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Queensland Health
Clinical Excellence Queensland
Maternity and Neonatal Clinical Guideline
Preterm labour and birth

Queensland Clinical Guideline: Preterm labour and birth
Document title: Preterm labour and birth

Publication date: June 2020
Document number: MN20.6-V9-R25
The document supplement is integral to and should be read in conjunction
Document supplement:
with this guideline.
Amendments: Full version history is supplied in the document supplement.
Replaces document: MN14.6-V8-R19
Author: Queensland Clinical Guidelines
Health professionals in Queensland public and private maternity and
Audience:
neonatal services
Review date: June 2025
Queensland Clinical Guidelines Steering Committee
Endorsed by:
Statewide Maternity and Neonatal Clinical Network (Queensland)
Email: [email protected]
Contact:
URL: www.health.qld.gov.au/qcg
Cultural acknowledgement
We acknowledge the Traditional Custodians of the land on which we work and pay our
respect to the Aboriginal and Torres Strait Islander Elders past, present and emerging.
Disclaimer
This guideline is intended as a guide and provided for information purposes only. The information has been
prepared using a multidisciplinary approach with reference to the best information and evidence available at
the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in
every respect.
The guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation
from the guideline, taking into account individual circumstances, may be appropriate.
This guideline does not address all elements of standard practice and accepts that individual clinicians are
responsible for:
• Providing care within the context of locally available resources, expertise, and scope of practice
• Supporting consumer rights and informed decision making, including the right to decline intervention or
ongoing management
• Advising consumers of their choices in an environment that is culturally appropriate and which enables
comfortable and confidential discussion. This includes the use of interpreter services where necessary
• Ensuring informed consent is obtained prior to delivering care
• Meeting all legislative requirements and professional standards
• Applying standard precautions, and additional precautions as necessary, when delivering care
• Documenting all care in accordance with mandatory and local requirements
Queensland Health disclaims, to the maximum extent permitted by law, all responsibility and all liability
(including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for
any reason associated with the use of this guideline, including the materials within or referred to throughout
this document being in any way inaccurate, out of context, incomplete or unavailable.
Recommended citation: Queensland Clinical Guidelines. Preterm labour and birth. Guideline No.
MN20.6-V9-R25. Queensland Health. June 2020. Available from: http://www.health.qld.gov.au/qcg.
© State of Queensland (Queensland Health) 2020
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Refer to online version, destroy printed copies after use Page 2 of 25

Flow Chart: Assessment and management of preterm labour (< 37 weeks)
Review History In-utero transfer

• Medical, surgical, obstetric, social • Aim for in-utero transfer wherever possible
• If gestation < 28 weeks, accept a high level of risk for
Assess for signs and symptoms birth en-route (unless it puts mother’s life at risk)
• Pelvic pressure • Coordinate transfer via RSQ phone: 1300 799 127
• Lower abdominal cramping
• Lower back pain Antenatal corticosteroids (< 35+0 weeks)
• Vaginal loss–mucous, blood, fluid • Recommend course of betamethasone (2 doses)
• Regular uterine activity o 11.4 mg IM then 2nd dose in 24 hours
o Consider 2nd dose at 12 hours if PTB likely within 24
Physical examination
hours
• Vital signs
• If risk of PTB remains ongoing in 7 days (or more),
• Abdominal palpation
consider repeat dose
• Fetal surveillance–FHR, CTG
• Sterile speculum exam Tocolysis
o Identify if ROM • Nifedipine 20 mg oral
o Visualise cervix/membranes • If contractions persist after 30 minutes repeat dose
o High vaginal swab • If contractions persist after further 30 minutes repeat
o Test for fFN dose
o TVCL (if available) • Maintenance therapy 20 mg every 6 hours for 48
• Low vaginal/anorectal GBS swab hours
• Cervical dilatation–if indicated
Discuss with obstetrician
o Sterile digital vaginal exam
• If contraindications exist
unless ROM, placenta praevia
• If other options required (indomethacin, salbutamol)
• Ultrasound–if available
o Fetal growth and wellbeing
Antibiotics:
Laboratory • If established labour (or imminent risk of PTB) give
Consider as clinically appropriate
• High vaginal swabs for MC&S intrapartum GBS prophylaxis regardless of GBS
• Swab for GBS (vaginal/anorectal) status or membrane status
• Midstream urine for MC&S • If chorioamnionitis (membranes intact or ruptured)
o Ampicillin (or amoxycillin) 2 g IV initial dose, then
1 g IV every 6 hours
o Gentamicin 5 mg/kg IV daily
Consider admission if: o Metronidazole 500 mg IV every 12 hours
• fFN > 50 ng/mL or • If penicillin hypersensitivity and chorioamnionitis:
• Cervical dilation or o Lincomycin OR clindamycin 600 mg IV every 8
• Cervical change over 2–4 hours or hours and
• ROM or o Gentamicin 5 mg/kg IV daily and
• Contractions regular and painful or o Metronidazole 500 mg IV every 12 hours
• Further observation or investigation • If labour does not ensue (and no evidence of
indicated or chorioamnionitis) and membranes intact then cease
• Other maternal or fetal concerns antibiotics
• If PPROM, refer to Queensland Clinical shortGuide:
PPROM and PROM
No Admission Magnesium sulfate

indicated? • Recommend if gestational age less than 30+0 weeks
if birth imminent (within 24 hrs)
• Consider if gestational age 30+0–33+6 weeks
• Labour established or birth imminent (within 24 hrs)
Yes o Loading dose: 4 g IV bolus over 15 minutes
o Maintenance dose: 1 g/hour for 24 hours or until
birth–whichever occurs first
Admit
• Analgesia if required Prepare for birth
• Clinical surveillance • Recommend vaginal birth unless there are specific
• Fetal monitoring/continuous CTG contraindications to vaginal birth or maternal
• Consult as required conditions necessitating caesarean section
• Plan care with the woman
Management after threatened preterm labour
• Plan care according to clinical circumstances
o Maternal and fetal assessments
Discharge o Transfer back to referring hospital where feasible
• Provide information re: signs and o Discharge if usual criteria met
symptoms and returning for care o Inform the woman, GP and usual care provider
• Arrange follow-up as indicated about recommendations for future care
Queensland Clinical Guidelines: Preterm labour and birth. Flowchart version: F20.6-1-V9-R25
CTG: Cardiotocograph, EOGBSD: early onset group B Streptococcus disease, fFN: Fetal fibronectin, FHR: Fetal heart rate, g: grams, GBS: Group
B Streptococcus, GP: general physician, hrs: hours, IM: Intramuscular, IV: Intravenous, kg: kilogram, MC&S: microscopy, culture & sensitivity,
mg: milligrams, PROM: Prelabour rupture of membranes, PPROM: Preterm prelabour rupture of membranes, PTB: Preterm birth, RSQ: Retrieval
Services Queensland, ROM: Rupture of membranes, TVCL: Transvaginal cervical length, >: greater than, <: less than

Table of Contents
Abbreviations ......................................................................................................................................... 5
Definition of terms .................................................................................................................................. 5
1 Introduction ..................................................................................................................................... 6
1.1 Background ............................................................................................................................ 6
1.2 Perinatal mental health .......................................................................................................... 6
2 Risk assessment ............................................................................................................................ 7
3 Risk reduction ................................................................................................................................. 8
3.1 Progesterone therapy ............................................................................................................ 9
3.2 Cervical cerclage ................................................................................................................... 9
4 Clinical assessment of preterm labour ......................................................................................... 10
4.1 Cervical length ..................................................................................................................... 11
4.1.1 Assessment of cervical length ......................................................................................... 11
4.1.2 Cervical length and risk of preterm birth .......................................................................... 11
4.2 Fetal fibronectin testing........................................................................................................ 12
4.2.1 Fetal fibronectin results .................................................................................................... 13
4.3 Assess need for admission .................................................................................................. 13
5 Management of preterm labour .................................................................................................... 14
5.1 Planning care ....................................................................................................................... 14
5.2 In-utero transfer ................................................................................................................... 15
5.3 Antenatal corticosteroids ..................................................................................................... 16
5.4 Tocolysis .............................................................................................................................. 17
5.4.1 Nifedipine ......................................................................................................................... 17
5.4.2 Other tocolytics ................................................................................................................ 18
5.5 Antibiotics............................................................................................................................. 19
5.6 Magnesium sulfate for neuroprotection ............................................................................... 20
5.7 Mode of preterm birth .......................................................................................................... 20
6 Management after threatened preterm labour ............................................................................. 21
References .......................................................................................................................................... 22
Appendix A: Magnesium sulfate for fetal neuroprotection ................................................................... 24
Acknowledgements .............................................................................................................................. 25
List of Tables
Table 1. Perinatal mental health ............................................................................................................ 6

Table 2. Risk factors associated with preterm birth ............................................................................... 7
Table 3. Risk reduction measures ......................................................................................................... 8
Table 4. Progesterone therapy .............................................................................................................. 9
Table 5. Cervical cerclage ..................................................................................................................... 9
Table 6. Clinical assessment ............................................................................................................... 10
Table 7. Cervical length assessment................................................................................................... 11
Table 8. Cervical length and risk of preterm birth ................................................................................ 11
Table 9. Fetal fibronectin testing ......................................................................................................... 12
Table 10. fFN results ........................................................................................................................... 13
Table 11. Assessment of need for admission ..................................................................................... 13
Table 12. Planning care ....................................................................................................................... 14
Table 13. In-utero transfer ................................................................................................................... 15
Table 14. Antenatal corticosteroids ..................................................................................................... 16
Table 15. Tocolysis .............................................................................................................................. 17
Table 16. Nifedipine ............................................................................................................................. 17
Table 17. Other tocolytics .................................................................................................................... 18
Table 18. Antibiotics ............................................................................................................................ 19
Table 19. Magnesium sulfate for neuroprotection ............................................................................... 20
Table 20. Mode of preterm birth .......................................................................................................... 20
Table 21. Management of threatened preterm labour ......................................................................... 21

Abbreviations
BP Blood pressure
BV Bacterial vaginosis
CI Confidence interval
CS Caesarean section
CTG Cardiotocograph
fFN Fetal fibronectin
FHR Fetal heart rate
GBS Group B streptococcus
GP General practitioner
IM Intramuscular
IV Intravenous
MC&S Microscopy, culture and sensitivity
OR Odds ratio
PPROM Preterm prelabour rupture of membranes
PROM Prelabour rupture of membranes
PTB Preterm birth
QH Queensland Health
RR Risk ratio
RSQ Retrieval Services Queensland
TVCL Transvaginal cervical length
Definition of terms
In this guideline, cervical incompetence is defined as the woman’s inability to
Cervical support a full term pregnancy due to a functional or structural defect of the
incompetence cervix. This is often characterised by dilatation and shortening of the cervix
prior to 37 weeks gestation.1
Fetal fibronectin (fFN) is a glycoprotein thought to promote adhesion
between the fetal chorion and maternal decidua.
• Normally present in low concentrations in the cervicovaginal secretions
Fetal fibronectin between 18 and 34–36 weeks gestation, rising as term approaches2
Elevated levels of fFN (typically greater than 50 ng/mL) in cervicovaginal
secretions after 22 weeks gestation are associated with an increased risk of
preterm birth (PTB).
May include (but not limited to) obstetrician/gynaecologist, neonatologist,
Health care social worker, Aboriginal and Torres Strait Islander health worker, general
providers practitioner, midwife, nurse, nurse practitioner, obstetrician, maternal-fetal
medicine specialists, social worker pharmacy, anaesthetics.
Imminent risk of Substantial risk of birth within 24 hours as clinically determined by the
PTB woman’s health care provider.
Gestational age less than 37+0 completed weeks with subcategories of PTB
based on weeks of gestational age3:
• Moderately preterm (32+0–33+6 weeks)
Preterm • Very preterm (28+0–31+6 weeks)
• Extremely preterm (less than 27+6 weeks)
• Where gestational age is less than 25+6 weeks refer to the Queensland
Clinical Guideline Perinatal care at the threshold of viability4
In this guideline, short cervix is defined as less than 25 mm in the second
Short cervix
trimester of pregnancy.

1 Introduction
Preterm labour is a multifactorial condition associated with a high risk of neonatal morbidity and
mortality, especially at lower gestational ages. The incidence of preterm birth (PTB) continues to rise
world-wide. In Queensland in 2017, PTB (less than 37 weeks gestation) occurred in 9.4% of all
pregnancies. In Australia in 2017, PTB accounted for5:
• 1 in 11 births
• 8.7% of all singleton births
• 66% of all twin births
• 14.2% of all the births to Aboriginal and/or Torres Strait Islander women
• 18.4% of all perinatal deaths
1.1 Background
Gestational age, along with individual circumstances and preferences may impact antenatal clinical
management and neonatal outcomes.6 Preterm is commonly defined as gestational age less than
37+0 completed weeks with subcategories of PTB based on weeks of gestational age3:
• Moderately preterm (32+0 to 33+6 weeks)
• Very preterm (28+0 to 31+6 weeks)
• Extremely preterm (less than 27+6 weeks)
Where gestational age is less than 25+6 weeks refer to the Queensland Clinical Guideline Perinatal
care at the threshold of viability.4
1.2 Perinatal mental health

Early and unexpected labour, birth and the hospitalisation of a preterm baby can be distressing for
mothers and families. Early recognition, referral and treatment (if required) of mental health issues
may assist the woman with the often difficult decision making associated with preterm labour and
birth.7
Table 1. Perinatal mental health
Aspect Consideration
• In Australia 10% of women experience antenatal anxiety and/or
depression, increasing to 16% in the postnatal period8
Context • Women, and families, experience significantly higher levels of stress,
anxiety and depression when facing the diagnosis of preterm labour
and/or birth compared with those who birth a baby at term9
• Recommend screening women regularly throughout the pregnancy using
validated tools9 (e.g. Edinburgh Postnatal Depression Scale (EDPS))
Strategies
• Offer referral to perinatal mental health support (e.g. social work, mental
health teams, peer support groups)
• Share and discuss information with the woman and her family, in a
manner that enables informed choice and supports woman centred care
• Offer information to women and families based on individual
circumstances
o Refer to Queensland Clinical Guidelines parent information:
Communication
 Preterm labour and birth10
 Transferring a sick or unwell baby11
• Adhere to usual/standard care recommendations (e.g. women centred
care, respectful communication, consent and informed decision making)
o Refer to Queensland Clinical Guidelines Standard care12
• Support models of care that maximise continuity (e.g. midwifery continuity
of care, case management, midwife navigator, social work, general
practitioner (GP))
Model of care
• A multidisciplinary healthcare approach to care is essential
o Involve the relevant healthcare providers to support the woman’s
individual choice

2 Risk assessment
The cause of spontaneous preterm labour remains unidentified in up to half of all cases.13 Although
many factors have been associated with an increased risk of spontaneous PTB3, there is a relative
paucity of high level research.13,14 The majority of women with traditional risk factors will not
experience PTB and of those women who do, many have no identifiable risk factors. Whether or not
some risk factors are markers for other conditions and/or other risk factors is unknown.
Table 2. Risk factors associated with preterm birth
• Age of woman3,5:
o Younger than 20 years
o Older than 40 years
• Women who smoke during pregnancy5:
o 13.6% babies are born preterm compared to 8.1% of babies whose
mothers did not smoke
• Women residing in rural and remote areas5:
Maternal
o 13.5% babies are born preterm compared to 8.4% in major cities
characteristics
• Women who identify as Aboriginal and/or Torres Strait Islander5:
o 14.2% babies are born preterm compared to 8.5% of babies born to
non-Indigenous women
• Late or no antenatal care
• Lack of continuity of care
• Low socio-economic status
• High or low body mass index (BMI)
• Multiple birth5:
o 66% of twins
o 98.2% of all other multiples (triplets and higher order)
• Presence of fetal fibronectin (fFN) in the vaginal secretions
• Short cervical length15:
o Previous PTB recurrence risk related to gestational age of prior PTB16
o Approximately 30% of women who give birth prematurely in a prior
pregnancy will give birth before 37 weeks in a subsequent pregnancy6
 Extremely preterm: 0.5%, AOR 2.0, (95% CI 1.6 to 2.3)16
 Very preterm: 6.8%, AOR 3.0, (95% CI 2.9 to 3.2)16
Medical and  Moderately preterm: 37.7%, AOR 2.2, (95% CI 2.2 to 2.3)16
pregnancy • Genital tract infections1:
conditions o Bacterial vaginosis17 risk of PTB doubled
• Urinary tract infections18
• Vaginal bleeding18
• Assisted reproduction18 associated with two-fold risk of PTB
• Preterm prelabour rupture of membranes (PPROM)
• Surgical procedures involving the cervix19
• Uterine anomalies18
• Polyhydramnios/oligohydramnios
• Chronic medical conditions
• Acute medical conditions (e.g. preeclampsia, antepartum haemorrhage)

3 Risk reduction
Table 3. Risk reduction measures
• Assess risk factors preconception
• Perform a comprehensive review of all previous pregnancies because the
most important historical risk factor is prior spontaneous PTB13,20
• Counsel women, and refer to appropriate clinicians in the multidisciplinary
team (as appropriate) about modifiable risk factors
Assessment and o Smoking cessation interventions reduce PTB rate by 18% (RR 0.86,
counselling 95% CI 0.74–0.98)17
o Optimisation of control of underlying chronic diseases reduces risk14
o Lifestyle (e.g. balanced diet, activity limitations, stress management)
• Perform a psychosocial assessment and refer as appropriate for support
(e.g. social work or mental health services, health worker, peer support)
• Refer to Section 6 Perinatal mental health
• Bacterial vaginosis (BV) has been associated with increased risk of PTB17
• Women with previous PTB may benefit from routine screening and
treatment of BV17
Bacterial o Routine screening and treatment for asymptomatic BV, in women with
vaginosis (BV) low risk pregnancies, is of minimal benefit
• In women with abnormal vaginal flora, treatment with antibiotics may
reduce the risk of PTB
o Refer to Section 5.5 Antibiotics
• Asymptomatic bacteriuria has been associated with risk of PTB
• Urinary tract infection is associated with threatened preterm labour
Bacteriuria
• Screen and recommend treatment for urinary tract infections
(asymptomatic bacteriuria, cystitis, pyelonephritis) with antibiotics
• Recommend serial transvaginal cervical length (TVCL) measurement for
high risk women with prior PTB
o The optimal frequency has not been established21
o From 14–24 weeks gestation, serial TVCL every two1 weeks may be
appropriate22
• Consider cervical length measurement in women with low risk
Cervical length pregnancies during mid-trimester ultrasound15
measurement • Change in transvaginal sonographic cervical length over time is not a
clinically useful test to predict PTB in women with singleton or twin
pregnancies
o A single cervical length measurement obtained at 18–24 weeks19,23
gestation appears to be a better test to predict PTB than changes in
cervical length over time24
• Refer to Section 4.1.2 Cervical length and risk of preterm birth

3.1 Progesterone therapy

Table 4. Progesterone therapy
• Progesterone therapy is reported to reduce the risk of PTB before 34
weeks from 27.5% to 18.1% (RR 0.66; 0.52 to 0.83) in women with short
cervical length25
Context • Limited evidence about the optimal progesterone regimen and longer term
health effects
• One meta-analysis showed no difference in effect between 90 mg, 100 mg
and 200 mg progesterone pessaries for women with a short cervix25
• Consider prophylactic progesterone therapy from 16–24 weeks
gestation25,26 for women with a singleton pregnancy and a prior
spontaneous PTB
• If indicated, recommend vaginal progesterone suppository 200 mg daily
until at least 34 weeks gestation, or rupture of membranes or birth,
Recommendation whichever occurs first27
• Consider progesterone therapy for asymptomatic women with an
incidentally diagnosed short cervix on TVCL assessment in the second
trimester25
• No intervention has yet been shown to improve outcomes for women with
a short cervix and a multiple pregnancy28
*Refer to an Australian pharmacopoeia for complete drug information
3.2 Cervical cerclage

Table 5. Cervical cerclage
• Compared with no treatment, cervical cerclage reduces the incidence of
PTB in women at risk of recurrent PTB before 37 weeks gestation (RR
0.77, 95% CI 0.66 to 0.89)29
Context • Consider individual clinical circumstances and the potentially serious risks
associated with the procedure26,29
• If cervical cerclage is offered, counsel women about the risk of uterine
contractions, bleeding, ruptured membranes or infection29
• Consider for women with history of26:
o One or more prior spontaneous PTB and/or second-trimester loss
related to painless/painful cervical dilation30 and in the absence of
labour or placental abruption or
o Prior cerclage due to painless cervical dilation in second trimester30 or
o Cervical incompetence
• May be indicated if TVCL less than 25 mm before 24 weeks if19:
o PPROM in a previous pregnancy or
o A history of cervical trauma/surgery or
o Prior spontaneous PTB before 34 weeks gestation and
o Current pregnancy singleton
• Limited data about the effectiveness of rescue cerclage particularly
beyond 24 weeks gestation, therefore individualise decisions1
Recommendation
• Multiple dilation and evacuations or cervical surgery (e.g. cone biopsy,
large loop excision of the transformation zone, laser ablation, diathermy)
or other abnormalities (e.g. Mullerian anomaly) are not themselves an
indication for cerclage
• Not recommended for women with:
o Funnelling of the cervix without cervical shortening of 25 mm or less23
o An incidentally identified short cervix without a history of spontaneous
PTB or second trimester loss19
o Multiple pregnancy31
• Emergency cerclage with cervical dilation more than 1 cm prior to
neonatal viability may be considered based on clinical presentation1
• If cervical cerclage used, ensure a plan is in place for removal of the
suture19
4 Clinical assessment of preterm labour

Identifying and treating women with symptoms of preterm labour, provides the opportunity to utilise
interventions to minimise the impact of PTB. Only around 10% of women who present with symptoms
of preterm labour (contractions) will deliver preterm.2
Appropriate clinical diagnosis of preterm labour may reduce unnecessary interventions and
hospitalisations.
Table 6. Clinical assessment
• Medical
• Surgical
Review history • Obstetric
• Psychosocial and lifestyle
• Refer to Table 2. Risk factors associated with preterm birth
• The most common sequence preceding PTB is cervical ripening
(shortening of the cervix), followed by decidual membrane activation and
then contractions7 characterised by:
o Cervical effacement/dilatation
Signs and
o Pelvic pressure
symptoms
o Lower abdominal cramping
o Lower back pain
o Vaginal loss (mucous, blood or fluid)
o Regular uterine activity
• Vital signs
• Abdominal palpation to assess uterine tone, contractions, fetal size and
presentation
• Sterile speculum examination to:
o Confirm or exclude rupture of membranes
o Assess liquor (e.g. clear, meconium stained, bloody)
o Visualise cervix and membranes
• Collect high vaginal swab for microscopy culture and sensitivity
(MC&S) to test for BV
Physical
• Perform test for the presence of fFN (if not contraindicated)
examination
o Refer to Section 4.2 Fetal fibronectin testing
• If indicated, perform TVCL measurement
o Refer to Section 4.1 Cervical length
• Collect either a vaginal-rectal swab or a vaginal-perianal swab for Group B
streptococcus (GBS)
• Assess cervical dilatation by sterile digital vaginal examination unless
contraindicated by:
o Ruptured membranes
o Suspected placenta praevia
• Fetal heart rate (FHR)
• Continuous CTG
o Consider gestational age (interpret with caution if less than 28 weeks
Fetal surveillance
gestation)
• Ultrasound examination for fetal growth and wellbeing
o Fetal number, presentation, liquor volume and placenta localisation
• High vaginal swabs for BV (MC&S)
Laboratory
• Genital swab for GBS (vaginal-rectal or vaginal-perianal)
investigations
• Midstream specimen of urine for bacteriology (MC&S)

4.1 Cervical length

Transvaginal ultrasound of cervical length (TVCL) can aid in assessing the risk of PTB.
• TVCL must be performed by a credentialed clinician
• Lack of local capability to perform TVCL is not a reason for transfer
4.1.1 Assessment of cervical length
Table 7. Cervical length assessment
• To determine risk of PTB, various cervical lengths between 18–24 weeks
of gestation, have been used (e.g. TVCL less than 25 mm, less than 20
mm or less than 15 mm)15
• Short cervical length is associated with an increased risk of PTB
Context o The shorter the cervical length, the greater the risk15,19
o Refer to Table 8. Cervical length and risk of preterm birth
• When performed by trained operators, transvaginal ultrasound is more
reliable, reproducible and predictive for cervical length assessment
compared to transabdominal ultrasound23
• Recommend TVCL measurement to women with identified, suspected or
high risk of preterm labour (where available)
o Refer to Section 2 Risk assessment
• Consider assessment of cervical length in women with low risk
pregnancies during routine mid-trimester ultrasound (where available)15
• Consider therapeutic interventions when the TVCL is measured at less
Recommendation
than 25 mm15
• fFN testing, alongside TVCL measurement, has been shown to increase
the predictive quality of PTL risk
o Consider fFN testing in conjunction with TVCL measurement in
symptomatic and asymptomatic women with risk factors of PTL
o Refer to Section 4.2 Fetal fibronectin testing32
4.1.2 Cervical length and risk of preterm birth
Table 8. Cervical length and risk of preterm birth
Cervical length Likelihood ratio for birth at X weeks gestation33

(mm) < 28 28–30 31–33 34–36
<2 745.29 74.29 44.22 99.36
5 119.19 36.81 24.26 18.10
7 62.08 27.80 19.08 11.15
10 26.79 18.24 13.31 6.53
12 16.29 13.77 10.47 4.93
15 8.26 9.04 7.30 3.47
18 4.45 5.93 5.09 2.60
20 3.03 4.48 4.01 2.20
22 2.10 3.38 3.15 1.89
25 1.25 2.22 2.20 1.53

4.2 Fetal fibronectin testing

In this guideline the quantitative fFN test is preferred because of its ability to provide a quantifiable test
result that better informs management over and above other tests that only provide a ‘positive’ or
‘negative’ result (e.g. non-quantitative fFN/Quickcheck® or Actim Partus®).
Table 9. Fetal fibronectin testing
• fFN is a glycoprotein thought to promote adhesion between the fetal
chorion and maternal decidua
o Normally present in low concentrations in the cervicovaginal secretions
between 18 and 34–36 weeks gestation, rising as term approaches2
• Elevated levels of fFN (typically greater than 50 ng/mL) in cervicovaginal
Context secretions after 22 weeks gestation are associated with an increased risk
of PTB34
• A negative fFN is associated with a 99.5% negative predictive value for
PTB within 7 days and 99.2% in the next 14 days2
• Consider use of the QUIPP® app to assist with interpretation and
management decisions
• Symptomatic women with threatened preterm labour:
o Between 22+0 and 36+0 weeks gestation and
o Intact membranes and
o Cervical dilatation less than or equal to 3 cm
Indications OR
• Asymptomatic women, greater than 22 weeks gestation, with a history of:
o Cervical surgery/trauma35 or
o PTB in previous pregnancy or
o Late miscarriage in previous pregnancy36
• Cervical dilatation more than 3 cm
• Ruptured membranes
Contraindications
• Cervical cerclage in situ
• Presence of soaps, gels, lubricants or disinfectants
• Visual evidence of moderate or gross bleeding
• Within 24 hours of vaginal intercourse
Relative
contraindications • A negative fFN result of less than 10 ng/mL is still valid:
o If a woman reports having intercourse in the previous 24 hours
o In the presence of moderate or gross vaginal bleeding
• Performed during sterile speculum examination prior to any examination
of the cervix or vagina
Procedure • Use only sterile water as a lubricant
• Obtain the sample for testing from the posterior fornix of the vagina
• Follow test kit instructions
• Quantitative fFN testing may improve assessment of overall risk37, reduce
unnecessary transfer and ultimately reduce longer term costs38
Quantitative fFN
• Avoids unnecessary interventions
testing
• Identifies women for targeted interventions
• Provides reassurance to health care providers and the woman

4.2.1 Fetal fibronectin results
Table 10. fFN results
• Low risk of birth within 7–14 days2
• fFN less than 10 ng/mL
fFN less than 50 o Higher negative predictive value for PTB (2.7%)39
ng/mL (negative) • False negative result may occur due to40:
o Use of lubricant with speculum examination
o Intravaginal disinfectants
• High risk of birth within 7–14 days
• fFN greater than 200 ng/mL35
o Higher positive predictive value for PTB (38%)41
 Provides reassurance to clinicians to provide immediate intervention
fFN 50 ng/mL or
and/or transfer
more
(positive) • False positive may occur as a result of recent:
o Vaginal intercourse
o Digital vaginal examination
o Transvaginal ultrasound
o Bleeding
4.3 Assess need for admission

Use clinical judgement and appropriate consultation in assessing the need for admission. Consider
the fFN result in the context of the overall clinical circumstances, the resources available and the
service capability of the facility [refer to Section 5 Management of preterm labour]. If membranes are
ruptured use alternate care pathways.
Table 11. Assessment of need for admission
Aspect Assessment (assumes intact membranes)

• Consider admission for reassessment and/or therapeutic interventions if
any of the following19:
o fFN test greater than or equal to 50 ng/mL
 Admission recommended if fFN test greater than 200 ng/mL
o TVCL changes and/or less than 25 mm (if measured)
o Cervical dilation (painless or painful)
Admission
o Cervical change over 2–4 hours
indicated
o Contractions regular and painful
o Further observation or investigation indicated
o Other maternal or fetal concerns
• Refer to Table 12. Planning care
• If membranes ruptured refer to Queensland Clinical Guidelines: Preterm
prelabour rupture of membranes42
• If fFN less than 50 ng/mL and admission not otherwise indicated,
discharge home if19:
o Maternal vital signs within normal parameters
o Normal fetal heart rate (FHR) and/or CTG relevant to gestational age
o No signs of chorioamnionitis
o Contractions infrequent/irregular
o No/minimal cervical change
• Inform woman about:
o Signs and symptoms of preterm labour
Admission not
o Risk reduction measures appropriate to the circumstances
indicated
 Refer to Section 3 Risk reduction
o When to seek clinical advice
• Arrange follow-up:
o If fFN 0–9 ng/mL routine follow-up as per usual model of care
 Less than 2% birth within two weeks
 Less than 2% birth before 34 weeks
o If fFN 10–49 ng/mL return for medical review within 7 days
 Less than 2% birth within two weeks
 5–15% birth before 34 weeks

5 Management of preterm labour

Tocolysis and steroids are the main strategies to manage preterm labour. Transfer to a centre with
higher service capability may also be necessary. Management options will depend on:
• Gestational age and individual clinical circumstances
• Resource (equipment and human) availability to provide the required care (e.g.
cardiotocograph (CTG), one to one midwifery care when indicated)
• Acuity level of the facility (care is provided in accordance with the Clinical Service
Capability Framework (CSCF))43
• If necessary, refer to a service with higher level capability for further advice when access
to services are unavailable/limited
There are current validated technologies (e.g. QUIPP® app) being utilised in some Queensland
facilities. These may assist in diagnosing preterm labour using fFN and TVCL results and may help
decision making.
5.1 Planning care

Use clinical judgement and appropriate consultation in planning care.
Table 12. Planning care
% birthing
fFN before
Care considerations within
ng/mL 34+0
2 weeks
weeks
• Develop local protocols that:
o Are contextually and culturally appropriate
o Consider in-utero transfer (as relevant to service
capability)
o Identify referral processes that support women accessing
the most appropriate treatment in a timely way
• Admit for observation
• Offer analgesia
• Administer corticosteroids if less than 35+0 weeks
• Measure TVCL if resources available
All women
requiring • Communicate with multidisciplinary team as relevant to the
circumstances (e.g. neonatology consultation, social worker
admission
referral, anaesthetic involvement)
• Discuss plan for ongoing care with the woman in a manner
that supports informed choice
• Document plan of care in the health record
• Clinical reassessment as required
• If labour is established or birth appears imminent, and
gestational age is less than 30 weeks, commence
magnesium sulfate for neuroprotection of the fetus
o Refer to Appendix A: Magnesium sulfate for fetal
neuroprotection
As for all women requiring admission and consider
50–199 • Tocolysis if delay of birth indicated and no contraindications 5–15 10–15
• All clinical circumstances including history of PTB
As for all women requiring admission and
200-499 • Commence tocolysis if delay of birth indicated and no 30 30
contraindications
As for all women requiring admission and
• Commence tocolysis if delay of birth indicated and no
≥ 500 or
contraindications 50 75
more
• Prepare for administration of magnesium sulfate (if
gestational age less than or equal to 30 weeks)

5.2 In-utero transfer

Table 13. In-utero transfer
• Neonatal outcomes are improved if PTB occurs in centres that manage high
numbers of preterm babies44-46
Context
• If transfer required, contact Retrieval Services Queensland (RSQ) on 1300 799
127
• May accept a high level of risk of birth occurring en-route when gestational age is
less than 28+0 weeks
o Transfer discussions and decisions occur between senior clinicians
o Use RSQ conference calls to facilitate involvement of all relevant clinicians in
the most time efficient manner
o Discuss with RSQ medical co-ordinator the tasking of a second aeromedical
clinician to accompany the flight nurse
Principles for • Transfer decisions involve both obstetric and neonatal clinicians, particularly at the
transfer receiving site and the RSQ medical co-ordinator from an aeromedical asset
allocation perspective
• Recognise that retrieval platforms may not be immediately available (e.g. due to
pilot and crew hours, weather or aircraft service needs)
• Decisions about transfer may be escalated within RSQ by receiving or transferring
clinicians, or by the flight nurse as required
• RSQ will co-ordinate a combined services audit of births less than 28+0 weeks
gestational age occurring outside a level 6 neonatal unit
• If birth is considered a possibility en-route:
o Perform clinical assessment of the woman by the transferring consultant or
equivalent
 Refer to Section 4.3 Assess need for admission
Clinical assessment
• Reassess the woman after initial stabilisation to review timelines around transfer
decisions, particularly if there are delays in transfer or transfer is not immediately
feasible
• If clinically appropriate, use tocolysis to allow in-utero transfer
• Accountability and responsibility for transfer decisions and their outcomes reside
with the transferring and receiving consultants
o Accountability and responsibility for transfer decisions and outcomes does not
reside with the flight nurse
• The transferring consultant (or equivalent) is responsible for:
o Discussing risks and benefits of in-utero transfer with the woman/partner/family
Accountability and including the limited resuscitation that will be provided should birth occur en-
responsibilities route
o Ensuring comprehensive documentation in the health record and transfer
documents of
 Discussions that have occurred with woman and family
 Clinical assessment of the woman and the assessed risk of PTB
 Discussions between receiving and transferring clinicians about the planned
transfer
• Contact RSQ to task a neonatal retrieval team to meet the aircraft
• Intubation and/or full resuscitation is not generally feasible within the aircraft
If birth occurs environment
en-route o Neonatal resuscitation measures (should birth occur en-route) may include (but
are not necessarily limited to) keeping baby warm, administering oxygen,
providing continuous positive airway pressure (CPAP) via bag and mask)
• If preterm birth is very likely and life sustaining interventions are planned or may
be a possibility, recommend in-utero transfer
• In-utero transfer not indicated if palliative care planned
o Refer to Queensland Clinical Guideline Perinatal care at the threshold of
viability4
Recommendation • If life sustaining interventions are to be initiated only if a specific gestational age
achieved (e.g. interventions only if gestation reaches 24 weeks) then arrange
transfer prior to the specified gestation (i.e. don’t wait until 24 weeks+0 days)
• If gestational age uncertain, then discuss with the receiving neonatal and obstetric
unit
• Inform the family that transfer does not oblige or necessarily equate to a final
decision for life sustaining interventions

5.3 Antenatal corticosteroids

Table 14. Antenatal corticosteroids
• Administration of antenatal corticosteroids at less than 35+0 weeks
gestation are associated with:
o Significant reduction in rates of neonatal death, respiratory distress
syndrome and intraventricular haemorrhage (IVH)47
o Reduction in necrotising enterocolitis, respiratory support, intensive
care admissions and systemic infections in the first 48 hours of life
compared with no treatment or treatment with placebo47
Context • Beneficial effect demonstrated regardless of membrane status47
• No evidence of long term harm or benefit (in early childhood) from multiple
courses of antenatal corticosteroids48
• If the risk of PTB persists seven or more days after initial course, repeat
dose(s) are associated with48:
o Less respiratory distress and fewer serious health problems in the first
few weeks after birth
o Small reduction in size at birth
• Routinely recommend corticosteroids to women with a viable fetus who
are at increased risk of PTB47 before 35+0 weeks gestational age47,49
• Determine the need for further weekly repeat dose(s) based on clinical
assessment of the ongoing risk of PTB
Recommendation o If the risk of PTB persists seven or more days after initial course,
consider a repeat dose of corticosteroids48
o Seek expert obstetric/neonatal advice if uncertainty exists about
continued risk of PTB
o If there is maternal diabetes, monitor blood glucose levels
• Initial course of antenatal corticosteroids (two doses, 24 hours apart)38,49
o 1st dose: Betamethasone 11.4 mg IM
o 2nd dose: Betamethasone 11.4 mg IM, 24 hours after 1st dose (if PTB
Administration*
likely within 24 hours, consider repeat dose at 12 hours)
• Repeat dose of antenatal corticosteroids (single dose)
o Betamethasone 11.4 mg IM

5.4 Tocolysis
Table 15. Tocolysis
• Tocolytic drugs may delay birth and allow19:
o Administration of corticosteroids
o Administration of magnesium sulfate for neuroprotection
o In-utero transfer to an appropriate level facility
Context • Tocolysis not associated with a clear reduction in perinatal mortality or
serious neonatal morbidity
• No evidence to support the use of prophylactic tocolytic therapy after
contractions have ceased
• Recommend when a 48 hour delay in birth will benefit the newborn
• There is limited evidence about the use of tocolytics in the setting of
PPROM50
• Gestational age is a major determinant for management
• Tocolysis in women with PPROM before 34+0 weeks associated with50:
PPROM
o A lower risk of birth within 48 hours
o An increased risk of chorioamnionitis without significant maternal or
neonatal benefit
• Tocolysis before viability not generally recommended50
• Maternal contraindications to tocolysis (agent specific)
• Any condition where prolongation of pregnancy is contraindicated
including but not limited to:
o In-utero fetal death/lethal fetal anomalies
Contraindications o Suspected fetal compromise
o Maternal bleeding with hemodynamic instability
o Severe pre-eclampsia
o Placental abruption
o Chorioamnionitis
5.4.1 Nifedipine
Table 16. Nifedipine
• Nifedipine is a calcium channel blocker that relaxes smooth muscle
• Nifedipine is the tocolytic of choice51,52
Context • Do not use sustained release formulation
o Immediate release formulation available with special scheme access
(SAS) authority
• If there are contraindications to nifedipine, liaise with an obstetrician to
determine alternate tocolysis53
• Contraindications include:
o Maternal hypotension or cardiac disease (risk of fluid overload)
Cautions*
o Previous adverse reaction to calcium channel blockers
• Use cautiously with magnesium sulfate
o Concomitant use may increase effects of magnesium sulfate and the
risk of hypotension
• Nifedipine 20 mg oral stat53
• If contractions persist after 30 minutes repeat nifedipine 20 mg oral
Administration*
• If contractions persist after a further 30 minutes repeat nifedipine 20 mg
oral
• If blood pressure (BP) stable: nifedipine 20 mg oral every 6 hours for 48
Maintenance* hours—maximum dose is 160 mg/day53
• Further maintenance therapy is ineffective54
• CTG until contractions cease (relative to gestation)
• BP, pulse and respiratory rate
Observations o Every thirty minutes for first hour, then hourly for four hours
o Review frequency in accordance with clinical circumstances
• Temperature every four hours
5.4.2 Other tocolytics
Table 17. Other tocolytics
• Compared to placebo, betamimetics are effective tocolytic agents55,56, but
significant adverse side effects including maternal death from pulmonary
Betamimetics
oedema have been reported56
(salbutamol,
• No evidence to support oral betamimetics for maintenance after
terbutaline)*
threatened preterm labour57
• Not recommended unless there are contraindications to other tocolytics
• Potent inhibitor of uterine contractility by inhibiting cyclo-oxygenase (COX)
enzyme55 but limited high level evidence with few adequate trials58,59
• Risks for the fetus and neonate include58,60:
o Constriction of the fetal ductus arteriosus (increased risk with advancing
gestational age; the effects are transient and reversible with short term
administration; longer administration may lead to pulmonary
hypertension in the fetus and neonate)
Inhibitors of
o Alteration of fetal (especially cerebral) blood flow
prostaglandin
o Reduced renal function (may result in oligohydramnios)
synthesis
o Necrotising enterocolitis
(indomethacin)*
• Because of the potential adverse fetal and neonatal effects, consider use
of indomethacin only where:
o Gestational age is less than 28+0 weeks
o There is failure to achieve tocolysis with other tocolytic regimens
o Contraindications to other tocolytics exist (e.g. cardiac disease)
• With indomethacin administration, ensure close monitoring of fetal
wellbeing

5.5 Antibiotics
Table 18. Antibiotics
Preterm labour • If preterm labour ensues or there is imminent risk of PTB, give intrapartum
(or imminent risk antibiotic prophylaxis for prevention of early onset Group B streptococcal
of PTB) without disease irrespective of GBS status or membrane status
evidence of • Refer to Queensland Clinical Guideline: Early onset Group B
chorioamnionitis* streptococcal disease61
• Signs of chorioamnionitis include62:
o Maternal fever greater than 38 °C (present in 95–100% of cases)
Signs of o Maternal tachycardia greater than 100 beats per minute (bpm) (present
chorioamnionitis in 50–80% of cases)
(intact or o Fetal tachycardia greater than 160 bpm (present in 40–70% of cases)
ruptured o Uterine tenderness
membranes) * o Offensive smelling vaginal discharge
o Increased white cell count (greater than 15x109/L)
o Elevated C-reactive protein (CRP)
• Do not inhibit labour, but consider hastening birth under broad spectrum
intravenous antibiotic cover
• Suspect chorioamnionitis in women with PPROM if labour ensues
• Optimal antibiotic regimen not established—if no local protocols exist
suggested regimen63:
o Ampicillin (or amoxycillin) 2 g IV initial dose, then 1 g IV every 6 hours
o Metronidazole 500 mg IV every 12 hours
Management of
chorioamnionitis • If allergic to penicillin:
o Lincomycin 600 mg IV in 100 mL over 1 hour every 8 hours OR
clindamycin 600 mg IV in 50–100 mL over at least 20 minutes every 8
hours
o Metronidazole 500 mg IV every 12 hours
• Continue antibiotic treatment after birth
• Consider oral antibiotics once woman is afebrile and tolerating oral
medication
• Routine administration of prophylactic antibiotics to women in threatened
preterm labour with intact membranes and without evidence of infection is
not recommended49,64
• If preterm labour does not commence and no other indications:
Woman not in
o If intact membranes, cease antibiotics
preterm labour
o Refer to Queensland Clinical Guideline: Early onset Group B
streptococcal disease61
• If PPROM refer to Queensland Clinical Guideline: Preterm prelabour
rupture of membranes–preterm (PPROM)42

5.6 Magnesium sulfate for neuroprotection

Table 19. Magnesium sulfate for neuroprotection
• Magnesium sulfate administered shortly before birth may assist in
reducing the risk of cerebral palsy and protect gross motor function in
those babies born preterm19,49
o Number needed to treat (NNT): 63 babies for one baby to avoid
cerebral palsy (95% CI 44–155)65
o Number needed to treat to benefit (NNTB): 42 babies for combined
Context death or cerebral palsy (95% CI 24–346)65
o The effect may be greatest at early gestations and is not associated
with adverse long-term fetal or maternal outcome66
• In one follow-up randomised controlled trial, magnesium sulfate was not
associated with improved neurological, cognitive, behavioural, growth or
functional outcomes in school age children although mortality advantage
could not be excluded67
• Recommend magnesium sulfate to women with a viable fetus before 30+0
weeks gestation 19,66 where birth is expected or planned within 24 hours19
o Consider magnesium sulfate for women between 30+0 and 33+6 weeks
gestation19
• If birth is planned, commence administration as close to four hours prior to
birth as possible66
• Best effect when given for at least four hours within the six hours prior to
birth
Recommendation
• If birth is expected to occur within four hours, commence magnesium
*
sulfate immediately, as there may still be benefit from administration66
• In situations where urgent birth is necessary, do not delay birth to
administer magnesium sulfate66
• If birth does not occur after giving magnesium sulfate and PTB (less than
30 weeks gestation) again appears imminent (planned or expected within
24 hours), a repeat dose of magnesium sulfate may be considered at the
discretion of the obstetrician66
• Refer to Appendix A: Magnesium sulfate for fetal neuroprotection
5.7 Mode of preterm birth

Table 20. Mode of preterm birth
• There is insufficient high quality evidence about whether mode of birth
affects neonatal morbidity and outcomes68,69
• Preterm caesarean section (CS) is usually technically more difficult to
perform and is not without risk to the baby as the lower segment is usually
not well formed70
Context
o A classical incision may be required with risks to future pregnancies
including scar dehiscence, uterine rupture, placental adherence and
maternal death
o Discuss implications of decision with the woman
• Early consultation with anaesthetic team required
Singleton vertex • Recommend vaginal birth unless there are specific contraindications to
presentation vaginal birth or maternal conditions necessitating CS68
Breech • The evidence regarding optimal mode of birth for preterm breech is
presentation conflicting and unclear due to a lack of high quality studies
26+0 weeks or • Base decisions on individual circumstances and maternal preferences
more gestation • CS is not generally recommended where vaginal birth is imminent68
• CS for fetal indications alone not generally recommended at less than
25+6 weeks or
25+0 weeks gestation4
less gestation
• Refer to Queensland Clinical Guideline: Perinatal care at the threshold of
(vertex or breech)
viability4

6 Management after threatened preterm labour

When PTB does not occur following admission for threatened preterm labour, co-ordinate care and
discharge planning with the family, relevant health care professionals and the referring hospital (as
required).
Table 21. Management of threatened preterm labour
• Plan care relevant to the underlying clinical circumstances
• Use clinical judgement and as clinically appropriate consider:
o Consultation/referral/transfer
o Serial TVCL
Prolonged o Progesterone
admission o Fetal assessments
o Maternal investigations and assessments
o Repeat fFN testing
o Planning for PTB
• Frequency of clinical observations (e.g. temperature, blood pressure)
• If discharge home is not considered an option, transfer back to the
referring hospital where feasible
• Consider:
o Individual clinical circumstances and likelihood of PTB
Back transfer o Gestational age, and maternity and neonatal clinical service capability
of the receiving hospital
o Access to required ongoing monitoring and clinical surveillance
o Preferences of the woman and her family
• Retrieval logistics and aircraft availability
• Consider usual discharge criteria including:
o Maternal vital signs
o Signs of chorioamnionitis
o Membrane status
o If contractions infrequent/irregular
o Cervical change/TVCL (if measured)
o Normal CTG relevant to gestational age
o fFN test result
Discharge
• Inform woman of:
o Signs and symptoms of preterm labour
o Risk reduction measures appropriate to the circumstances
 Refer to Section 3 Risk reduction
o When to seek clinical advice
o Refer to Queensland Clinical Guidelines Preterm labour and birth10
parent information
• Determine follow-up and on-going clinical surveillance requirements
• Inform the woman, the usual health care provider and/or referring hospital
Referral and about the recommendations for follow-up and ongoing clinical surveillance
follow-up (e.g. GP, birth centre, private midwife)
• Offer social worker referral as indicated

References
1. The Society of Obstetricians and Gynaecologists of Canada. Cervical insufﬁciency and cervical cerclage. Clinical Practice Guideline
No. 373. Journal of Obstetrics and Gynaecology Canada 2019;41(2):233-47.
2. McCue B, Torbenson VE. Fetal Fibronectin: the benefits of a high negative predictive value in management of preterm labor.
Contemporary Obstetrics and Gynecology. [Internet]. 2017 [cited 2019 October 10]; 62(9):1-6.
3. World Health Organization. Born too soon: the global action report on preterm birth. [Internet]. 2012 [cited 2019 October 03].
Available from: http://www.who.int.
4. Queensland Clinical Guidelines. Perinatal care at the threshold of viability Guideline No. MN14.32-V1-R19. [Internet]. Queensland
Health. 2014. [cited 2019 October 09]. Available from: http://www.health.qld.gov.au
5. Australian Institute of Health and Welfare. Austalia's mothers and babies 2017-in brief. [Internet]. 2019 [cited 2019 October 03].
Available from: https://www.aihw.gov.au.
6. Phillips C, Velji Z, Hanly C, Metcalfe A. Risk of recurrent spontaneous preterm birth: a systematic review and meta-analysis. British
Medical Journal. [Internet]. 2017 [cited 2019 October 09]; DOI:10.1136/bmjopen-2016-015402.
7. Horsch A, Tolsa J-F, Gilbert L, Chêne L, Müller-Nix C, Graz M, et al. Improving maternal mental health following preterm birth using
an expressive writing intervention: a randomized controlled trial. Child Psychiatry & Human Development. [Internet]. 2016 [cited 2020
April 7]; 47(5):780-91 DOI:10.1007/s10578-015-0611-6.
8. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Mental health care in the perinatal period.
College Statement C-Obs 48. [Internet]. 2018 [cited 2020 April 7]. Available from: http://www.ranzcog.edu.au/.
9. Accortt E, Cheadle A, Dunkel Schetter C. Prenatal depression and adverse birth outcomes: an updated systematic review. Maternal
& Child Health Journal. [Internet]. 2015 [cited 2020 April 7]; 19(6):1306-37 DOI:10.1007/s10995-014-1637-2.
10. Queensland Clinical Guidelines. Consumer information: preterm labour and birth. Guideline No. C20.6-2-V2-R25. [Internet].
Queensland Health. 2020. [cited 2020 April 20]. Available from: http://www.health.qld.gov.au
11. Queensland Clinical Guidelines. Consumer information: baby needing transfer. Guideline No. C18.18-1-V2-R23. [Internet].
Queensland Health. 2018. [cited 2019 October 08]. Available from: http://www.health.qld.gov.au
12. Queensland Clinical Guidelines. Standard care. Guideline No. MN18.50-V1-R23. [Internet]. Queensland Health. 2018. [cited 2019
October 03]. Available from: http://www.health.qld.gov.au
13. Iams JD, Berghella V. Care for women with prior preterm birth. American Journal of Obstetrics and Gynecology. 2010; 203(2):89-
100.
14. Piso B, Zechmeister-Koss I, Winkler R. Antenatal interventions to reduce preterm birth: an overview of Cochrane systematic
reviews. Cochrane Database of Systematic Reviews. 2014; 7(1):265.
15. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Measurement of cervical length for
prediction of preterm birth. College Statement C-Obs 27. [Internet]. 2017 [cited 2019 October 03]. Available from:
http://www.ranzcog.edu.au/.
16. Yang J, Baer RJ, Berghella V, Chambers C, Chung P, Coker T, et al. Recurrence of preterm birth and early term birth. Obstetrics
and Gynecology. [Internet]. 2016 [cited 2019 October 3]; 128(2):364-72.
17. Department of Health. Clinical practice guidelines: pregnancy care guidelines. [Internet]. 2019 [cited 2019 October 03]. Available
from: http://www.health.gov.au.
18. Zeynep Asli Oskovi K, Ozgu-Erdinc AS. Prediction of preterm birth: maternal characteristics, ultrasound markers, and biomarkers:
an updated overview. Journal of Pregnancy. [Internet]. 2018 [cited 2020 April 20]; 2018 DOI:10.1155/2018/8367571.
19. National Institute for Health and Clinical Excellence (NICE). Preterm labour and birth. [Internet]. 2015 [cited 2019 October 03].
Available from: http://www.nice.org.uk.
20. Edlow AG, Srinivas SK, Elovitz MA. Second-trimester loss and subsequent pregnancy outcomes: what is the real risk? American
Journal of Obstetrics and Gynecology. 2007; 197(6):581 e1-6.
21. Son M, Miller, Emily S. Predicting preterm birth: cervical length and fetal fibronectin. Seminars in Perinatology. [Internet]. 2017
[cited 2019 October 03]; DOI:10.1053/j.semperi.2017.08.002.
22. Melamed N, Pittini A, Hiersch L, Yogev Y, Korzeniewski SJ, Romero R, et al. Do serial measurements of cervical length improve
the prediction of preterm birth in asymptomatic women with twin gestations? 2016; 215 DOI:10.1016/j.ajog.2016.06.034.
23. Westerway SC, Pedersen LH, Hyett J. Cervical length measurement: comparison of transabdominal and transvaginal approach.
Australasian Journal Of Ultrasound In Medicine. [Internet]. 2015 [cited 2020 January 25]; 18(1):19-26.
24. Conde-Agudelo AR, Roberto R. Predictive accuracy of changes in transvaginal sonographic cervical length over time for preterm
birth: a systematic review and metaanalysis. American Journal of Obstetrics and Gynecology. [Internet]. 2015 [cited 2019 October 03];
DOI:10.1016/j.ajog.2015.06.015.
25. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Progesterone: use in the second and third
trimester of pregnancy for the prevention of preterm birth. College Statement C-Obs 29b. [Internet]. 2017 [cited 2019 October 03].
Available from: http://www.ranzcog.edu.au/.
26. Jarde A. Effectiveness of progesterone, cerclage and pessary for preventing preterm birth in singleton pregnancies: a systematic
review and network meta-analysis. [Internet]. 2017 [cited 2019 October 03]; DOI:10.1111/1471-0528.14624.
27. Hösli I, Sperschneider C, Drack G, Zimmermann R, Surbek D, Irion O. Tocolysis for preterm labor: expert opinion. Archives Of
Gynecology And Obstetrics. [Internet]. 2014 [cited 2019 October 03]; 289(4):903-9 DOI:10.1007/s00404-013-3137-9.
28. The American College of Obstetricians and Gynecologists. Prediction and prevention of preterm birth. Practice Bulletin Number
130. Obstetrics and Gynecology. 2012; DOI:10.1097/AOG.0b013e3182723b1b
29. Alfirevic Z, Stampalija T, Medley N. Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy. Cochrane
Database of Systematic Reviews. [Internet]. 2017 [cited 2019 October 03]; (6) DOI:10.1002/14651858.CD008991.pub3.
30. Boelig RC, Berghella V. Current options for mechanical prevention of preterm birth. Seminars in Perinatology. [Internet]. 2017
[cited 2020 February 26]; 41(8):452-60 DOI:10.1053/j.semperi.2017.08.003.
31. Norwitz E. Transvaginal cervical cerclage. [Internet]. Waltham MA: UpToDate Inc; January 2020 [cited 2020 April 9]. Available
from: htps://www.uptodate.com.
32. Suff N, Story L, Shennan A. The prediction of preterm delivery: what is new? Seminars in Fetal and Neonatal Medicine. 2019;
24(1):27-32.
33. Celik E, To M, Gajewska K, Smith GC, Nicolaides KH. Cervical length and obstetric history predict spontaneous preterm birth:
development and validation of a model to provide individualized risk assessment. Ultrasound Obstetrics and Gynecology. [Internet].
2008 [cited 2020 February 23]; 31(5):549-54 DOI:10.1002/uog.5333.
34. Berghella V, Hayes E, Visintine J, Baxter JK. Fetal fibronectin testing for reducing the risk of preterm birth. Cochrane Database of
Systematic Reviews. [Internet]. 2008 [cited 2019 October 03]; DOI:10.1002/14651858.CD006843.pub2.
35. Vandermolen BI, Hezelgrave NL, Smout EM, Abbott DS, Seed PT, Shennan AH. Quantitative fetal fibronectin and cervical length
to predict preterm birth in asymptomatic women with previous cervical surgery. American Journal of Obstetrics and Gynecology. 2016
[cited 2020 January 28]; 215(4):480-1.
36. Sarah P, Alison D, Sean D. Prediction of recurrent preterm delivery in asymptomatic women-an anxiety reducing measure?
European Journal of Obstetrics & Gynecology and Reproductive Biology. [Internet]. 2019 [cited 2019 November 21];
DOI:10.1016/j.eurox.2019.100064.
37. Abbott DS, Radford SK, Seed PT, Tribe RM, Shennan AH. Evaluation of a quantitative fetal fibronectin test for spontaneous
preterm birth in symptomatic women. American Journal of Obstetrics and Gynecology. 2013; 208(2):122 e1-6.
38. The American College of Obstetricians and Gynecologists. Management of preterm labor. Practice Bulletin No. 171.
2016;128(4):e155-e64.

39. Abbott DS, Hezelgrave NL, Seed PT, Norman JE, David AL, Bennett PR, et al. Quantitative fetal fibronectin to predict preterm birth
in asymptomatic women at high risk. [Internet]. 2015 [cited 2020 February 26]; 125(5):1168-76 DOI:10.1097/aog.0000000000000754.
40. Kiefer DG, Vintzileos AM. The utility of fetal fibronectin in the prediction and prevention of spontaneous preterm birth. 2008;
1(3):106-12.
41. Hezelgrave NL, Shennan AH. Quantitative fetal fibronectin to predict spontaneous preterm birth: a review. Women's Health. 2016
[cited 2020 January 28]; 12(1):121-8 DOI:10.2217/whe.15.74.
42. Queensland Clinical Guidelines. Preterm prelabour rupture of membranes (PPROM). Guideline No. MN18.48-V1-R23. [Internet].
Queensland Health. 2018. [cited 2019 October 08]. Available from: http://www.health.qld.gov.au
43. Queensland Health. Maternity services. Clinical services capability framework for public and licensed private health facilities v3.2.
[Internet]. 2014 [cited 2019 October 09]. Available from: http://www.health.gov.au.
44. Rochow N, Landau-Crangle E, Lee S, Schünemann H, Fusch C. Quality indicators but not admission volumes of neonatal
intensive care units are effective in reducing mortality rates of preterm infants. PloS one. [Internet]. 2016 [cited 2020 May 14]; 11(8):1-
12 DOI:10.1371/journal.pone.0161030.
45. Edwards K, Impey L. Extreme preterm birth in the right place: a quality improvement project. BMJ Journals. [Internet]. 2019 [cited
2020 May 14]; DOI:10.1136/archdischild-2019-31774.
46. David AL, Soe A. Extreme prematurity and perinatal management. Obstetrician & Gynaecologist. [Internet]. 2018 [cited 2020 May
14]; 20(2):109-17.
47. Roberts D, Brown J, Medley N, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of
preterm birth. [Internet]. 2017 [cited 2019 October 03]; DOI:10.1002/14651858.CD004454.pub3.
48. Crowther CA, McKinlay CJD, Middleton P, Harding JE. Repeat doses of prenatal corticosteroids for women at risk of preterm birth
for improving neonatal health outcomes. [Internet]. 2015 [cited 2019 October 03]; DOI:10.1002/14651858.CD003935.pub4.
49. World Health Organization. WHO recommendations on interventions to improve preterm birth outcomes. [Internet]. 2015 [cited
2019 October 03]. Available from: http://www.who.int.
50. Mackeen AD, Seibel-Seamon J, Muhammad J, Baxter JK, Berghella V. Tocolytics for preterm premature rupture of membranes.
Cochrane Database of Systematic Reviews. [Internet]. 2014 [cited 2019 October 03]; (2) DOI:10.1002/14651858.CD007062.pub3.
51. Conde-Agudelo A, Romero R, Kusanovic JP. Nifedipine in the management of preterm labor: a systematic review and
metaanalysis. American Journal of Obstetrics and Gynecology. 2011; 204(2):134 e1-20.
52. Flenady V, Wojcieszek AM, Papatsonis DNM, Stock OM, Murray L, Jardine LA, et al. Calcium channel blockers for inhibiting
preterm labour and birth. Cochrane Database of Systematic Reviews. [Internet]. 2014 [cited 2019 October 03]; (6)
DOI:10.1002/14651858.CD002255.pub2.
53. Australian Medicines Handbook. Drugs for preterm labour. Nifedipine. Salbutamol. [Internet]. Adelaide: Australian Medicines
Handbook Pty Ltd; July 2019 [cited 2019 October 03]. Available from: http://www.amh.net.au/.
54. Gaunekar NN, Raman P, Bain E, Crowther CA. Maintenance therapy with calcium channel blockers for preventing preterm birth
after threatened preterm labour. Cochrane Database of Systematic Reviews [Internet]. 2013 [cited 2019 October 03]; (10)
DOI:10.1002/14651858.CD004071.pub2.
55. Haas DM, Caldwell DM, Kirkpatrick P, McIntosh JJ, Welton NJ. Tocolytic therapy for preterm delivery: systematic review and
network meta-analysis. British Medical Journal. [Internet]. 2012 [cited 2019 October 03]; 345:e6226 DOI:10.1136/bmj.e6226.
56. Neilson JP, West HM, Dowswell T. Betamimetics for inhibiting preterm labour. Cochrane Database of Systematic Reviews.
[Internet]. 2014 [cited 2019 October 03]; DOI:10.1002/14651858.CD004352.pub3.
57. Dodd JM, Crowther CA, Middleton P. Oral betamimetics for maintenance therapy after threatened preterm labour. Cochrane
Database of Systematic Reviews. [Internet]. 2012 [cited 2019 October 03]; 12:CD003927 DOI:10.1002/14651858.CD003927.pub3.
58. King J, Flenady V, Cole S, Thornton S. Cyclo-oxygenase (COX) inhibitors for treating preterm labour. Cochrane Database of
Systematic Reviews. [Internet]. 2005; DOI:10.1002/14651858.CD001992.pub2.
59. Reinebrant HE, Pileggi-Castro C, Romero CLT, dos Santos RAN, Kumar S, Souza JP, et al. Cyclo-oxygenase (COX) inhibitors for
treating preterm labour. Cochrane Database of Systematic Reviews. [Internet]. 2015 [cited 2019 October 03];
DOI:10.1002/14651858.CD001992.pub3.
60. Hammers AL, Sanchez-Ramos L, Kaunitz AM. Antenatal exposure to indomethacin increases the risk of severe intraventricular
hemorrhage, necrotizing enterocolitis, and periventricular leukomalacia: a systematic review with metaanalysis. American Journal of
Obstetrics and Gynecology. [Internet]. 2015 [cited 2020 January 27]; 212(4):505-.
61. Queensland Clinical Guidelines. Early onset of Group B streptococcus disease. Guideline No. MN16.20-V3-R21. [Internet].
Queensland Health. 2016. [cited 2019 November 19]. Available from: http://www.health.qld.gov.au
62. Tita AT, Andrews WW. Diagnosis and management of clinical chorioamnionitis. Clinical Perinatology. 2010; 37(2):339-54.
63. Australasian Society for Infectious Diseases. Management of perinatal infections. [Internet]. 2014 [cited 2020 February 23].
Available from: http://www.asid.net.au/.
64. Flenady V, Hawley G, Stock OM, Kenyon S, Badawi N. Prophylactic antibiotics for inhibiting preterm labour with intact membranes.
Cochrane Database of Systematic Reviews. [Internet]. 2013 [cited 2019 December 17]; DOI:10.1002/14651858.CD000246.pub2.
65. Doyle LW, Crowther CA, Middleton P, Marret S, Rouse D. Magnesium sulphate for women at risk of preterm birth for
neuroprotection of the fetus. Cochrane Database of Systematic Reviews. [Internet]. 2009; DOI:10.1002/14651858.CD004661.pub3.
66. The Antenatal Magnesium Sulphate for Neuroprotection Guideline Development Panel. Antenatal magnesium sulphate prior to
preterm birth for neuroprotection of the fetus, infant and child: national clinical practice guidelines. The University of Adelaide. [Internet].
2010 [cited 2019 October 08]. Available from: http://www.nhmrc.gov.au.
67. Doyle LW, Anderson PJ, Haslam R, Lee KJ, Crowther C. School-age outcomes of very preterm infants after antenatal treatment
with magnesium sulfate vs placebo. JAMA. 2014; 312(11):1105-13.
68. World Health Organization. WHO recommendation on the optimal mode of birth for women in refractory preterm labour. 2015.
Available from: http://www.who.int.
69. Thomas PE, Petersen SG, Gibbons K. The influence of mode of birth on neonatal survival and maternal outcomes at extreme
prematurity: a retrospective cohort study. [Internet]. 2016 [cited 2020 April 2]; 56:60-8.
70. Alfirevic Z, Milan SJ, Livio S. Caesarean section versus vaginal delivery for preterm birth in singletons. Cochrane Database of
Systematic Reviews. [Internet]. 2012 [cited 2019 October 09]; DOI:10.1002/14651858.CD000078.pub3.

Appendix A: Magnesium sulfate for fetal neuroprotection

In the absence of local monitoring protocols, the following guidance is provided.
• One to one midwifery care in birth suite or high dependency unit for the
duration of therapy
Resources
• Resuscitation and ventilator support immediately available
• Calcium Gluconate 1 g available in case of respiratory depression
• Maternal cardiac conduction defects (heart block)
• Hypermagnesaemia
Contraindications • Maternal myasthenia gravis–use cautiously and monitor closely
• Concomitant nifedipine use cautiously and monitor closely
• Reduced renal function monitor plasma magnesium level/urine output
Route • IV infusion via controlled infusion device
Loading dose • 4 g IV bolus over 20 minutes
Maintenance
• 1 g/hour for 24 hours or until birth, whichever occurs first
dose
• Related to hypermagnesaemia
Side effects • Common (more than 1%): nausea and vomiting, flushing
• Infrequent (0.1–1%): headache, dizziness
• Vital signs: BP, pulse, respiratory rate
• Oxygen saturation (SpO2)
Baseline • Patellar reflex
observations • Abdominal palpation
• Monitor contractions for 10 minutes
• Fetal heart rate (FHR)/CTG
• BP, pulse, and RR every 5minutes (for minimum 20 minutes) until stable
• SpO2 continuously
• Contractions for 10 minutes every 30 minutes
• If greater than or equal to 24 weeks gestation continuous CTG
o Interpret CTG relevant to gestational age if less than 28 weeks
Monitoring during
o If CTG not able to be performed document reason
loading dose
• If less than 24 weeks gestation
• Observe for side effects auscultate FHR every15–30 minutes
• Check deep tendon reflexes (patellar or, if epidural insitu, biceps) after
completion of loading dose
o If absent and do not commence maintenance dose–notify obstetrician
• BP, pulse, temperature, respiratory rate, and SpO2 every 30 minutes
• Contractions for 10 minutes every 30 minutes
• If greater than or equal to 24 weeks gestation continuous CTG
Monitoring during o If less than 28 weeks interpret CTG relevant to gestational age
maintenance • If less than 24 weeks gestation auscultate FHR every15–30 minutes
dose • Strict fluid balance monitoring and documentation
o If urine output less than 25 mL/hour, notify medical officer
• Deep tendon reflexes hourly
o Record as A=Absent, N=Normal, B=Brisk
• Repeat baseline observations/vital signs
Monitoring post • Minimum 4 hourly or more frequently as clinically indicated
infusion • If renal function normal serum magnesium monitoring not usually required
o Therapeutic serum magnesium levels are 1.7–3.5 mmol/L
• Respiratory rate less than 12 breaths/minute or more than 4
breaths/minute below baseline
Discontinuation
• Diastolic BP decreases more than 15 mmHg below baseline
and urgent
• Absent deep tendon reflexes
medical review
• Urine output less than 25 mL/hour or less than 100 mL over 4 hours
• Magnesium serum levels greater than 3.5 mmol/L
Adapted from: The Antenatal Magnesium Sulphate for Neuroprotection Guideline Development Panel. Antenatal magnesium
sulphate prior to preterm birth for neuroprotection of the fetus, infant and child: national clinical practice guidelines. The
University of Adelaide. 2010 [cited 2019, October 09]. Available from: www.nhmrc.gov.au.

Acknowledgements
Queensland Clinical Guidelines gratefully acknowledge the contribution of Queensland clinicians and
other stakeholders who participated throughout the guideline development process particularly:
Working Party Clinical Lead

Associate Professor Rebecca Kimble, Pre-eminent Specialist, Obstetrician and Gynaecologist, Royal
Brisbane and Women’s Hospital
QCG Program Officer

Ms Emily Holmes
Peer review panel members (2020)

Professor Andrew Shennan, Professor of Obstetrics, King’s College London
Dr Scott Peterson, Staff Specialist, Mater Mothers Hospital Brisbane
Dr Yogesh Chadha, Staff Specialist, Obstetrics and Gynaecology, Royal Brisbane and Women’s
Hospital
Mrs Rhonda Taylor, Clinical Midwifery Consultant, The Townsville Hospital
Ms Patricia Smith, Nursing and Midwifery Director, Royal Brisbane and Women’s Hospital
Ms Alecia Staines, Consumer Representative, Maternity Consumer Network
Ms Leah Hardiman, Consumer Representative, Mothers and Babies Australia
Working Party Members (2014)

Ms Michelle Barrett, Clinical Nurse Consultant, Retrieval Services Queensland
Ms Karen Bettenay, Pharmacist, Royal Brisbane and Women’s Hospital
Dr Anthony Brown, GP Obstetrician, Mareeba
Dr Yogesh Chadha, Staff Specialist, Obstetrics and Gynaecology, Royal Brisbane and Women’s
Hospital
Dr Lindsay Cochrane, Staff Specialist, Obstetrics and Gynaecology, Caboolture Hospital
Dr Mark Davies, Neonatologist, Royal Brisbane and Women’s Hospital
Ms Louisa Dufty, Director of Nursing/Operations Manager, Emerald Hospital
Dr Hasthika Ellepola, Staff Specialist, Obstetrics and Gynaecology, Logan Hospital
Associate Professor Vicki Flenady, Director Translating Research into Practice (TRIP) Centre, Mater
Medical Research Institute, Brisbane
Ms Kim-Lee Foran, Consumer Representative, Miscarriage, Stillbirth and Neonatal Death Support
(SANDS)
Ms Susan Foyle, Maternity Unit Manager, Caboolture Hospital
Ms Sara Haberland, Clinical Midwife, Birth Suite, Royal Brisbane and Women’s Hospital
Mrs Tracey Johnson, Registered Nurse/Eligible Midwife, Warwick Hospital
Dr Christopher King, Obstetrician, Mt Isa Hospital
Dr Alka Kothari, Staff Specialist, Obstetrics and Gynaecology, Redcliffe Hospital
Associate Professor Kassam Mahomed, Staff Specialist, Obstetrics and Gynaecology, Ipswich
Hospital
Dr Bruce Maybloom, Medical Officer, Queensland
Dr Thomas McHattie, Clinical Director Obstetrics and Gynaecology, Bundaberg Hospital
Ms Nickie Morton, Midwifery Unit Manager, Royal Brisbane and Women’s Hospital
Dr Edwin Ozumba, Senior Staff Specialist, Obstetrics and Gynaecology, Rockhampton Base Hospital
Dr Carol Portmann, Staff Specialist, Obstetrics and Maternal Fetal Medicine, Royal Brisbane and
Women’s Hospital
Dr Renuka Sekar, Staff Specialist, Maternal Fetal Medicine, Royal Brisbane and Women’s Hospital
Ms Pamela Sepulveda, Clinical Midwifery Consultant, Logan Hospital
Professor Andrew Shennan, Professor of Obstetrics, King’s College London
Ms Rhonda Taylor, Clinical Midwifery Consultant, Health & Wellbeing Service Group, The Townsville
Hospital
Queensland Clinical Guidelines Team

Associate Professor Rebecca Kimble, Director
Ms Jacinta Lee, Manager
Ms Stephanie Sutherns, Clinical Nurse Consultant
Ms Cara Cox, Clinical Nurse Consultant
Ms Emily Holmes, Clinical Nurse Consultant
Steering Committee
Funding
This clinical guideline was funded by Healthcare Improvement Unit, Queensland Health

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Queensland Health

Clinical Excellence Queensland

Maternity and Neonatal Clinical Guideline

Preterm labour and birth

Document title: Preterm labour and birth

© State of Queensland (Queensland Health) 2020

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Flow Chart: Assessment and management of preterm labour (< 37 weeks)

Review History In-utero transfer

No Admission Magnesium sulfate

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Table 1. Perinatal mental health ............................................................................................................ 6

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1.2 Perinatal mental health

Table 1. Perinatal mental health

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Table 2. Risk factors associated with preterm birth

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3.1 Progesterone therapy

3.2 Cervical cerclage

4 Clinical assessment of preterm labour

Table 6. Clinical assessment

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4.1 Cervical length

4.1.1 Assessment of cervical length

Table 7. Cervical length assessment

4.1.2 Cervical length and risk of preterm birth

Table 8. Cervical length and risk of preterm birth

Cervical length Likelihood ratio for birth at X weeks gestation33

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4.2 Fetal fibronectin testing

Table 9. Fetal fibronectin testing

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4.2.1 Fetal fibronectin results

Table 10. fFN results

4.3 Assess need for admission

Table 11. Assessment of need for admission

Aspect Assessment (assumes intact membranes)

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5 Management of preterm labour

5.1 Planning care

Table 12. Planning care

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5.2 In-utero transfer

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5.3 Antenatal corticosteroids

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Table 16. Nifedipine

5.4.2 Other tocolytics

Table 17. Other tocolytics

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5.6 Magnesium sulfate for neuroprotection

5.7 Mode of preterm birth

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6 Management after threatened preterm labour

Table 21. Management of threatened preterm labour

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