In humans, preterm birth refers to the birth of a baby of less than 37 weeks gestational

age. Premature birth, commonly used as a synonym for preterm birth, refers to the birth
of a premature infant. Because it is by far the most common cause of prematurity,
preterm birth is the major cause of neonatal mortality in developed countries. Premature
infants are at greater risk for short and long term complications, including disabilities and
impediments in growth and mental development. Significant progress has been made in
the care of premature infants, but not in reducing the prevalence of preterm birth.[1] The
cause for preterm birth is in many situations elusive and unknown; many factors appear
to be associated with the development of preterm birth, making the reduction of preterm
birth a challenging proposition. WHO defines prematurity as babies born before 37 weeks
from the first day of the last menstrual period
Babies born this early are at risk because their internal organs,
including the lungs, and fat to keep them warm have not fully
developed. But with each advance in modern medicine, the chances of
survival for the baby are increasing.
Babies born before week twenty four and weighing about 2lbs have a
fifty percent (1 in 2) chance of surviving given the appropriate
treatment in a neonatal intensive care unitPart of a hospital that is
dedicated to the care and attention of newborn infants that are
seriously ill or premature. It contains a variety of specialized
equipment and is staffed by a team of nurses and neonatologists who
are specially trained in the pathophysiology of the newborn.
Visit our comprehensive glossary for more pregnancy terms and
definitions., or NICU, but are at increased risk of mental and physical
defects, such as cerebral palsy. This can be a frightening and worrying
experience for many mothers, but specialists, called neonatologists,
are trained to bring their experience and care to the neonatal intensive
care unitPart of a hospital that is dedicated to the care and attention of
newborn infants that are seriously ill or premature. It contains a variety
of specialized equipment and is staffed by a team of nurses and
neonatologists who are specially trained in the pathophysiology of the
newborn.
Visit our comprehensive glossary for more pregnancy terms and
definitions.. These dedicated professionals will do everything they can
to ensure that the outcome is a happy one.
By week twenty eight, the chances of survival are over ninety percent
(9 in 10), and every week that the baby remains in the uterus and
gains weight increases the likelihood of a successful outcome. By the
time your baby weighs more than 3lbs, the chances of survival are
ninety five percent.

Symptoms of premature labor

Premature labor often begins without warning, and it can be very

difficult to know if it has started. Even your doctor may have trouble
confirming the diagnosis. The problem is that medical centers may
have different criteria for determining whether premature labor has
begun, and many of the warning signs are also part of a normal and
healthy pregnancy.
Premature labor may begin like normal labor, often with the rupture
of the membranesRupturing of the amniotic sac releasing the amniotic
fluid. It is usually one of the first signs of the onset of labor. Also called
breaking of the waters.
Visit our comprehensive glossary for more pregnancy terms and definitions. , and a clear and
watery or mucusy and bloody vaginal discharge. You may then begin to
feel contractions, but they will feel more like a tightening of the uterus.
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The contractions will be just like regular labor contractions, and you
will feel your uterus hardening, with the contractions lasting between
60 and 90 seconds. A contraction will occur at least every ten minutes.
But at this stage of your pregnancy, labor contractions may not be as
strong as they would be at term.
Other symptoms of premature labor you should look for include a
dull lower backache, that is impossible to relieve even if you change
your position. This vague ache will not be the same as your regular
lower back pains, instead it may be rhythmic and constant. You may
also feel increased pelvic pressure, and gas pains, digestive problems
and maybe diarrhea.
The most common causes of repetitive contractions or cramps at this
stage in your pregnancy is dehydration, a full bladder or too much
activity. Try going to the bathroom, then drinking a couple of glasses of
water or juice. Rest for an hour and see if the contractions disappear.
If the signs of premature labor are still present, you should contact
your doctor or midwife immediately, even if it is the middle of the
night. Your doctor will encourage you to drink plenty of fluid to ensure
that you are hydrated, or you may be placed on an IVThe delivery of
fluid, often glucose, directly into the vein using a plastic catheter, and
bag of fluid.
Visit our comprehensive glossary for more pregnancy terms and definitions. . The nurses will
record your weight, blood pressure and temperature and a urine
sample will be analyzed to try and determine why you are cramping. A
sample from the back of your vagina may be cultured for bacteria and
tested for fetal fibronectin, a chemical that is produced by the fetal

membranes. If you test negative for fetal fibronectin it is unlikely that

you will enter labor for at least two weeks, but a positive test does not
indicate an imminent delivery.
Instead, a pelvic exam will be performed and your cervix will be
examined for signs of effacementA term used to describe the process
during labor whereby the vagina shortens and the walls of the cervix
thin as it is stretched by the fetus. At its finish, the cervix becomes one
with the lower segment of the uterus. Doctors measure the extent of
effacement during labor by vaginal examination and express its
progress as a percentageof full effacement.
Visit our comprehensive glossary for more pregnancy terms and
definitions. or dilationThe opening of the cervix during labor, caused by
the contractions of the uterus. The cervix dilates so that it will be large
enough for the baby to pass through the birth canal during delivery.
Visit our comprehensive glossary for more pregnancy terms and
definitions., which would indicate the onset of uterine contractions. If
there no changes to the cervix, your doctor may perform regular pelvic
exams at frequent intervals or place you on an external fetal monitor
to measure your contractions.
Premature labor is easier to stop the sooner it is diagnosed. Using
the external fetal monitor you will be checked for contractions every
five to ten minutes lasting for thirty seconds or more within an hour.
Cervical dilation of more than 1 inch (2.5cm) and more than three
quarters effaced are also necessary to confirm the diagnosis. Only
about one third of women who think they are in premature labor
have actually entered labor.

Incidence of premature labor

Premature labor occurs in about five to ten percent (1 - 2 in 20)
pregnancies. The cause in over half of cases is unknown. About twenty
to thirty percent (2 - 3 in 10) of cases are triggered by premature
rupture of membranes, or PROM, but this is often the result of some
other problem.

Risk factors for premature labor

Statistically, there are many factors that may put you at risk of
premature labor, and they can be broadly categorized as general
health problems, medical history problems and obstetrical
complications.

Your general health will be carefully monitored throughout your

pregnancy by your healthcare provider. While unusual, it is possible
that your premature labor is not premature at all, but simply the
result of an incorrect calculation of your due date. If you have had no
prenatal care, there is an increased risk of premature labor because
of poor general health.
General health problems & premature labor
poor nutrition
smoking during pregnancy
cocaine use during pregnancy
untreated maternal diseases (and complications such as anemia)
maternal infections (including syphilis and pyelonephritis)
overwork, stress and anxiety
physical trauma (such as an auto accident or bad fall resulting from domestic
abuse)
teenage pregnancy
Women who have a history of premature labor are more likely to
enter premature labor in a subsequent pregnancy. Your doctor will
examine your medical history for factors which may increase your risk
of premature labor.
Medical history problems & premature labor
two or more second trimester miscarriages or therapeutic abortions
hypertension (high blood pressure)
diabetes mellitus
thyroid problems
previous abdominal or uterine surgery (including fibroids, cyst removal but not
cesarean sections)
cone biopsy of the cervix
DES daughter
Premature rupture of membranes or PROM is the most common trigger
of premature labor, but other obstetrical problems may also be risk
factors.
Obstetrical complications & premature labor
multiple pregnancy
congenital abnormality of the fetus or uterus
uterine structural problems (large-sized uterus, double uterus, abnormally shaped
uterus or irritable uterus)
cervical problems (incompetent cervix, cervix less than 1cm long, cervix dilated
more than 1cm)
retained IUD
placental problems (placental abruption, placenta previa or placenta accreta

polyhydramnios
stillbirth

Managing premature labor

If you are experiencing uterine contractions, but the cervix has not yet
effaced or dilated your doctor will check to see if the membranes are
intact. If they have not yet ruptured, there is a good chance that the
labor can be stopped or delayed. While the decision to stop
premature labor is a controversial one, it is considered beneficial for
the baby and does reduce the risk of complications.
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At first your doctor or midwife will prescribe bed rest and plenty of
fluids. In many cases, simply rehydrating the body and resting on your
side (the left is considered the most effective) is enough to halt the
progress of premature labor. If you are in hospital, an IV may be
administered to provide fluids. Bed rest and rehydration effectively
stops premature labor in about half of cases.
If bed rest does not prove effective, it may be necessary to administer
tocolyticA term used to describe the medical interruption and halting of
contractions during premature labor.
Visit our comprehensive glossary for more pregnancy terms and definitions. medications to
relax the uterus and slow the contractions. Used safely since the
1970s, there are three types of drugs to arrest premature labor
including magnesium sulfate, beta-adrenergics such as ritodrine
(Yutopar) and terbutaline (Brethine) and sedative-narcotics. These
drugs are effective in stopping premature labor in about seventy
percent (7 in 10) cases.
Like all such drugs, they must be administered in a hospital or birthing
center, and carry the risk of side effects including increased heart rate
and palpitations, lowered blood pressure, anxiety and tremors. If
successful, your doctor may prescribe continued medication orally at
home.
The decision to use drugs is a difficult one, that is based on both your
physical health and the stage of pregnancy. Many doctors feel that the
labor should be allowed to continue without the intervention of drugs
after week thirty two or week thirty four. Before administering any
tocolytic medicationsA term used to describe the medical interruption
and halting of contractions during premature labor.
Visit our comprehensive glossary for more pregnancy terms and definitions. medications,

your doctor will want to check your medical record to make sure you
are healthy.
Checklist for administering tocolytic medications
history of heart disease
history of diabetes mellitus
chronic hypertension and signs of preeclampsia
correct pregnancy location
severe placental problems
infection of the amniotic fluid
the baby is alive and well
congenital abnormalities
hyperthyroidism (Grave's disease)
dilated cervix
If your doctor feels that premature labor may cause you or your baby
more harm than the tocolytic medications, then they may still be
administered. Labor after week thirty five will not be arrested if your
membranes have ruptured and your cervix has dilated more than four
centimetres. An L/S ratio and phosphatidyl glycerol test will be
performed to check the maturity of your baby's lungs.
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There is no evidence of an increased risk of congenital abnormalities or

developmental problems as a result of using ritodrine, terbutaline or
magnesium sulfate. If your baby is delivered within twenty four hours
of treatment using either ritodrine or terbutaline, its blood glucose
level will be monitored for hypoglycemia, or low blood sugar. A sugar
solution will be administered if necessary. Magnesium sulfate therapy
may result in poor muscle tone during the first two hours after delivery.
Ritodrine and terbutaline may affect you for a day or two after
treatment. While not dangerous you may experience increased heart
rate, nausea and vomiting, headaches, insomnia, water retention in
the lungs resulting in chest pains and breathlessness or dyspnea. You
may experience similar side effects from magnesium sulfate therapy
including fever, headaches, nausea and constipation.
If you show signs of infection you may be given an antibiotic before the
tocolytic drugs are administered. Pain and anxiety may be reasons for
your doctor to give you a mild sedative or antianxiety medication.
Sometimes these medications used in combination with fluid
administered intravenously can be enough to calm your contractions.
Your doctor may consider using morphine or pethidine, but these drugs

can aggravate the uterus and have a negative effect on your baby and
are only used in cases of extreme pain.
After your labor has been stopped there are three different options for
management. The treatment you receive will depend on your doctor's
personal preference and other factors. If drugs were administered, you
may remain in hospital for additional rest and observation for a couple
of days. Your doctor may decide to let you return home, while you take
oral tocolytic medication or receive terbutaline from a pump through a
needle placed in the fat under your skin. Depending on your condition
and the stage of pregnancy your doctor may recommend home uterine
activity monitoring.

If labor cannot be stopped

After the membranes have ruptured it is unlikely that labor can be
arrested. Since there is an increased risk of infection, your doctor will
recommend that you go to the hospital, where you will be monitored
and given antibiotics if needed. The hospital will also be equipped with
a neonatal intensive care unitPart of a hospital that is dedicated to the
care and attention of newborn infants that are seriously ill or
premature. It contains a variety of specialized equipment and is staffed
by a team of nurses and neonatologists who are specially trained in the
pathophysiology of the newborn.
Visit our comprehensive glossary for more pregnancy terms and
definitions. or NICU, which is capable of providing the necessary care
to your premature baby after delivery.
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Because the baby's head is smaller and softer when premature, labor
is generally shorter and easier than a full term delivery. An
episiotomyA surgical procedure in which an incision is made in the
perineum to enlarge the vaginal opening and faciliate delivery of the
baby or prevent tearing of the perineum. It is closed with absorbable
sutures.
There are two types of episiotomy; the medilateral, cut at 45 degrees
with midline, and median cut in the midline. The former offers more
room for delivery but is more painful postpartum, while the latter heals
more easily, but provides less room for delivery.
Visit our comprehensive glossary for more pregnancy terms and
definitions. will probably be performed, and forceps used for delivery to
protect your baby from pressure changes in the birth canal.

If there are no signs of contractions within one or two days, an

oxytocinOxytocin is a pregnancy hormone that both stimulates breast
milk production and stimulates uterine contractions. Synthetic
oxytocins have been created to induce labor.
Visit our comprehensive glossary for more pregnancy terms and
definitions. will be administered to stimulate labor. You will probably be
given an epiduralA regional anesthetic introduced into the base of the
spine used during labor and for cesarean sections. Also known as an
epidural block.
Visit our comprehensive glossary for more pregnancy terms and
definitions. instead of analgesic medicationsA form of painkilling agent
that doesn't induce unconciousness in the patient.
Visit our comprehensive glossary for more pregnancy terms and
definitions., which can depress the baby's respiratory sytem. Your baby
will be closely monitored for signs of fetal distressA condition, usually
discovered in labor, in which the fetal heartbeat follows an abnormal
pattern. The fetal heartbeat is recorded using electronic fetal
monitoring.
The acid balance of the fetal blood is measured, and labor is allowed to
continue if it falls within prescribed ranges, and the abnormal
heartbeat does not recur or persist.
If nescessary, attempts will be made to stabilize the fetus by
administering oxygen to the mother, increasing her fluid intake or
prescribing an agent to help the uterus relax. In some cases a cesarean
section may be required.
Visit our comprehensive glossary for more pregnancy terms and
definitions. resulting from a lack of oxygen, using electronic fetal
monitoring and if necessary a cesarean section will be performed.

Malpositions and malpresentations

Malpositions are abnormal positions of the vertex of the fetal
head (with the occiput as the reference point) relative to the
maternal pelvis. Malpresentations are all presentations of the
fetus other than vertex.
PROBLEM

The fetus is in an abnormal position or presentation that

may result in prolonged or obstructed labour.

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Clinical
principles

GENERAL MANAGEMENT

Make a rapid evaluation of the general condition of the

woman including vital signs (pulse, blood pressure,
respiration, temperature).
Assess fetal condition:
- Listen to the fetal heart rate immediately after a
contraction:

Rapid initial
assessment
Talking with women
and their families
Emotional and
psychological support
Emergencies

- Count the fetal heart rate for a full

minute at least once every 30
minutes during the active phase
and every 5 minutes during the
second stage;
- If there are fetal heart rate
abnormalities (less than 100 or
more than 180 beats per minute),
suspect fetal distress.
- If the membranes have ruptured, note the
colour of the draining amniotic fluid:
- Presence of thick meconium
indicates the need for close
monitoring and possible
intervention for management of
fetal distress;
- Absence of fluid draining after
rupture of the membranes is an
indication of reduced volume of
amniotic fluid, which may be
associated with fetal distress.

Provide encouragement and supportive care.

Review progress of labour using a partograph.

General care principles

Clinical use of blood,
blood products and
replacement fluids
Antibiotic therapy
Anaesthesia and
analgesia
Operative care
principles
Normal Labour and
childbirth
Newborn care
principles
Provider and
community linkages
Symptoms
Shock

Vaginal bleeding in
Note: Observe the woman closely. Malpresentations increase the early pregnancy
risk for uterine rupture because of the potential for obstructed
labour.
Vaginal bleeding in
later pregnancy and
labour

DIAGNOSIS

Vaginal bleeding after

childbirth

DETERMINE THE PRESENTING PART

Headache, blurred
The most common presentation is the vertex of the fetal vision, convulsions or
head. If the vertex is not the presenting part, see Table loss of consciousness,
elevated blood
S-12.
If the vertex is the presenting part, use landmarks of the pressure
fetal skull to determine the position of the fetal head (Fig
Unsatisfactory
S-9).
progress of Labour
Figure S-9
Malpositions and
malpresentations
Landmarks of the fetal skull
Shoulder dystocia
Labour with an
overdistended uterus
Labour with a scarred
uterus

DETERMINE THE POSITION OF THE FETAL HEAD

Fetal distress in
Labour

Prolapsed cord
The fetal head normally engages in the maternal pelvis in
an occiput transverse position, with the fetal occiput
Fever during
transverse in the maternal pelvis (Fig S-10).
pregnancy and labour
Figure S-10
Occiput transverse positions

Fever after childbirth

Abdominal pain in
early pregnancy
Abdominal pain in
later pregnancy and
after childbirth
Difficulty in breathing
Loss of fetal
movements

With descent, the fetal head rotates so that the fetal

occiput is anterior in the maternal pelvis (Fig S-11).
Failure of an occiput transverse position to rotate to an
occiput anterior position should be managed as an occiput
posterior position.
Figure S-11
Occiput anterior positions

Prelabour rupture of
membranes
Immediate newborn
conditions or problems
Procedures
Paracervical block
Pudendal block
Local anaesthesia for
caesaran section
Spinal (subarachnoid)
anaesthesia
Ketamine
External version
Induction and
augmentation of labour
Vacuum extraction
Forceps delivery

An additional feature of a normal presentation is a wellflexed vertex (Fig S-12), with the fetal occiput lower in
the vagina than the sinciput.
Figure S-12
Well-flexed vertex

Caesarean section
Symphysontomy
Craniotomy and
craniocentesis
Dilatation and
curettage
Manual vacuum
aspiration
Culdocentesis and
colpotomy

Episiotomy
Manual removal of
placenta
Repair of cervical tears
Repair of vaginal and
perinetal tears
Correcting uterine
inversion

If the fetal head is well-flexed with occiput anterior or

occiput transverse (in early labour), proceed with
delivery.
If the fetal head is not occiput anterior, identify and
manage the malposition (Table S-11).

Repair of ruptured
uterus

If the fetal head is not the presenting part or the fetal

head is not well-flexed, identify and manage the
malpresentation (Table S-12).

Postpartum
hysterectomy

TABLE S-11 Diagnosis of malpositions

TABLE S-12 Diagnosis of malpresentations

MANAGEMENT
OCCIPUT POSTERIOR POSITIONS

Uterine and uteroovarian artery ligation

Salpingectomy for
ectopic pregnancuy
Appendix
Essential drugs for
managing
complications in
pregnancy and
childbirth

Index
Spontaneous rotation to the anterior position occurs in 90% of
cases. Arrested labour may occur when the head does not rotate
and/or descend. Delivery may be complicated by perineal tears or
extension of an episiotomy.

If there are signs of obstruction or the fetal heart rate is

abnormal (less than 100 or more than 180 beats per
minute) at any stage, deliver by caesarean section.
If the membranes are intact, rupture the membranes
with an amniotic hook or a Kocher clamp.
If the cervix is not fully dilated and there are no signs of

obstruction, augment labour with oxytocin.

If the cervix is fully dilated but there is no descent in

the expulsive phase, assess for signs of obstruction
(Table S-10):
- If there are no signs of obstruction, augment
labour with oxytocin.

If the cervix is fully dilated and if:

- the fetal head is more than 3/5 palpable above
the symphysis pubis or the leading bony edge of
the head is above -2 station, perform caesarean
section;
- the fetal head is between 1/5 and 3/5 above the
symphysis pubis or the leading bony edge of the
head is between 0 station and -2 station:
- Delivery by vacuum extraction
and symphysiotomy;
- If the operator is not proficient
in symphysiotomy, perform
caesarean section;
- the head is not more than 1/5 above the
symphysis pubis or the leading bony edge of the
fetal head is at 0 station, deliver by vacuum
extraction or forceps.

BROW PRESENTATION
In brow presentation, engagement is usually impossible and
arrested labour is common. Spontaneous conversion to either
vertex presentation or face presentation can rarely occur,
particularly when the fetus is small or when there is fetal death
with maceration. It is unusual for spontaneous conversion to
occur with an average-sized live fetus once the membranes have
ruptured.

If the fetus is alive, deliver by caesarean section.

If the fetus is dead and:
- the cervix is not fully dilated, deliver by

caesarean section;
- the cervix is fully dilated:
- Deliver by craniotomy;
- If the operator is not proficient
in craniotomy, deliver by
caesarean section.
Do not deliver brow presentation by vacuum extraction,
outlet forceps or symphysiotomy.
FACE PRESENTATION
The chin serves as the reference point in describing the position
of the head. It is necessary to distinguish only chin-anterior
positions in which the chin is anterior in relation to the maternal
pelvis (Fig S-24 A) from chin-posterior positions (Fig S-24 B).

Figure S-24
Face presentation

Prolonged labour is common. Descent and delivery of the head

by flexion may occur in the chin-anterior position. In the chinposterior position, however, the fully extended head is blocked

by the sacrum. This prevents descent and labour is arrested.

CHIN-ANTERIOR POSITION

If the cervix is fully dilated:

- Allow to proceed with normal childbirth;
- If there is slow progress and no sign of
obstruction (Table S-10), augment labour with
oxytocin;
- If descent is unsatisfactory, deliver by forceps.

If the cervix is not fully dilated and there are no signs of

obstruction, augment labour with oxytocin. Review
progress as with vertex presentation.

CHIN-POSTERIOR POSITION

If the cervix is fully dilated, deliver by caesarean

section.
If the cervix is not fully dilated, monitor descent,
rotation and progress. If there are signs of obstruction,
deliver by caesarean section.

If the fetus is dead:

- Deliver by craniotomy;
- If the operator is not proficient in craniotomy,
deliver by caesarean section.
Do not perform vacuum extraction for face presentation.

COMPOUND PRESENTATION
Spontaneous delivery can occur only when the fetus is very small
or dead and macerated. Arrested labour occurs in the expulsive
stage.

Replacement of the prolapsed arm is sometimes possible:

- Assist the woman to assume the knee-chest
position (Fig S-25);
- Push the arm above the pelvic brim and hold it
there until a contraction pushes the head into the
pelvis.
- Proceed with management for normal childbirth.
Figure S-25
Knee-chest position

If the procedure fails or if the cord prolapses, deliver by

caesarean section.

BREECH PRESENTATION
Prolonged labour with breech presentation is an indication for
urgent caesarean section. Failure of labour to progress must be
considered a sign of possible disproportion (Table S-10)

The frequency of breech presentation is high in preterm

labour.

EARLY LABOUR
Ideally, every breech delivery should take place in a hospital with

surgical capability.

Attempt external version if:

- breech presentation is present at or after 37
weeks (before 37 weeks, a successful version is
more likely to spontaneously revert back to breech
presentation);
- vaginal delivery is possible;
- membranes are intact and amniotic fluid is
adequate;
- there are no complications (e.g. fetal growth
restriction, uterine bleeding, previous caesarean
delivery, fetal abnormalities, twin pregnancy,
hypertension, fetal death).

If external version is successful, proceed with normal

childbirth.
If external version fails, proceed with vaginal breech
delivery (see below) or caesarean section.

VAGINAL BREECH DELIVERY

A vaginal breech delivery by a skilled health care

provider is safe and feasible under the following
conditions:
- complete (Fig S-20) or frank breech (Fig S-21);
- adequate clinical pelvimetry;
- fetus is not too large;
- no previous caesarean section for cephalopelvic
disproportion;
- flexed head.

Examine the woman regularly and record progress on a

partograph.
If the membranes rupture, examine the woman

immediately to exclude cord prolapse.

Note: Do not rupture the membranes.

If the cord prolapses and delivery is not imminent,

deliver by caesarean section.
If there are fetal heart rate abnormalities (less than 100
or more than 180 beats per minute) or prolonged labour,
deliver by caesarean section.
Note: Meconium is common with breech labour
and is not a sign of fetal distress if the fetal heart
rate is normal.

The woman should not push until the cervix is fully dilated.
Full dilatation should be confirmed by vaginal examination.

CAESAREAN SECTION FOR BREECH PRESENTATION

A caesarean section is safer than vaginal breech delivery

and recommended in cases of:
- double footling breech;
- small or malformed pelvis;
- very large fetus;
- previous caesarean section for cephalopelvic
disproportion;
- hyperextended or deflexed head.
Note: Elective caesarean section does not improve
the outcome in preterm breech delivery.

COMPLICATIONS
Fetal complications of breech presentation include:

cord prolapse;
birth trauma as a result of extended arm or head,
incomplete dilatation of the cervix or cephalopelvic

disproportion;

asphyxia from cord prolapse, cord compression, placental

detachment or arrested head;

damage to abdominal organs;

broken neck.

TRANSVERSE LIE AND SHOULDER PRESENTATION

If the woman is in early labour and the membranes are

intact, attempt external version:
- If external version is successful, proceed with
normal childbirth;
- If external version fails or is not advisable,
deliver by caesarean section (page P-43).

Monitor for signs of cord prolapse. If the cord prolapses

and delivery is not imminent, deliver by caesarean
section.

Note: Ruptured uterus may occur if the woman is left unattended

.
In modern practice, persistent transverse lie in labour is
delivered by caesarean section whether the fetus is alive or
dead.

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Prematurity
In that they continue developing after birth, most animals are born not mature. At birth, a
normal human infant is relatively less mature than infants of some other primate species,
possibly to allow its disproportionately large head to fit through a pelvis adapted for
walking on two legs.
In humans, whereas the usual definition of preterm birth is birth before 37 weeks
gestation,[2] a "premature" infant is one that has not yet reached the level of fetal

development that generally allows life outside the womb. In the normal human fetus,
several organ systems mature between 34 and 37 weeks, and the fetus reaches adequate
maturity by the end of this period. One of the main organs greatly affected by premature
birth is the lungs. The lungs are one of the last organs to develop in the womb; because of
this, preemies typically spend the first days/weeks of their life on a ventilator. Therefore,
a significant overlap exists between preterm birth and prematurity: generally, preterm
babies are premature and term babies are mature. Prematurity can be reduced to a small
extent by using drugs to accelerate maturation of the fetus, and to a greater extent by
preventing preterm birth.

Epidemiology
In Europe and many developed countries the preterm birth rate is generally 5-9%, and in
the USA it has even risen to 12-13% in the last decades.[1] Three obstetric events precede
preterm birth: spontaneous preterm births are the 40-45% preterm births that follow
preterm labor and the 25-30% preterm births after premature rupture of membranes. The
remainder (30-35%) are preterm births that are induced for obstetrical reasons;
obstetricians may have to deliver the baby preterm because of a deteriorating intrauterine
environment (i.e. infection, intrauterine growth retardation) or significant endangerment
of the maternal health (i.e. preeclampsia, cancer). By gestational age, 5% of preterm
births occur at less than 28 weeks (extreme prematurity), 15% at 28-31 weeks (severe
prematurity), 20% at 32-33 weeks (moderate prematurity), and 60-70% at 34-36 weeks
(near term).[1]
As weight is easier to determine than gestational age, the World Health Organization
tracks rates of low birth weight (< 2,500 grams), which occurred in 16.5 percent of births
in less developed regions in 2000.[3] It is estimated that one-third of these low birth
weight deliveries are due to preterm delivery. Weight generally correlates to gestational
age, however, infants may be underweight for other reasons than a preterm delivery.
Neonates of low birth weight (LBW) have a birth weight of less than 2500 g (5 lb 8 oz)
and are mostly but not exclusively preterm babies as they also include small for
gestational age (SGA) babies. Weight-based classification further recognizes Very Low
Birth Weight (VLBW) which is less than 1500 g, and Extremely Low Birth Weight
(ELBW) which is less than 1000 g.[4] Almost all neonates in these latter two groups are
born preterm.
Preterm birth is a significant cost factor in healthcare, not even considering the expenses
of long-term care for individuals with disabilities due to preterm birth. A 2003 study in
the US determined neonatal costs to be $224,400 for a newborn at 500-700 g versus
$1,000 at over 3,000 g. The costs increase exponentially with decreasing gestational age
and weight.[5]
Epidemiology
The frequency of preterm births is about 5-9% in many developed countries and around
12-13% in the USA. The rate of preterm birth has increased in many locations

predominantly because of increasing preterm delivery of artificially conceived multiple

pregnancies.2About 7% of babies in the UK weigh less than 2.5 kg at birth, rising to 10%
in deprived areas such as Hackney.3
Simply labelling all babies born before 37 weeks as premature fails to illustrate the
marked gradation in terms of severity of the problem with increasing prematurity:

A baby born at 36 weeks will probably be a little slow to feed.

A baby born before 33 weeks will have more serious problems including,
possibly, immature lungs.
Birth before 28 weeks causes very significant problems but the survival rate is
quite remarkable.

Quoting figures may be misleading as they will vary considerably amongst units but
figures that are not atypical include 90% survival if over 800g, 50% survival if over 500g
and 80% survival before 28 weeks. These figures may also hide significant disability in
survivors.
Risk factors for premature delivery
There are a number of risk factors for early delivery:

Induction or caesarean section may have been undertaken because of serious

adverse intrauterine conditions:
o This may include fulminating pre-eclampsia or abruptio placentae.
o The decision that has to be made is "Is the baby safer in or out?" This is a
matter of balancing risks.
o Caesarean delivery is not associated with either reduced mortality or
neuro-disability at two years of age. It is advised therefore that the method
of delivery of these infants should be based on obstetric or maternal
indications rather than the perceived outcome of the baby.4
Multiple pregnancy often leads to premature labour and this may be very early if
multiple means more than twins.
Other causes of a large uterus e.g. polyhydramnios.
The classical story of cervical incompetence is one of progressively earlier
labours in successive pregnancies with premature rupture of membranes and a
painless early dilation of the cervix.
Low socio-economic status, inadequate or absent antenatal care and poor maternal
nutrition all predispose to premature labour. Low body mass index and
periodontal disease are associated with premature delivery.2
African-American and Afro-Caribbean women are two to three times more likely
to deliver early than white women. However, not all of this difference can be
explained by socioeconomic factors - gene/environment interactions are a factor.5
Smoking and excessive alcohol consumption are also risk factors.
Heroin withdrawal or too rapid reduction of methadone during the last trimester
can induce premature labour:

Drug abusers must be encouraged to comply closely with their regimen

and reduction of methadone should be slow in the last trimester.
o Cocaine can also cause premature labour. It is a potent vasoconstrictor and
this can have a devastating effect on placental function.
Maternal age under 17 or over 35 years old.
Bacterial vaginosis predisposes to premature labour.
o

Presentation
The premature baby will look small and unprepared for this world. The baby who is also
SFD may have little subcutaneous fat and the skin may appear wrinkled.
Because mortality rates have fallen, the focus for perinatal interventions is to reduce
long-term morbidity, especially the prevention of brain injury and abnormal brain
development. The premature baby faces a number of problems (these may be accentuated
if there is also IUGR):

Hypothermia is a great risk, especially if there is little subcutaneous fat. A

premature baby is less able to shiver and to maintain homeostasis.
Hypoglycaemia is also a risk, especially if SFD. There may also be
hypocalcaemia. Both can cause convulsions that may produce long term brain
damage.
The more premature the baby, the greater the risk of respiratory distress
syndrome. Steroids before delivery may reduce the risk but it is still very real. If
the baby requires oxygen it must be monitored very carefully as if the levels are
too high the premature baby is susceptible to retrolental fibroplasia and blindness.
The premature baby is more susceptible to neonatal jaundice and to kernicterus at
a lower level of bilirubin than a more mature baby.
They are susceptible to infection and to necrotising enteritis.
They are susceptible to intraventricular brain haemorrhage with serious long term
effects.

All these are problems faced by the neonatologist in the Special Care Baby Unit but when
the baby is eventually discharged from hospital and goes home with the family, that is not
the end of problems. The baby who is just slightly premature will probably have little on
no long term problems but those who are very premature and who have a stormy start to
life often suffer many and serious problems.
Supporting the parents
When a baby is in SCBU it is a very emotional and traumatic time for both the parents,
not just the mother. They should be encouraged to visit and stay with the baby as much as
possible. Breastfeeding may be rather difficult but it should be encouraged.6 Breastmilk is
the best food for any baby but especially premature babies. Mothers who are producing
more than their own baby needs should be encouraged to donate to the local SCBU as it
is always welcome.

The baby is attached to monitors and has tubes in and out of the body. It may not be
possible to hold the baby or it may not be possible to do so for long. This should be
encouraged as much as is compatible with the safety of the baby but bonding is much
more difficult than with a normal, healthy, full term baby.
Whilst trying to keep a positive attitude, the parents must also come to terms with the fact
that the baby could die. There may also be difficult decisions about switching off
ventilators and the expected quality of life if the child survives. Communicating in these
situations can be difficult and parents may have trouble taking in what they are told at
such an emotional time.7 They may wish to discuss matters with the familiar face of their
family doctor who is outside the hospital but who understands the issues involved.

Immunisations
Premature babies need to be protected by immunisations as much as any other baby and
prematurity is not a contraindication to immunisation even if the immune system may be
immature. The timing of immunisations is based on the child's chronological age from
birth and not on the child's putative age based on maturity.8
Long term problems of premature babies
Morbidity is inversely related to gestational age; however, there is no gestational age
(including term) that is wholly exempt.9 Severe problems such as cerebral palsy,
blindness and deafness may affect as many as 10 to 15% of significantly premature
babies. There is some evidence that the incidence of cerebral palsy is falling in premature
babies born between 28-31 weeks.10
Figures about outcomes for premature babies have to be interpreted with a degree of
circumspection to be sure that like is being compared with like:

Percentages should be taken with caution.

Different studies use different criteria for the degree of prematurity for inclusion.
There is a gradation of risk.
Being both premature and small for dates would seem to add further to the risk.

Sight and hearing

About 1 in 4 babies with birth weight below 1.5 kg has peripheral or central hearing
impairment or both.11
Infants who undergo early screening and treatment for retinopathy of prematurity have
improved long-term functional and structural outcomes compared with those who receive
conventional screening and treatment.12 However, the increased survival of lower birth
weight infants has increased the prevalence of aggressive, posterior retinopathy of
prematurity that may be unresponsive to conventional treatment.

In a multicentre study 66% of babies under 1.25 kg developed ROP, but only 6% required
treatment.13

Follow up to school
Cognitive and neuromotor impairments at 5 years of age increase with decreasing
gestational age. Many of these children need a high level of specialised care:14

About half of infants born at 2428 weeks of gestation have a disability at 5 years,
similar to the proportion observed in the UK-based EPICure study.15
In the infants born later (2932 weeks' gestation), about a third have a disability at
5 years.

Behavioural and psychomotor problems

A study from Liverpool has looked at children of 7 and 8 who were born before 32 weeks
and who were well enough to attend mainstream school.16 They were compared with fullterm children of similar age in their class at school:

Disabilities can be subtle and numerous and so a range of tests was used.
The preterm children had a higher incidence of motor impairment and this
affected how well they did at school even when their intelligence was normal.
Over 30% had developmental coordination disorder (DCD) compared with 6% of
classmates.
The preterm children were significantly more likely be overactive, easily
distractible, impulsive, disorganised and lacking in persistence. They also tended
to overestimate their ability.
Attention deficit hyperactivity disorder (ADHD) was found in 8.9% of the
preterm children and 2% of controls.
The children who had been the most premature were not necessarily those with
the lowest scores.

Although major disabilities have been reduced, the levels of disability tested in this study
did not seem lower than those found in children born 10 or 20 years earlier, despite
improvements in care of the newborn.

Brain development
IUGR may be very important in terms of early growth of the brain leading to poor IQ and
developmental skills.17 Individuals who were born before 33 weeks gestation continue to
show noticeable decrements in brain volumes and striking increases in lateral ventricular
volume into adolescence.18

Emotional development - teens and beyond

A study of teenagers in mainstream schools who were born before 29 weeks gestation
showed that compared with mainstream classmates, they have higher levels of parent and
teacher reported emotional, attentional, and peer problems well into their teens. Despite
these problems, they do not show signs of more serious conduct disorders, delinquency,
drug use, or depression.19
A study of 18 and 19 years olds who were born before 33 weeks gestation showed that
they had different personalities from controls with increased neuroticism and decreased
extraversion scores. This was more marked in females than males.13
A study of pre-term children who had reached 19 to 22 years of age showed that they
were, on average, shorter than their contemporaries, more likely to use prescription
medicines and less likely to have attended higher education.20
Prevention
Interventions to reduce the morbidity and mortality of preterm birth can be primary
(directed to all women), secondary (aimed at eliminating or reducing existing risk), or
tertiary (intended to improve outcomes for preterm infants).21 Most efforts so far have
been tertiary interventions.

Primary - Problems of social deprivation, poor maternal nutrition and substance

abuse must all be addressed. Smoking should cease and, as explained in the article
on fetal alcohol syndrome, alcohol consumption should be avoided as there may
be no safe lower limit.22
Secondary - Antenatal care is important and should be easily accessible to all
women.
Tertiary - Interventions when complications arise e.g. regionalised care, treatment
with antenatal corticosteroids, tocolytic agents and antibiotics.

Ethical issues
The success of improved survival in very premature infants has raised some serious
ethical issues. It is now possible to save more and more smaller and earlier babies but is
this a good thing?

Such babies have a very high incidence of both physical and behavioural
problems. This may be blindness, deafness, mental handicap or ADHD. Is the
quality of life really worth the enormous input?
The term bed blockers is usually used pejoratively of the elderly but tiny, very
early babies spend a very long time in SCBU cots that are in short supply. They
may be depriving other babies of facilities from which they would extract greater
benefit. The cost of SCBU care is also very high and finance is not a limitless
resource.

However, premature babies can become extremely productive, as shown by the

list of famous premature babies on the premature babies uk website. It includes
Albert Einstein, Isaac Newton and Charles Darwin.
When should neonatologists decide that the quality of life that they salvage is not
worthy of the effort? When would it be better to let tiny babies die? This is a very
difficult question that will raise much passion and prejudice but it is an extremely
important issue that does require sober assessment.
The high survival rates that are achieved by some units for very premature babies
has fuelled a debate about the upper limit for termination of pregnancy.

Signs and symptoms

Symptoms of imminent spontaneous preterm birth are signs of premature labor; such
signs consists of four or more uterine contractions in one hour before 37 weeks' gestation.
In contrast to false labor, true labor is accompanied by cervical shortening and
effacement. Also, vaginal bleeding in the third trimester, heavy pressure in the pelvis, or
abdominal or back pain could be indicators that a preterm birth is about to occur. A
watery discharge from the vagina may indicate premature rupture of the membranes that
surround the baby. While the rupture of the membranes may not be followed by labor,
usually delivery is indicated as infection (chorioamnionitis) is a real threat to both, fetus
and mother. In some cases the cervix dilates prematurely without pain or perceived
contractions, so that the mother may not have warning signs until very late in the birthing
process.

Causes
As the cause of labor still remains elusive, the exact cause of preterm birth is also
unsolved. Labor is a complex process involving many factors. Four different pathways
have been identified that can result in preterm birth and have considerable evidence:
precocious fetal endocrine activation, uterine overdistension, decidual bleeding, and
intrauterine inflammation/infection.[6] Activation of one or more of these the these
pathways may have been gradually over weeks, even months.[6] From a practical point a
number of factors have been identified that are associated with preterm birth, however, an
association does not establish causality.

Maternal background
A number of factors have been identified that are linked to a higher risk of a preterm
birth: low socio-economic or educational standing and single motherhood,[1] as well as
age at the upper and lower end of the reproductive years be it more than 35[7] or less than
18 years of age.[1] Further, in the US and the UK Afro-American and Afro-Caribbean
women have preterm birth rates of 15-18% more than double than that of the white

population. This discrepancy is not seen in comparison to Asian or Hispanic immigrants

and remains unexplained.[1]
Pregnancy interval makes a difference as women with a 6 months span or less between
pregnancies have a two-fold increase in preterm birth.[8] Studies on type of work and
physical activity have given conflicting results, but it is opined that stressful conditions,
hard labor, and long hours are probably linked to preterm birth.[1] Patients who had
undergone previous induced abortions have been shown to have a higher risk of preterm
birth only if the termination was performed surgically but not medically.[9] Adequate
maternal nutrition is important. Women with a low BMI are at increased risk for preterm
birth.[10] Further, women with poor nutritional status may also be deficient in vitamins and
minerals. Adequate nutrition is critical for fetal development and a diet low in saturated
fat and cholesterol may help reduce the risk of a preterm delivery.[11] Obesity does not
directly lead to preterm birth; however, it is associated with diabetes and hypertension
which are risk factors by themselves.[1] Women with a previous preterm birth are at higher
risk for a recurrence at a rate of 15-50% depending on number of previous events and
their timing.[12] To some degree those individuals may have underlying conditions (i.e.
uterine malformation, hypertension, diabetes) that persist. Genetic make-up is a factor in
the causality of preterm birth. An intra- and transgenerational increase in the risk of
preterm delivery has been demonstrated.[13][14] No single gene has been identified, and it
appears with the complexity of the labor initiation, that numerous polymorphic genetic
interactions are possible.

Factors during pregnancy

Multiple pregnancies (twins, triplets, etc.) are a significant factor in preterm birth. The
March of Dimes Multicenter Prematurity and Prevention Study found that 54% of twins
were delivered preterm vs. 9.6% of singleton births.[15] Triplets and more are even more
endangered. The use of fertility medication that stimulates the ovary to release multiple
eggs and of IVF with embryo transfer of multiple embryos has been implicated as an
important factor in preterm birth. Maternal medical conditions increase the risk of
preterm birth, and often labor has to be induced for medical reasons; such conditions
include high blood pressure[16], pre-eclampsia[17], maternal diabetes[18], asthma, thyroid
disease, and heart disease. In a number of women anatomical issues prevent that the baby
is carried to term. Some women have a weak or short cervix[16] (the strongest predictor of
premature birth)[19][20][21] The cervix may also have been compromised by previous
cervical conization or loop excision. In women with uterine malformations the capacity
of the uterus to hold the growing pregnancy may be limited and preterm labor ensues.[22]
Women with vaginal bleeding during pregnancy are at higher risk for preterm birth.
While bleeding in the third trimester may be a sign of placenta previa or placental
abruption conditions that occur frequently preterm even earlier bleeding that is not
caused by these two conditions is linked to a higher preterm birth rate.[23] Women with
abnormal amounts of amniotic fluid, too much (polyhydramnios) or too little
(oligohydramnios) are also at risk.[1] The mental status of the women is of significance.
Anxiety[24] and depression have been linked to preterm birth.[1] Finally, the use of tobacco,
cocaine, and excessive alcohol during pregnancy also increases the chance of preterm

delivery. Tobacco is the most commonly abused drug during pregnancy and also
contributes significantly to low birth weight delivery.[25][26] Babies with birth defects are at
higher risk of being born preterm.[27]
Infection
Infections play a major role in the genesis of preterm birth and may account for 25-40%
of events.[28] The frequency of infection in preterm birth is inversely related to the
gestational age.[1] Endotoxins released by microorganisms and cytokines stimulate
deciduasl responses including the release of prostaglandins which may stimulate uterine
contractions. Further the decidual response may include release of matrix-degrading
enzymes that weaken fetal membranes leading to premature rupture.[28] Intrauterine
infection appears to be a chronic process.[28] Typical organisms identified in the uterus
before rupture of the membranes are genital Mycoplasma spp and specifically
Ureaplasma urealyticum. Micro-organisms may reach the decidua in a number of ways,
ascending, hematogeneous, iatrogenic by a procedure, or retrograde through the fallopian
tubes. From the deciduas they may reach the space between the amnion and chorion, the
amniotic fluid, and finally the fetus. A chorioamnionitis also may lead to sepsis of the
mother. Fetal infection not only is linked to preterm birth but to significant long-term
handicap including cerebral palsy.[1] It has been reported that asymptomatic colonization
of the decidua occurs in up to 70% of women at term using a DNA probe suggesting that
the presence of micro-organism alone may be insufficient to initiate the infectious
response. Bacterial vaginosis has been linked to preterm birth raising the risk by a factor
of 1.5 - 3.[29] As the condition is more prevalent in black women in the US and the UK, it
has been suggested to be an explanation for the higher rate of preterm birth in this
population. It is opined that bacterial vaginosis before or during pregnancy may affect the
decidual inflammatory response that leads to preterm birth.[1] A number of maternal
bacterial infections are associated with preterm birth including pyelonephritis,
asymptomatic bacteriuria, pneumonia, and appendicitis. Also periodontal disease has
been shown repeatedly to be linked to preterm birth.[30] In contrast, viral infections, unless
accompanied by a significant febrile response, are considered not to be a major factor in
relation to preterm birth.[1]

Clinical tests
Helpful clinical test should predict a high risk for preterm birth during the early and
middle part of the third trimester, when their impact is significant. Many women
experience false labor (not leading to cervical shortening and effacement) and are falsely
labelled to be in preterm labor. The study of preterm birth has been hampered by the
difficulty in distinguishing between "true" preterm labor and false labor.[6] These new test
are used to identify women at risk for preterm birth.

Fetal fibronectin
Fetal fibronectin has become the most important biomarker the presence of this
glycoprotein in the cervical or vaginal secretions indicates that the border between the

chorion and deciduas has been disrupted. A positive test indicates an increased risk of
preterm birth, and a negative test has a high predictive value.[1] It has been shown that
only 1% of women in questionable cases of preterm labor delivered within the next week
when the test was negative.[31]

Ultrasonography of the cervix

Obstetric ultrasound has become useful in the assessment of the cervix in women at risk
for premature delivery. A short cervix preterm is undesirable: At 24 weeks gestation a
cervix length of less than 25 mm defines a risk group for preterm birth. Further, the
shorter the cervix the greater the risk.[32] It also has been helpful to use ultrasonography in
women with preterm contractions, as those whose cervix length exceeds 30 mm are
unlikely to deliver within the next week.[33]

Intervention
Historically efforts have been primarily aimed to improve survival and health of preterm
infants (tertiary intervention). Such efforts, however, have not reduced the incidence of
preterm birth. Increasingly primary interventions that are directed at all women, and
secondary intervention that reduce existing risks are looked upon as measures that need
to be developed and implemented to prevent the health problems of premature infants and
children.[34]

Primary (aimed at all women)

Preconceptional
Raising public and professional awareness about the scope of the problem and its
significance as the major contributor to infant mortality is a beginning to reduce
avoidable risk factor. Among them is the need to reduce repeated uterine instrumentation
( ie repeated surgical abortions)[35] and to avoid risky choices in infertility treatments.
Adoption of specific professional policies can immediately reduce risk of preterm birth as
the experience in assisted reproduction has shown when the number of embryos during
embryo transfer were limited.[34] Society has established in many countries programs
specifically to protect pregnant women from hazardous work and night shift and provided
time for prenatal visits and paid pregnancy-leave. The EUROPOP study showed that
preterm birth is not related to type of employment, but to prolonged work (>42 h per
week) or prolonged standing (>6 h per day).[36] Also, night work has been linked to
preterm birth.[37] Health policies that take these findings into account can be expected to
reduce the rate of preterm birth.[34] Avoidance of weight extremes and good nutritional
support are important. Although a study failed to show that multivitamin preparation
taken prior to conception reduces the risk of preterm birth,[38] preconceptional intake of
folic acid is recommended to reduce birth defects. There is some evidence that long term
(> one year) use of folic acid may reduce premature birth.[39][40] Reducing smoking is
expected to benefit pregnant women and their offspring.[34]

During pregnancy
Interventions that should have been initiated prior to pregnancy, can still be instituted
during pregnancy including nutritional adjustments, use of vitamin supplements, and
smoking cessation.[34] Calcium supplementation as well as supplemental intake of C and
E vitamins could not be shown to reduce preterm birth rates.[41][42] Different strategies are
used in the administration of prenatal care, and future studies need to determine if the
focus should be on screening for high risk women, or widened support for low-risk
women, or to what degree these approaches should be merged.[34] While periodontal
infection has been linked with preterm birth, randomized trials have not shown that
periodontal care during pregnancy reduces preterm birth rates.[34]
Screening of low risk women

Screening for asymptomatic bacteriuria followed by appropriate treatment reduces

pyelonephritis and reduces the risk of preterm birth.[43] Extensive studies have been
carried out to determine if other forms of screening in low-risk women followed by
appropriate intervention are beneficial, including: Screening for and treatment of
Ureaplasma urealyticum, group B streptococcus, Trichomonas vaginalis, and bacterial
vaginosis did not reduce the rate of preterm birth.[34] Routine ultrasound examination of
the length of the cervix identifies patients at risk, but cerclage is not proven useful, and
the application of a progesterone is under study.[34] Screening for the presence of
fibronectin in vaginal secretions is not recommended at this time in women at low risk.
Self-care

Self-care methods to reduce the risk of preterm birth include proper nutrition, avoiding
stress, seeking appropriate medical care, avoiding infections, and the control of preterm
birth risk factors (e.g. working long hours while standing on feet, carbon monoxide
exposure, domestic abuse, and other factors). Self-monitoring vaginal pH followed by
yogurt treatment or clindamycin treatment if the pH was too high all seem to be effective
at reducing the risk of preterm birth.[44][45]

Secondary (reducing existing risks)

Women are identified to be at increased risk for preterm birth on the basis of their past
obstetrical history or the presence of known risk factors. Preconception intervention can
be helpful in selected patients in a number of ways. Patients with certain uterine
anomalies may have a surgical correction (i.e. removal of a uterine septum), and those
with certain medical problems can be helped by optimizing medical prior to conception,
be it for asthma, diabetes, hypertension and others.
During pregnancy
Reducing indicated preterm birth

A number of agents have been studies for secondary prevention of indicated preterm
birth. Trials using low-dose aspirin, fish oil, vitamin C and E, and calcium to reduce
preeclampsia demonstrated some reduction in preterm birth only when low-aspirin was
used.[34] Interestingly, even if agents such as calcium or antioxidants were able to reduce
preeclampsia, a resulting decrease in preterm birth was not observed.[34]
Reducing spontaneous preterm birth

Reduction in maternal activity pelvic rest, limited work, bed rest is frequently
recommended although there is no clear proof of its efficacy. Also, increasing medical
care by more frequent visits and more education has not shown a reduction in preterm
birth rates.[46] Use of nutritional supplements such as omega-3 polyunsaturated fatty acids
is based on the observation that populations who have a high intake of such agents are at
low risk for preterm birth, presumably as these agents inhibit production of
proinflammatory cytokines. A randomized trial showed a significant decline in preterm
birth rates,[47] and further studies are in the making.
Antibiotics
Studies examining the use of antibiotics have provided mixed results; a Cochrane review
of 15 trials shows no major benefit,[48] in contrast a review by Lamont suggested that
treatment of bacterial vaginosis if initiated prior to 20 w gestation is beneficial.[49] It has
been suggested that the presence of a chronic chorioamnionitis may not be amenable to
antibiotics, thus the difficulty to demonstrate their effectiveness.[34]
[edit] Progesterone

Progesterone, often given in the form of 17-hydroxyprogesterone caproate, relaxes the

uterine musculature, maintains cervical length, and has anti-inflammatory properties, and
thus exerts activities expected to be beneficial in reducing preterm birth. Two metaanalyses demonstrated a deduction in the risk of preterm birth in women with recurrent
preterm birth by 40-55%.[50][51] However, progesterone is not effective in all populations,
as a study involving twin gestations failed to see any benefit.[52]
Cervical cerclage
In preparation for childbirth, the woman's cervix shortens. Preterm cervical shortening is
linked to preterm birth and can be detected by ultrasonography. Cervical cerclage is a
surgical intervention that places a suture around the cervix to prevent its shortening and
widening. Numerous studies have been performed to assess the value of cervical cerclage
and the procedure appears helpful primarily for women with a short cervix and a history
of preterm birth.[53] Instead of a prophylactic cerclage, women at risk can be monitored
during pregnancy by sonography, and when shortening of the cervix is observed, the
cerclage can be performed. Women with a short cervix but no history of preterm birth,
and women with twin gestation, do not benefit from a cerclage.[34]

Tertiary (preterm birth imminent)

Tertiary interventions are aimed at women who are about to go into preterm labor, or
rupture the membranes or bleed preterm. The use of the fibronectin test and
ultrasonography improves the diagnostic accuracy and reduces false-positive diagnosis.
While treatments to arrest early labor where there is progressive cervical dilatation and
effacement will not be effective to gain sufficient time to allow the fetus to grow and
mature further, it may defer delivery sufficiently to allow the mother to be brought to a
specialized center that is equipped and staffed to handle preterm deliveries.[54] Centers for
the care of women with preterm delivery are usually staffed by maternal-fetal specialists
and highly trained staff and linked to neonatal intensive care units (vi). In a hospital
setting women are hydrated via intravenous infusion as dehydration can lead to premature
uterine contractions.
Glucocorticosteroids
Severely premature infants may have underdeveloped lungs, because they are not yet
producing their own surfactant. This can lead directly to respiratory distress syndrome,
also called hyaline membrane disease, in the neonate. To try to reduce the risk of this
outcome, pregnant mothers with threatened premature delivery prior to 34 weeks are
often administered at least one course of glucocorticoids, a steroid that crosses the
placental barrier and stimulates growth in the lungs of the fetus. Typical glucocorticoids
that would be administered in this context are betamethasone or dexamethasone, often
when the fetus has reached viability at 23 weeks. In cases where premature birth is
imminent, a second "rescue" course of steroids may be administered 12 to 24 hours
before the anticipated birth. There is no research consensus on the efficacy and sideeffects of a second course of steroids, but the consequences of RDS are so severe that a
second course is often viewed as worth the risk. Beside reducing respiratory distress,
other neonatal complication are reduced by the use of glucocorticosteroids, namely
intraventricular haemorrhage, necrotising enterocolitis, and patent ductus arteriosus.[55]
Despite being used for over 50 years to treat respiratory distress syndrome,
glucocorticosteroid therapy is still controversial. Much of this concern is based on when
these steroids should be administered (i.e. prenatally or postnatally) or for how long (i.e.
acutely or chronically). For instance, recent clinical research has shown that the postnatal
administration of dexamethasone can lead to permanent neuromotor and cognitive
deficits.[56] This has led to a drastic reduction in the postnatal use of glucocorticosteroids
in prematurely born infants. In addition, a recent large scale study has found that a second
rescue dose of betamethasone prenatally does not improve preterm birth outcomes and
leads to decreased weight, length, and head circumference.[57] Finally, while
glucocorticosteroid exposure in the adult is considered safe, recent animal research has
shown that a single exposure to these same drugs during brain development causes rapid
brain degeneration.[58][59] Despite these concerns, there is a consensus that the benefits of a
single regimen of prenatal glucocorticosteroids vastly outweigh the potential risks.[60]
The routine administration of antibiotics to all women with threatened preterm labor
reduces the risk of the baby to get infected with group B streptococcus and has been
shown to reduce related mortality rates.[61]

Research reported at the 2008 conference of the Society for Maternal-Fetal Medicine
suggests that administration of magnesium sulfate (Epsom salt) to women just before
premature birth can cut the rate of cerebral palsy in half. While the compound is cheap
and safe, it may make mothers and infants groggy, and details are pending scientific
publication.[39]
[edit] Tocolysis
Anti-contraction medications (tocolytics), such as 2-agonist drugs (ritodrine, terbutaline,
fenoterol), calcium-channel blockers nifedipine and oxytocin antagonists (atosiban)
appear only to have a temporary effect in delaying delivery. Tocolysis has not fulfilled its
promise as it is rarely successful beyond 24-48 hours because current medication do not
alter the fundamentals of labor activation.[6] However, just gaining 48 hours is sufficient
to allow the pregnant women to be transferred to a center specialized for management of
preterm deliveries and give administered corticosteroids the possibility to reduce neonatal
organ immaturity. Meta-analyses indicate that calcium-channel blockers and an oxytocin
antagonist can delay delivery by 2-7 days, and 2-agonist drugs delay by 48 hours but
carry more side effects.[34] Meta-analyses of magnesium sulfate failed to support it as a
tocolytic agent.[6]
When membranes rupture prematurely, obstetrical management looks for development of
labor and signs of infection. Administration of corticosteroids is indicated prior to 34
weeks gestation. Prophylactic antibiotic administration has been shown to prolong
pregnancy and reduced neonatal morbidity.[62] Because of concern about necrotizing
enterocolitis, amoxicillin or erythromycin has been recommended, but not amoxycillin +
clavulanic acid.[62]
The routine use of cesarean section for early delivery of infants expected to have very
low birth weight is controversial,[34] and a decision concerning the route and time of
delivery probably needs to be made on a case by case basis.

The preterm baby

Mortality and morbidity
The shorter the term of pregnancy, the greater the risks of mortality and morbidity for the
baby primarily due to the related prematurity. Preterm-premature babies ("preemies" or
"premies") have an increased risk of death in the first year of life (infant mortality), with
most of that occurring in the first month of life (neonatal mortality). Worldwide,
prematurity accounts for 10% of neonatal mortality, or around 500,000 deaths per year.[63]
In the U.S. where many infections and other causes of neonatal death have been markedly
reduced, prematurity is the leading cause of neonatal mortality at 25%.[64] Prematurely
born infants are also at greater risk for having subsequent serious chronic health problems
as discussed below.

The earliest gestational age at which the infant has at least a 50% chance of survival is
referred to as the limit of viability. As NICU care has improved over the last 40 years,
viability has reduced to approximately 24 weeks,[65][66] although rare survivors have been
documented as early as 21 weeks.[2] This date is controversial as gestation in this case
was measured from the date of conception rather than the date of her mother's last
menstrual period gestation appear 2 weeks less than if calculated by the more common
method.[67] As risk of brain damage and developmental delay is significant at that
threshold even if the infant survives, there are ethical controversies over the
aggressiveness of the care rendered to such infants. The limit of viability has also become
a factor in the abortion debate.
[edit] Specific risks for the preterm neonate
Preterm infants usually show physical signs of prematurity in reverse proportion to the
gestational age. As a result they are at risk for numerous medical problems affecting
different organ systems.

Neurological problems include apnea of prematurity, hypoxic-ischemic

encephalopathy (HIE), intracranial hemorrhage, retinopathy of prematurity
(ROP), developmental disability, and cerebral palsy.
Cardiovascular complications may arise from the failure of the ductus arteriosus
to close after birth: patent ductus arteriosus (PDA).
Respiratory problems are common, specifically the respiratory distress syndrome
(RDS or IRDS) (previously called hyaline membrane disease). Another problem
can be chronic lung disease (previously called bronchopulmonary dysplasia or
BPD).
Gastrointestinal and metabolic issues can arise from hypoglycemia, feeding
difficulties, rickets of prematurity, hypocalcemia, inguinal hernia, and necrotizing
enterocolitis (NEC).
Hematologic complications include anemia of prematurity, thrombocytopenia,
and hyperbilirubinemia (jaundice) that can lead to kernicterus.
Infectious include sepsis, pneumonia, and urinary tract infection [3]

A new mother holds her premature baby at Kapiolani Medical Center NICU in Honolulu,
Hawaii

[edit] Neonatal care

In developed countries premature infants are usually cared for in a neonatal intensive care
unit (NICU). The physicians who specialize in the care of very sick or premature babies
are known as neonatologists. In the NICU, premature babies are kept under radiant
warmers or in incubators (also called isolettes), which are bassinets enclosed in plastic
with climate control equipment designed to keep them warm and limit their exposure to
germs. Modern neonatal intensive care involves sophisticated measurement of
temperature, respiration, cardiac function, oxygenation, and brain activity. Treatments
may include fluids and nutrition through intravenous catheters, oxygen supplementation,
mechanical ventilation support, and medications. In developing countries where
advanced equipment and even electricity may not be available or reliable, simple
measures such as kangaroo care (skin to skin warming), encouraging breastfeeding, and
basic infection control measures can significantly reduce preterm morbidity and
mortality.
Long term sequelae
Most children even if born very preterm adjust very well during childhood and
adolescence.[68] As survival has improved, the focus of interventions directed at the
newborn has shifted to reduce long-term disabilities, particularly those related to brain
injury.[68] Some of the complications related to prematurity may not be apparent until
years after the birth. A long-term study demonstrated that the risks of medical and social
disabilities extend into adulthood and are higher with decreasing gestational age at birth
and include cerebral palsy, mental retardation, disorders of psychological development,
behavior, and emotion, disabilities of vision and hearing, and epilepsy.[69] Also it was
shown that higher levels of education were less likely to be obtained with decreasing
gestational age at birth.[69] People born prematurely may be more susceptible to
developing depression as teenagers.[70] Some of these problems can be described as being
within the executive domain and have been speculated to arise due to decreased
myelinization of the frontal lobes.[71] Throughout life they are more likely to require
services provided by physical therapists, occupational therapists, or speech therapists.
Further long-term studies are needed to get a better picture about the sequalae of preterm
birth.[68]

Notable preterm births

James Elgin Gill (born on 20 May 1987 in Ottawa, Canada) was the earliest premature
baby in the world. He was 128 days premature (21 weeks and 5 days gestation) and
weighed 1 pound 6 ounces (624 g). He survived and is quite healthy.[72][73]
Amillia Taylor is also often cited as the most-premature baby.[74] She was born on 24
October 2006 in Miami, Florida, at 21 weeks and 6 days gestation.[75] This report has
created some confusion her gestation was measured from the date of conception (through
in-vitro fertilization) rather than the date of her mother's last menstrual period making her
appear 2 weeks younger than if gestation was calculated by the more common method.[70]
At birth she was 9 inches (23 cm) long and weighed 10 ounces (283 grams).[74] She

suffered digestive and respiratory problems, together with a brain hemorrhage. She was
discharged from the Baptist Children's Hospital on 20 February 2007.[74]
The record for the smallest premature baby to survive was held for some time by
Madeline Mann, who was born at 26 weeks weighing 9.9 oz (280 g) and 9.5 inches (24
cm) long.[76] This record was broken in September 2004 by Rumaisa Rahman, who was
born in the same hospital[77] at 25 weeks gestation. At birth she was eight inches (20 cm)
long and weighed 244 grams (8.6 ounces). Her twin sister was also a small baby,
weighing 563 grams (1 pound 4 ounces) at birth. During pregnancy their mother had
suffered from pre-eclampsia, which causes dangerously high blood pressure putting the
baby into distress and requiring birth by caesarean section. The larger twin left the
hospital at the end of December, while the smaller remained there until 10 February 2005
by which time her weight had increased to 1.18 kg (2 pounds 10 ounces).[78] Generally
healthy, the twins had to undergo laser eye surgery to correct visual problems, a common
occurrence among premature babies.
Historical figures who were born prematurely include Johannes Kepler (born in 1571 at 7
months gestation), Isaac Newton (born in 1643, small enough to fit into a quart mug,
according to his mother), Winston Churchill (born in 1874 at 7 months gestation), and
Anna Pavlova (born in 1885 at 7 months gestation).[79]

Summary
Description

Premature labor is defined clinically as progressive cervical dilatation and/or

effacement with regular uterine contractions before the completion of 37 weeks of
gestation
Spontaneous premature labor is the leading cause of preterm delivery
In most cases premature labor will result in preterm birth
Approx. 1 in 10 births in the US are premature
In some cases it will be appropriate to try to delay delivery with the use of
tocolytic drugs

Urgent action
Arrange urgent admission (using an ambulance if necessary) to delivery suite for women
in advanced labor.

Key points

10% of births in US are preterm

These preterm births account for an enormous cost to the healthcare system and
society in general

Despite our best efforts little impact has been made in the prevention of preterm
birth
The main role of tocolysis is to allow fetal exposure to steroids to enhance fetal
lung maturity

Background
Cardinal features

Premature labor is defined clinically as progressive cervical dilatation and/or