NICE Guideline on Preterm labour and birth, 2015.

The following guideline was developed by the National Collaborating Centre for Women's and Children's Health (NCC-WCH) on behalf of the National Institute for Health and Care Excellence (NICE). These guidelines relate to pre-term labour and birth.

Following are the major recommendations of the guidelines:-

Information and Support

When giving information and support to women at increased risk of preterm labour, with suspected, diagnosed or established preterm labour, or having a planned preterm birth (and their family members or carers as appropriate):

• Give this information and support as early as possible, taking into account the likelihood of preterm birth and the status of labour


• Bear in mind that the woman (and her family members or carers) may be particularly anxious


• Give both oral and written information


• Describe the symptoms and signs of preterm labour


• Explain to the woman about the care she may be offered

For women who are having a planned preterm birth or are offered treatment for preterm labour (and their family members or carers as appropriate), provide information and support that includes:

• Information about the likelihood of the baby surviving and other outcomes (including long-term outcomes) and risks for the baby, giving values as natural frequencies (for example, 1 in 100)


• Explaining about the neonatal care of preterm babies, including location of care


• Explaining about the immediate problems that can arise when a baby is born preterm


• Explaining about the possible long-term consequences of prematurity for the baby (how premature babies grow and develop)


• Ongoing opportunities to talk about and state their wishes about resuscitation of the baby


• An opportunity to tour the neonatal unit


• An opportunity to speak to a neonatologist or paediatrician

Prophylactic Vaginal Progesterone and Prophylactic Cervical Cerclage

Offer a choice of either prophylactic vaginal progesterone or prophylactic cervical cerclage to women:

• With a history of spontaneous preterm birth or mid-trimester loss between 16⁺⁰ and 34⁺⁰ weeks of pregnancy and


• In whom a transvaginal ultrasound scan has been carried out between 16⁺⁰ and 24⁺⁰ weeks of pregnancy that reveals a cervical length of less than 25 mm

Discuss the benefits and risks of prophylactic progesterone and cervical cerclage with the woman and take her preferences into account.

Offer prophylactic vaginal progesterone to women with no history of spontaneous preterm birth or mid-trimester loss in whom a transvaginal ultrasound scan has been carried out between 16⁺⁰ and 24⁺⁰ weeks of pregnancy that reveals a cervical length of less than 25 mm.

Consider prophylactic cervical cerclage for women in whom a transvaginal ultrasound scan has been carried out between 16⁺⁰ and 24⁺⁰ weeks of pregnancy that reveals a cervical length of less than 25 mm and who have either:

• Had preterm prelabour rupture of membranes (P-PROM) in a previous pregnancy or


• A history of cervical trauma

Diagnosing P-PROM

In a woman reporting symptoms suggestive of P-PROM, offer a speculum examination to look for pooling of amniotic fluid and:

• If pooling of amniotic fluid is observed, do not perform any diagnostic test but offer care consistent with the woman having P-PROM (see "Antenatal Prophylactic Antibiotics for Women with P-PROM," "Identifying Infection in Women with P-PROM," and "Maternal Corticosteroids")


• If pooling of amniotic fluid is not observed, consider performing an insulin-like growth factor binding protein-1 test or placental alpha-microglobulin-1 test of vaginal fluid

If the results of the insulin-like growth factor binding protein-1 or placental alpha-microglobulin-1 test are positive, do not use the test results alone to decide what care to offer the woman, but also take into account her clinical condition, her medical and pregnancy history and gestational age, and either:

• Offer care consistent with the woman having P-PROM (see "Antenatal Prophylactic Antibiotics for Women with P-PROM," "Identifying Infection in women with P-PROM," and "Maternal Corticosteroids") below or


• Re-evaluate the woman's diagnostic status at a later time point

If the results of the insulin-like growth factor binding protein-1 or placental alpha-microglobulin-1 test are negative and no amniotic fluid is observed:

• Do not offer antenatal prophylactic antibiotics


• Explain to the woman that it is unlikely that she has P-PROM, but that she should return if she has any further symptoms suggestive of P-PROM or preterm labour

Do not use nitrazine to diagnose P-PROM.

Do not perform diagnostic tests for P-PROM if labour becomes established in a woman reporting symptoms suggestive of P-PROM.

Antenatal Prophylactic Antibiotics for Women with P-PROM

Offer women with P-PROM oral erythromycin 250 mg 4 times a day¹ for a maximum of 10 days or until the woman is in established labour (whichever is sooner).

For women with P-PROM who cannot tolerate erythromycin or in whom erythromycin is contraindicated, consider oral penicillin for a maximum of 10 days or until the woman is in established labour (whichever is sooner).

Do not offer women with P-PROM co-amoxiclav as prophylaxis for intrauterine infection.

Identifying Infection in Women with P-PROM

Use a combination of clinical assessment and tests (C-reactive protein, white blood cell count and measurement of fetal heart rate using cardiotocography) to diagnose intrauterine infection in women with P-PROM.

Do not use any one of the following in isolation to confirm or exclude intrauterine infection in women with P-PROM:

• A single test of C-reactive protein


• White blood cell count


• Measurement of fetal heart rate using cardiotocography

If the results of the clinical assessment or any of the tests are not consistent with each other, continue to observe the woman and consider repeating the tests.

'Rescue' Cervical Cerclage

Do not offer 'rescue' cervical cerclage to women with:

• Signs of infection or


• Active vaginal bleeding or


• Uterine contractions

Consider 'rescue' cervical cerclage for women between 16⁺⁰ and 27⁺⁶ weeks of pregnancy with a dilated cervix and exposed, unruptured fetal membranes:

• Take into account gestational age (being aware that the benefits are likely to be greater for earlier gestations) and the extent of cervical dilatation


• Discuss with a consultant obstetrician and consultant paediatrician

Explain to women for whom 'rescue' cervical cerclage is being considered (and their family members or carers as appropriate):

• About the risks of the procedure


• That it aims to delay the birth, and so increase the likelihood of the baby surviving and of reducing serious neonatal morbidity

Diagnosing Preterm Labour for Women with Intact Membranes

Explain to women reporting symptoms of preterm labour who have intact membranes (and their family members or carers as appropriate):

• About the clinical assessment and diagnostic tests that are available


• How the clinical assessment and diagnostic tests are carried out


• What the benefits, risks and possible consequences of the clinical assessment and diagnostic tests are, including the consequences of false positive and false negative test results taking into account gestational age

Offer a clinical assessment to women reporting symptoms of preterm labour who have intact membranes. This should include:

• Clinical history taking


• A speculum examination (followed by a digital vaginal examination if the extent of cervical dilatation cannot be assessed)

If the clinical assessment suggests that the woman is in suspected preterm labour and she is 29⁺⁶ weeks pregnant or less, advise treatment for preterm labour.

If the clinical assessment suggests that the woman is in suspected preterm labour and she is 30⁺⁰ weeks pregnant or more, consider transvaginal ultrasound measurement of cervical length as a diagnostic test to determine likelihood of birth within 48 hours. Act on the results as follows:

• If cervical length is more than 15 mm, explain to the woman that it is unlikely that she is in preterm labour and:
  
  
  
  • Think about alternative diagnoses
  
  
  • Discuss with her the benefits and risks of going home compared with continued monitoring and treatment in hospital
  
  
  • Advise her that if she does decide to go home, she should return if symptoms suggestive of preterm labour persist or recur
  
  
  
  


• If cervical length is 15 mm or less, view the woman as being in diagnosed preterm labour and offer treatment as described in "Tocolysis" and "Maternal Corticosteroids" below.

Consider fetal fibronectin testing as a diagnostic test to determine likelihood of birth within 48 hours for women who are 30⁺⁰ weeks pregnant or more if transvaginal ultrasound measurement of cervical length is indicated but is not available or not acceptable. Act on the results as follows:

• If fetal fibronectin testing is negative (concentration 50 ng/ml or less), explain to the woman that it is unlikely that she is in preterm labour and:
  
  
  
  • Think about alternative diagnoses
  
  
  • Discuss with her the benefits and risks of going home compared with continued monitoring and treatment in hospital
  
  
  • Advise her that if she does decide to go home, she should return if symptoms suggestive of preterm labour persist or recur
  
  
  
  


• If fetal fibronectin testing is positive (concentration more than 50 ng/ml), view the woman as being in diagnosed preterm labour and offer treatment as described in "Tocolysis" and "Maternal Corticosteroids" below.

If a woman in suspected preterm labour who is 30⁺⁰ weeks pregnant or more does not have transvaginal ultrasound measurement of cervical length or fetal fibronectin testing to exclude preterm labour, offer treatment consistent with her being in diagnosed preterm labour (see "Tocolysis" and "Maternal Corticosteroids" below).

Do not use transvaginal ultrasound measurement of cervical length and fetal fibronectin testing in combination to diagnose preterm labour.

Ultrasound scans should be performed by healthcare professionals with training in, and experience of, transvaginal ultrasound measurement of cervical length.

Tocolysis

Take the following factors into account when making a decision about whether to start tocolysis:

• Whether the woman is in suspected or diagnosed preterm labour


• Other clinical features (for example, bleeding or infection) which may suggest that stopping labour is contraindicated


• Gestational age at presentation


• Likely benefit of maternal corticosteroids


• Availability of neonatal care (need for transfer to another unit)


• The preference of the woman

Consider nifedipine for tocolysis for women between 24⁺⁰ and 25⁺⁶ weeks of pregnancy who have intact membranes and are in suspected preterm labour.

Offer nifedipine for tocolysis to women between 26⁺⁰ and 33⁺⁶ weeks of pregnancy who have intact membranes and are in suspected or diagnosed preterm labour.

If nifedipine is contraindicated, offer oxytocin receptor antagonists for tocolysis.

Do not offer betamimetics for tocolysis.

Maternal Corticosteroids

For women between 23⁺⁰ and 23⁺⁶ weeks of pregnancy who are in suspected or established preterm labour, are having a planned preterm birth or have P-PROM (see "Diagnosing P-PROM" above), discuss with the woman (and her family members or carers as appropriate) the use of maternal corticosteroids in the context of her individual circumstances.

Consider maternal corticosteroids for women between 24⁺⁰ and 25⁺⁶ weeks of pregnancy who are in suspected or established preterm labour, are having a planned preterm birth or have P-PROM.

Offer maternal corticosteroids to women between 26⁺⁰ and 33⁺⁶ weeks of pregnancy who are in suspected, diagnosed or established preterm labour, are having a planned preterm birth or have P-PROM.

Consider maternal corticosteroids for women between 34⁺⁰ and 35⁺⁶ weeks of pregnancy who are in suspected, diagnosed or established preterm labour, are having a planned preterm birth or have P-PROM.

When offering or considering maternal corticosteroids, discuss with the woman (and her family members or carers as appropriate):

• How corticosteroids may help


• The potential risks associated with them

Do not routinely offer repeat courses of maternal corticosteroids, but take into account:

• The interval since the end of last course


• Gestational age


• The likelihood of birth within 48 hours

Magnesium Sulfate for Neuroprotection

Offer intravenous magnesium sulfate for neuroprotection of the baby to women between 24⁺⁰ and 29⁺⁶ weeks of pregnancy who are:

• In established preterm labour or


• Having a planned preterm birth within 24 hours

Consider intravenous magnesium sulfate for neuroprotection of the baby for women between 30⁺⁰ and 33⁺⁶ weeks of pregnancy who are:

• In established preterm labour or


• Having a planned preterm birth within 24 hours

Give a 4 g intravenous bolus of magnesium sulfate over 15 minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours (whichever is sooner).

For women on magnesium sulfate, monitor for clinical signs of magnesium toxicity at least every 4 hours by recording pulse, blood pressure, respiratory rate and deep tendon (for example, patellar) reflexes.

If a woman has or develops oliguria or other signs of renal failure:

• Monitor more frequently for magnesium toxicity


• Think about reducing the dose of magnesium sulfate

Fetal Monitoring

Monitoring Options: Cardiotocography and Intermittent Auscultation

Discuss with women in suspected, diagnosed or established preterm labour (and their family members or carers as appropriate):

• The purpose of fetal monitoring and what it involves


• The clinical decisions it informs at different gestational ages


• If appropriate, the option not to monitor the fetal heart rate (for example, at the threshold of viability)

Involve a senior obstetrician in discussions about whether and how to monitor the fetal heart rate for women who are between 23⁺⁰ and 25⁺⁶ weeks pregnant.

Explain the different fetal monitoring options to the woman (and her family members or carers as appropriate), being aware that:

• There is limited evidence about the usefulness of specific features to suggest hypoxia or acidosis in preterm babies


• A normal cardiotocography trace is reassuring and indicates that the baby is coping well with labour, but an abnormal trace does not necessarily indicate that fetal hypoxia or acidosis is present

Explain to the woman (and her family members or carers as appropriate) that there is an absence of evidence that using cardiotocography improves the outcomes of preterm labour for the woman or the baby compared with intermittent auscultation.

Offer women in established preterm labour but with no other risk factors a choice of fetal heart rate monitoring using either:

• Cardiotocography using external ultrasound or


• Intermittent auscultation

Fetal Scalp Electrode

Do not use a fetal scalp electrode for fetal heart rate monitoring if the woman is less than 34⁺⁰ weeks pregnant unless all of the following apply:

• It is not possible to monitor the fetal heart rate using either external cardiotocography or intermittent auscultation


• It has been discussed with a senior obstetrician


• The benefits are likely to outweigh the potential risks


• The alternatives (immediate birth, intermittent ultrasound and no monitoring) have been discussed with the woman and are unacceptable to her

Discuss with the woman (and her family members or carers as appropriate) the possible use of a fetal scalp electrode between 34⁺⁰ and 36⁺⁶ weeks of pregnancy if it is not possible to monitor the fetal heart rate using either external cardiotocography or intermittent auscultation.

Fetal Blood Sampling

Do not carry out fetal blood sampling if the woman is less than 34⁺⁰ weeks pregnant.

Discuss with the woman the possible use of fetal blood sampling between 34⁺⁰ and 36⁺⁶ weeks of pregnancy if the benefits are likely to outweigh the potential risks.

When offering fetal blood sampling, discuss this with the woman , and advise her that if a blood sample cannot be obtained a caesarean section is likely.

Mode of Birth

Discuss the general benefits and risks of caesarean section and vaginal birth with women in suspected, diagnosed or established preterm labour and women with P-PROM

Explain to women in suspected, diagnosed or established preterm labour and women with P-PROM about the benefits and risks of caesarean section that are specific to gestational age. In particular, highlight the difficulties associated with performing a caesarean section for a preterm birth, especially the increased likelihood of a vertical uterine incision and the implications of this for future pregnancies.

Explain to women in suspected, diagnosed or established preterm labour that there are no known benefits or harms for the baby from caesarean section, but the evidence is very limited.

Consider caesarean section for women presenting in suspected, diagnosed or established preterm labour between 26⁺⁰ and 36⁺⁶ weeks of pregnancy with breech presentation.

Timing of Cord Clamping for Preterm Babies (Born Vaginally or by Caesarean Section)

If a preterm baby needs to be moved away from the mother for resuscitation, or there is significant maternal bleeding:

• Consider milking the cord and


• Clamp the cord as soon as possible

Wait at least 30 seconds, but no longer than 3 minutes, before clamping the cord of preterm babies if the mother and baby are stable.

Position the baby at or below the level of the placenta before clamping the cord.

Footnotes

¹At the time of publication (November 2015), erythromycin did not have a UK marketing authorisation for use in pregnancy. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. The summaries of product characteristics for oral erythromycin recommend different dosages. The evidence reviewed for the guideline supports a dosage of 250 mg 4 times a day for prophylaxis in women with P-PROM.

²Be aware that if a swab for fetal fibronectin testing is anticipated, the swab should be taken before any digital vaginal examination.

³Although this use is common in UK clinical practice, at the time of publication (November 2015), nifedipine did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. The suggested dosage of nifedipine (as specified in the BNF) is a loading dose of 20 mg orally, followed by 10–20 mg 3 to 4 times daily adjusted according to uterine activity.

For full guidelines click on the following link:

NiCE Guideline on Preterm labour and birth.

Article Source: National Collaborating Centre for Women's and Children's Health. Preterm labour and birth. London (UK): National Institute for Health and Care Excellence (NICE); 2015 Nov 20. 24 p. (NICE guideline; no. 25).