Prevention and management of preterm (premature) labour

Premature labour is when labour occurs before you are 37 weeks pregnant.

Labour can be defined as regular contractions, which leads to the opening of the cervix (neck of the womb) resulting in the birth of your baby. It usually occurs between 37 and 42 weeks of pregnancy.

Premature labour is when labour occurs before 37 weeks. Approximately eight babies out of every 100 in the UK are born before the 37th week of pregnancy.

Usually it begins by itself, however sometimes it can be planned if it’s considered to be safest for the baby or the mother/ birthing person. This is the case in approximately 25% of premature births.

Very premature labour is much less common, with fewer than one in 100 babies being
born between 22 and 28 weeks of pregnancy.

What does this mean for my baby?

There are risks to the baby from being born before its due time.

The earlier a baby is born, the higher their likelihood of health problems at birth and later in life – such as problems with breathing, feeding and, most seriously, infection.

Your baby may need to be cared for in a baby unit and looked after by baby specialists.

We understand that this is a worrying and distressing time for parents. However, 80% of these premature babies (who are born after 28 weeks) will survive and only a small number will have severe long-term disabilities.

Choosing the right treatments to help stop or slow down early labour can reduce these risks. Your doctor and/or midwife will be happy to talk to you about this and give you further information about support groups that you may find helpful.

Your individualised situation, the outcome and the suitable treatment for your baby will be
discussed with you in detail by your team. Many children who survive with long-term health problems, still rate their quality of life as being good.

If you give birth before 24 weeks of pregnancy, it is unfortunately much less likely that your baby will survive. However, you will be supported to spend as much time as you can with your baby.

Breast feeding is crucial for premature babies: Your doctor and/or midwife/ nurse will talk to you about this and provide any support you need.

What causes premature labour?

The reason for preterm labour is unknown. However, it is thought that several factors, sometimes involving infection, can participate in causing changes in the cervix which can lead to the initiation of labour.
Other factors which have been identified to cause your labour to start earlier are:

• Your waters breaking before 37 weeks.
• Previous premature labour/birth prior to 37 weeks or early water breaking in
  previous pregnancy.
• Previous late miscarriage (more than 14 weeks of gestation).
• Vaginal bleeding after 14 weeks of gestation in this pregnancy.
• Different shaped / sized womb (i.e., heart shaped)
• Multiple pregnancy (Twins or triplets).
• Extra fluid around the baby (polyhydramnios).
• Being a smoker.
• Identification of a short cervix whether it’s after any certain procedure/
  treatment of the cervix or spontaneous shortage.
• Fertility treatment can also be regarded as a risk factor to preterm labour.

What can I do if I think my labour is starting early?

It’s crucial that you contact your maternity unit immediately if you are experiencing regular, painful tightening / contractions or you think your waters have broken. You are likely to be asked to come in.

It’s very likely you will be asked by your doctor or midwife whether you have had a premature birth in a previous pregnancy, as well as questions about your general health, any symptoms of abdominal pain tightening or bleeding, and whether you think your waters have broken.

Then you will be checked up, this may involve:

• A general examination and a check of your temperature, pulse and blood
  pressure
• An examination of your abdomen
• A check of your baby’s heartbeat
• We will ask you to give a blood sample to check for signs of infection
• You will be asked for a urine sample for testing.
• You might also be offered an ultrasound scan to check your baby’s wellbeing
  and assess their position in your womb.
• You will be offered a vaginal examination using a speculum (an instrument used to separate the walls of the vagina) to see whether the cervix is changing in preparation for labour or has already opened. By doing this examination, your doctor or midwife will also be able to see whether there is fluid leaking, which may indicate that your waters have broken. However, breaking your water before 37 weeks does not always means early labour.
• At the same time of the vaginal examination, we will be taking two types of swabs. The first type to check for infection and the other type is based on detecting fetal fibronectin, which may be taken from the top of the vagina if you are at between 24 and 34 weeks of pregnancy. This test helps to see whether you are likely to go into labour soon or not.
• Most people who are suspected to be in preterm labour, will have negative fetal fibronectin swab results, which is very reassuring, as less than one in 100 people with a negative test will go into labour within the next two weeks. On the other hand, a positive swab means that there is an increased chance you may go into labour. One in five people who have a positive swab
  go into labour within 10 days. It is worth mentioning that the accuracy of the swab result is reduced if there is bleeding, your waters have broken, or if you have had sexual intercourse in the last 24 hours prior to taking the swab.

What will happen next?

If you have had a negative fetal fibronectin swab, it’s confirmed you’re not in labour, and there are no concerns about you or your baby, you will be able to go home. You should also be offered a follow-up appointment with your midwife or consultant, depending on your individual circumstances.

If you are suspected to be in labour, you will be advised to stay in hospital and may be offered some of the following:

• A course of two to four corticosteroid injections, usually over a 24 to 48 hour period, to help with your baby’s development and reduce the chance of problems caused by being born early (unless you have already received steroids during your pregnancy).
• If it’s confirmed that your waters have broken, you may be offered a course of antibiotics to reduce the risk of an infection getting into the womb.
• You and your partner may be offered the chance to talk to one of the neonatal team about the care your baby is likely to receive if they are born early. You may also wish to visit the neonatal unit.
• If your waters have not broken, you may be given medication (tablets or via a drip) to try and stop labour. This will only be offered in the following conditions:
  • While you’re completing your course of corticosteroids
  • If you need to be transferred to a hospital where there is a neonatal intensive care unit, which could be some distance away. This is particularly the case if you are less than 32 weeks pregnant.
  • If you began using treatment with magnesium sulphate, through a drip in your arm. This would be strongly advised if you are less than 30 weeks pregnant and likely to give birth within the next 24 hours. These medications are not routinely recommended for people having twins or triplets, because it is not clear that they are beneficial in that situation. The benefit of magnesium sulphate is to decrease the chance of complications for your baby, in particular cerebral palsy. However, you may have minor side effects such as flushing and nausea. If you are advised to have this treatment, your doctor will discuss it fully with you.

How can we prevent premature labour?

It can be prevented in some situations, especially if you had a premature labour or had a late miscarriage in your previous pregnancy.

We will offer you a regular vaginal scan in pregnancy to measure the length of your cervix and if we identify that the cervix is getting shorter, then you may be advised to have a suture (stitch) put
around it to prevent it opening early.

Another option you may be offered is a hormone treatment (progesterone), to help stop you from labouring before your time.

What if my waters have broken but I am not in labour?

You will be asked to return to the hospital for regular check-ups.

This will involve doing regular examination for your temperature, pulse and blood pressure, taking
blood samples and swabs to check for infection, and checking fetal heart rate regularly. You will also be given a 10-day course of antibiotics to prevent infection.

What about future pregnancies?

Having your baby before their expected time means that you are at higher risk of having another premature birth in a future pregnancy. However, you are still expected to have a baby born at later than 37 weeks next time.

You will be advised to be under the care of a Consultant Obstetrician, who will discuss with you a plan for your pregnancy.

The plan of care will be very much individualised to your situation. Therefore, we have developed our specialised preterm / prematurity antenatal clinic with a dedicated staff of doctors, midwives, and health care support workers where you will be cared for.

I have concerns or other questions

You are always more than welcome to contact your midwife to ask any questions you may have, as all the midwives are happy to help. You can also ask to speak to your team of doctors and midwives at your maternity unit.

Making decisions together

Decisions about your care will be best made together. Your healthcare professionals should give you clear information, speak with you about your options and listen carefully to your views and concerns.

They will discuss with you the following:

• In early pregnancy, whether you are at high risk of preterm labour or not and they
  will offer the suitable care plan.
• They will ensure you know what to expect (what to look for as a signs of preterm
  labour).
• They will provide you with a full explanation of possible problems that could be
  associated with preterm labour, which could affect your baby and the care that they
  would likely need after their birth.
• They will also enable you to speak with a specialist about the care of your baby