PRE-TERM LABOUR
Guideline
Pre-term birth occurs in 7-12% of all births and accounts for over 85% of all perinatal
morbidity and mortality.
Significant underlying pathology triggering pre-term labour should be identified and
appropriately managed. Consultation with the Obstetrician on call for the day is
recommended for labour onset prior to 37 weeks. Prior to 35 weeks (+0 days)
gestation, ‘transfer of care’ to secondary care is indicated and prior to 32 weeks (+ 0
days) ‘transfer of care’ to tertiary services (CCDHB) is indicated.
Neonatal morbidity and mortality will be minimised by thorough clinical assessment,
management of infectious risk, appropriately directed tocolysis and additional cares
during progressive labour and delivery.
Liaison with paediatric and SCBU staff is fundamentally important.
Scope
All medical and midwifery staff employed by Hutt Valley DHB.
All Hutt Valley DHB Maternity access holders.
All Special Care Baby Unit staff
Definitions
Pre-term labour: Painful regular contractions with associated cervical changes prior
to 37 weeks (+0 days) gestation.
CTG
EFM
CBC
HVDHB
MSU
SCBU
CCDHB
Cardiotocograph
Electronic fetal monitoring
Full blood count
Hutt Valley District Health Board
Midstream urine
Special Care Baby Unit
Capital and Coast District Health Board
Policy Number: MATY056
Approved by Maternity Quality Committee
Facilitated by: Karen Wakelin
Next due date: October 2015
Page 1 of 7
Procedures
Principles of care for threatened pre-term labour include:
 Accessing specialist obstetric and neonatal services
 Establishing a diagnosis, including underlying pathology.
 Steroids administration if the pregnancy is less than 37 weeks (+0 days)
gestation.
 Prophylaxis for Group B Streptococcus and treating intrapartum fever.
 Planning management in accordance with degree of prematurity.
 Tocolysis when appropriate
 Expedite delivery for chorioamnionitis, perceived fetal compromise or major
antepartum haemorrhage
 Avoiding perinatal asphyxia and trauma during labour and birth.
Consultation with Obstetrician on call / Transfer of care
Obstetric Consultation
 All women with threatened or active pre-term labour should be admitted to Hutt
Valley DHB.
 Consultation with the Obstetrician on call is recommended for gestations prior to
37 weeks (+0 days).
 For gestation < 35 weeks, the LMC must recommend that responsibility for care
be transferred to secondary care (MOH, 2007). The obstetrician on call /
registrar must liaise with SCBU and paediatrician re availability of bed in
SCBU. If none available, consider transfer to CCDHB (refer transfer to CCDHB
policy).
 For gestations < 32 weeks, transfer of care to CCDHB (refer transfer to CCDHB
policy). The Obstetrician on call or registrar must consult with Obstetrician and
Neonatal consultant at CCDHB regarding transfer. The midwife liaises with
CCDHB midwife. If the clinical situation is sufficiently stable, then antenatal
maternal transfer is to be arranged.
 If the threatened pre-term labour completely settles, the woman will be transferred
back to the care of the referring practitioner or LMC on discharge from hospital.
The LMC will be contacted by a core midwife upon hospital discharge.
Acute assessment in Delivery Suite
LMCs are expected to give antenatal advice about the symptoms and signs of labour,
and the woman’s care plan should indicate who they are to contact if these develop
prematurely. Prior to 37 weeks gestation, it is recommended that a consultation
occurs and there will be an assessment on delivery suite .
Assessment to include:
 Confirm gestational age:
o Reviewing clinical data regarding LMP and scan results
o When possible, a copy of an early scan report should be obtained and
reviewed.
 Consider underlying pathology: eg. Chorioamnionitis, antepartum haemorrhage.
 Clinical examination should include:
o Maternal temperature and pulse
o Contraction pattern
o Fetal size, lie and presentation, liquor volume
Policy Number: MATY056
Approved by Maternity Quality Committee
Facilitated by: Karen Wakelin
Next due date: October 2015
Page 2 of 7





o Sterile speculum assessing for leakage of liquor
o Low vaginal / rectal (not anogenital) swab for Group B Streptococcus
o Cervical changes: avoid unnecessary vaginal examination especially if
membranes ruptured
o Continuous CTG while contracting
o MSU and CBC
Ultrasound: a formal scan at HVDHB scanning department is recommended when
clinical situation permits.
Antibiotics (Refer Appendix I)
Tocolysis (Refer Nifedipine Protocol)
Steroids (Refer Appendix II)
IV access
Delivery will be expedited when:
 Significant placental abruption
 Chorioamnionitis
 Fetal compromise
Gestational Age Based Management
Pre-term labour less than 32 weeks:
If pre-term labour is not settling after steroids and nifedipine then the Obstetrician /
registrar on call is to arrange for transfer to CCDHB after first consulting with the
Obstetrician and Neonatal consultant at CCDHB (refer Transfer to Wellington
Women’s Hospital policy).
Management of progressive pre-term labour 32-34 weeks (+ 6 days).
 Clinical assessment as above
 Liaison with SCBU and paediatrician re availability of bed on SCBU.
 Transfer to secondary care as per referral guidelines (MOH, 2007). Midwifery
care negotiated
 Continuous EFM throughout labour
 Paediatric attendance at birth
 Obstetric Registrar or Consultant to attend birth whenever feasible
 If an assisted vaginal delivery is indicated, forceps are preferable < 34 weeks
gestation
 Elective episiotomy if perineum resistant
 Pethidine should be used sparingly
35 weeks (+ 0 days) – 36 weeks (+6 days) gestation
 Under care of LMC unless other obstetric indications
 Consultation with Obstetrician on call advised –transfer of care only if other
clinical complications
 Clinical assessment (as above)
 Continuous EFM in labour with gestations 35+0 –35+6 weeks. For gestation 36+0
– 37 +0 weeks, continuous EFM only if indicated by other risk factors.
 Tocolysis not indicated
 Steroids (refer Appendix II)
 Antibiotics (refer Appendix I)
 Paediatric attendance at birth recommended.
Policy Number: MATY056
Approved by Maternity Quality Committee
Facilitated by: Karen Wakelin
Next due date: October 2015
Page 3 of 7
References
Bramberger, P. & Lawrence, J., Braun, D. & Saunders, B., Contreras, R. & Petitti, D. (2000). The
influence of intrapartum antibiotics on the clinical spectrum of early onset Group B Streptococcal
infection in term infants. Pediatrics, (106) 244-250.
Capital and Coast District Health Board. (2010). Pre-term Labour. Capital and Coast District Health
Board, Women’s and Children’s Health Directorate – Policies, Procedures Protocols, Guidelines.
Policy No. OB IP-16
Carlan, S. J., O’Brien, W. F., Parsons, M. T., Lense, J. J. (1993). Preterm premature rupture of
membranes; a randomised study of home versus hospital management. Obstetric Gynaecology, 81
(1) 61-64.
Flenady, V. & Jenkins-Manning, S. (2007). For the Queensland Clinical Practice Guidelines Working
Party on the prevention of early onset Group B Streptococcal Disease, Centre for Clinical Studies,
Mater Health Services: Brisbane
Grant, A. & Glazener, C. M. Elective caesarean section versus expectant management for delivery of
the small baby. [update of Cochrane Database Syst Rev. 2001; (1): CD000078; 11279676].
Grimwood, K., Darlow, B., Gosling, I., Green, R., Lennon, D., Martin, D. & Stone, P. (2001). Early
onset neonatal group B Streptococcal management strategy survey of New Zealand Centres:
Research Summary. Wellington
Guinn, D. A., Atkinson, M. W.(2001). Single vs weekly courses of antenatal corticosteroids for women
at risk of preterm delivery: A randomised controlled trial. JAMA, 286 (13) 1581-1587.
Kenyon, S. L., Taylor, D. J., Tarnow-Mordi, W. for the ORACLE II Collaborative Group. (2001). Broad
spectrum antibiotics for spontaneous preterm labour: The Oracle II randomised trial. Lancet, 357; 989994
Ministry of Health (2007). Guidelines for Consultation with Obstetric and Related Specialist Medical
Services (Referral Guidelines). Wellington: Ministry of Health
Norwitz, E. R. & Robinson, J. N. (2001). A systematic approach to the management of preterm labour.
[Review] [86 refs] [Journal Article. Review, Tutorial] Seminars in Perinatology. 25 (4): 223-235
Stutchfield, P., Whitaker, R., Russell, I. (2005). Antenatal betamethasone and incidence of neonatal
respiratory distress after elective caesarean section; Pragmatic randomised trial.
http://www.bmj.com/cgi/content/full/331/7518/662
Appendices
Appendix 1: Maternity Unit Antibiotic Guidelines (laminated and issued to HVDHB
Quick Reference folders)
Appendix 2: Steroid administration for anticipated pre-term birth (laminated and
issued to HVDHB Quick Reference Folders)
Appendix 3: Pre-term labour management algorithm (laminated and issued to
HVDHB Quick Reference Folders)
Policy Number: MATY056
Approved by Maternity Quality Committee
Facilitated by: Karen Wakelin
Next due date: October 2015
Page 4 of 7
Appendix I
Policy Number: MATY056
Approved by Maternity Quality Committee
Facilitated by: Karen Wakelin
Next due date: October 2015
Page 5 of 7
Appendix II
Steroid Administration for Anticipated Pre-term Delivery
Steroid Administration
Steroids are indicated when delivery is anticipated at 24-34 weeks (+ 6
days) gestation.

Betamethasone 11.4mg (Celestone chronodose, 2 x 5.7mg
ampoules) IM stat

Repeat one dose after 12 hours. In a non-acute setting 24 hours.

Delivery is ideally delayed until 24 hours after the first dose. Steroids
given even 30 minutes prior to delivery may be valuable.

Give 1st dose even if labour advanced.

Not contraindicated in presence of SRM or sepsis.
Maternity Unit Antibiotic Guidelines for Surgical Procedures
 Caesarean Section
 Manual removal of placenta
 Repair of extensive vaginal tears
 Emergency cervical cerclage
Cefuroxime 1.5g IV stat
Or if high risk anaphylaxis: clindamycin 900mg IV stat
Policy Number: MATY056
Approved by Maternity Quality Committee
Facilitated by: Karen Wakelin
Next due date: October 2015
Page 6 of 7
Appendix III
Policy Number: MATY056
Approved by Maternity Quality Committee
Facilitated by: Karen Wakelin
Next due date: October 2015
Page 7 of 7