour is diagnosed (gestation is less than 36 weeks) the obstetric registrar or consultant should consult with paediatric registrar/consultant to develop a management plan and/or arrange transfer to facility with level III neonatal nursery.

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Attachments
Attachment 1

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit. Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years. Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: 17 September 2009

REFERENCES International Preterm Labour Council 2003 Evidence-based labour ward guidelines for the diagnosis, management and treatment of spontaneous preterm labour Journal of Obstetrics and Gynaecology vol. 23. no. 4, 469-478. New South Wales Department of Health Policy Directive 2005 Tocolytic agents Protocols for administration for threatened preterm labour. Online: http://www.health.nsw.gov.au/policies/PD/2005/PD2005_249.html Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database of Systemic Reviews 2006, Issue 3. Art. No.: CD004454. DOI: 10.1002/14651858. CD004454.pub2. Royal College of Obstetricians and Gynaecologist 2002 Clinical Green Top Guidelines: Tocolytic Drugs for Women in Preterm Labour. Online: http://www.rcog.org.uk/index.asp?PageID=536 Royal College of Obstetricians and Gynaecologist 2004 Clinical Green Top Guidelines: Antenatal Corticosteroids to Prevent Respiratory Distress Syndrome. Online: http://www.rcog.org.uk/index.asp?PageID=511

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