Ref:MM204

Management of Preterm Labour Guideline

INITIATED BY: Antenatal Forum

APPROVED BY: Medicines Management and Expenditure

Committee

DATE APPROVED: 31.07.20

VERSION: 1

OPERATIONAL DATE: 10.08.20

DATE FOR REVIEW: 31.07.23

3 years from date of approval or if any

legislative or operational changes require

DISTRIBUTION: Midwifery and medical staff at Cwm

Morgannwg Taf University Health Board.
Share Point. WISDOM

FREEDOM OF INFORMATION STATUS: Open

Guidelines Definition
Clinical guidelines are systemically developed statements that assist clinicians
and patients in making decisions about appropriate treatments for specific
conditions.

They allow deviation from a prescribed pathway according to the individual

circumstances and where reasons can be clearly demonstrated and documented.

Minor Amendments
If a minor change is required to the document, which does not require a full
review please identify the change below and update the version number.

Type of Why change Page Date of Version Name of

change made number change 1 to 1.1 responsible
person

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CONTENTS

Guidelines Definition ............................................................................... i

Minor Amendments ................................................................................. i
1. Introduction ..................................................................................... 1
2. Information and support .................................................................... 2
3. Vaginal progesterone and cervical cerclage........................................... 2
4. Diagnosis of preterm labour (with intact membranes) ............................ 4
5. Fetal Fibronectin Testing .................................................................... 5
6. Tocolysis .......................................................................................... 7
7. Maternal Corticosteroids .................................................................. 10
8. Magnesium sulphate for neuroprotection ............................................ 11
9. In-utero transfer ............................................................................. 12
10. Intrapartum antibiotics .................................................................... 13
11. Fetal monitoring.............................................................................. 14
12. Mode of birth .................................................................................. 16
13. Timing of cord clamping for preterm babies (born vaginally or by caesarean
section) ................................................................................................. 17
14. Auditable standards ......................................................................... 17
15. References ..................................................................................... 19
Appendix 1 Fetal Fibronectin (fFN) Test Proforma ....................................... 20
Appendix 2 All Wales In Utero Transfer communication Form ....................... 21

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 1. Introduction

These guidelines have been developed for Cwm Taf Morgannwg University
Health Board, incorporating previous guidance from Cwm Taf University
Health Board and Abertawe Bro Morgannwg University Health Board.
These guidelines replace any previous health board versions.

Preterm labour is defined as onset of established labour between 24+0

and 36+6 weeks of pregnancy inclusive. Diagnosis is made by the onset
of regular uterine contractions leading to progressive cervical effacement
and dilation.

Preterm labour complicates around 10% of all pregnancies. The majority

of preterm births do so after spontaneous onset of preterm labour,
however some women give birth preterm electively when this is thought
to be in fetal or maternal interest. Preterm birth is the single biggest cause
of neonatal mortality and morbidity in the UK. The risk of neonatal
mortality increases as gestational age at birth decreases. Babies who
survive preterm birth have increased rates of disability. The major long-
term consequence of prematurity is neurodevelopmental disability.

Prevention of preterm birth is not always indicated and in most cases

labour between 34 and 37 weeks will be allowed to continue.

This guideline covers recommendations on:

 prophylactic vaginal progesterone and prophylactic cervical
cerclage
 magnesium sulphate (MgSO4) for neuroprotection
 intrapartum antibiotics
 diagnosing preterm labour
 tocolysis
 maternal corticosteroids

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  fetal monitoring
 mode of birth and clamping the cord

Preterm prelabour rupture of membranes (PPROM) is covered in a

separate guideline.

2. Information and support

Provide the woman and her family with oral and written information on
the care she will be offered. This information should include risks for the
baby (long and short term morbidity and as well as mortality). The
neonatal team should be closely involved in care planning and, where
possible, the parents should be given opportunity to visit the neonatal
unit as well as a consultation with a neonatal doctor.

3. Vaginal progesterone and cervical cerclage

Discuss both options and offer a choice of prophylactic vaginal

progesterone (Cyclogest® pessary 400mg daily, unlicensed) or
prophylactic cervical cerclage to women who have both:
 a history of spontaneous preterm birth up to 34+0 weeks of
pregnancy or mid-trimester loss from 16+0 weeks onwards and,

 results from a transvaginal ultrasound scan carried out between

16+0 and 24+0 weeks that show a cervical length of 25 mm or less.

Prophylactic vaginal progesterone can be considered for women who have

either:
 a history of spontaneous preterm birth up to 34+0 weeks or mid-
trimester loss from 16+0 weeks onwards or,

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  results from a transvaginal ultrasound scan carried out between
16+0 and 24+0 weeks that show a cervical length of 25 mm or less.

Treatment with vaginal progesterone should start between 16+0 and 24+0
weeks and continue until at least 34 weeks.

Prophylactic cervical cerclage can be considered for women when results

of a transvaginal ultrasound scan carried out between 16+0 and 24+0
weeks show a cervical length of 25 mm or less, and who have had either:
 preterm prelabour rupture of membranes (PPROM) in a previous
pregnancy or
 a history of cervical trauma (e.g. LLETZ or cone biopsy)

Rescue cervical cerclage

Rescue cervical cerclage should not be offered to women with:
 signs of infection or
 active vaginal bleeding or
 uterine contractions or
 ruptured membranes.

A rescue cervical cerclage can be considered for women between 16+0

and 27+6 weeks of pregnancy with a dilated cervix and exposed,
unruptured fetal membranes.

The gestational age and the extent of cervical dilation should be taken
into account and discussed with a consultant obstetrician.
The risks of the procedure as well as the aim to delay birth to increase
the likelihood of the baby surviving and to reduce the risk of serious
neonatal morbidity should be discussed with the woman (and her family).

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 4. Diagnosis of preterm labour (with intact
membranes)

When preterm labour is suspected information for the woman should

include:
 the clinical assessment and diagnostic tests that will be offered;
 how the clinical assessment and diagnostic tests are carried out;
 the benefits, risks and possible consequences of the clinical
assessment and diagnostic tests, including the consequences of
false positive and false negative test results taking into account
gestational age.

Clinical assessment of women reporting symptoms of preterm labour

should include:
 clinical history taking
 observations including maternal blood pressure, pulse, temperature
and respiratory rate.
 urinalysis
 fetal auscultation and cardiotocogram (CTG) depending on
gestation
 obstetric abdominal palpation including assessment of uterine
activity
 a speculum examination (only using water as lubricant)

If the clinical assessment suggests that the woman is in suspected

preterm labour and she is between 24+0 and 33+6 weeks pregnant
perform fetal fibronectin testing as a diagnostic test to determine
likelihood of birth within 48 hours.

If the neonatal unit operates a 36 week model fetal fibronectin testing

could be considered between 34+0 and 35+6 weeks gestation.
A senior obstetrician should be informed of a positive diagnosis.

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 5. Fetal Fibronectin Testing

Fetal Fibronectin (fFN) is a simple and quick bed-side test that can be
used to aid diagnosis, with high sensitivity. A negative test can be safely
relied upon to rule out preterm labour and therefore reduce unnecessary
intervention and hospital admissions.

Fetal fibronectin is a fibronectin protein produced by fetal cells. It is found

at the interface of the chorion and the decidua (between the fetal sac and
the uterine lining). Fetal fibronectin "leaks" into the vagina if a preterm
delivery is likely to occur and can be measured in a screening test.

A fFN test result <200 ng/mL gives clinicians confidence that preterm
labour is not imminent, as less than 1% of women with this result will
deliver within 7 days and 8% of women will deliver within 14 days.

Please complete the fFN test proforma found in Appendix 1.

Indications for fFN testing

If the clinical assessment suggests that the woman is in suspected
preterm labour and she is between 24+0 and 33+6 weeks pregnant.
Consider fFN testing between 34+0 and 35+6 weeks gestation if the
neonatal unit operates a 36 week model.

Contraindications for fFN testing

fFN testing should not be used in any of the following occasions:
 Ruptured membranes
 Cervical dilation of 3cms or more
 Cervical cerclage in situ
 Placenta praevia

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In the event of:
 moderate or gross vaginal bleeding or
 sexual intercourse within 24 hours
fFN can still be performed. However, only a result of <10 ng/mL can be
interpreted as a valid negative result. If the result is ≥10ng/mL clinical
judgement is advised.

Method for carrying out Fetal Fibronectin

The swab or specimen should not be contaminated with lubricants, soaps,
disinfectants or creams and therefore it is recommended to collect the
specimen prior to digital vaginal examination, collection of culture
specimens or transvaginal scanning.
1. Perform speculum examination (using only water as a lubricant) and
rotate swab across posterior fornix for 10 seconds to allow for absorption
of secretions.
2. Thoroughly mix swab in liquid extraction buffer provided for 10
seconds.
3. Squeeze swab against inside of tube.
4. If not testing immediately, snap the swab shaft and replace cap onto
test tube until it clicks. This sample is valid for testing for up to 8 hours
at room temperature.
5. When testing, remove swab and discard and place tube into stand.
6. At PeriLynx analyser – select test patient on main menu, scan user ID
(barcode) and press next.
7. Enter rapid fFN Cassette lot number and press next.
8. Enter patient ID and press next.
9. Insert the rapid fFN cassette and prepare pipette with 200μl (0.2ml)
from the patient sample collected in the buffer solution and press next.
10. Pipette 200μl (0.2ml) from the sample collected in the buffer solution
into the well of the rapid fFN cassette and press Start Test.
11. When testing is complete, the system will display and print the result.

6
 12. Result will be given in ng/mL and should be interpreted and managed
according to the table below taking clinical judgement into consideration:
fFn % who will % who will % who will Suggested management
value give birth give birth give birth Clinical judgement should
ng/mL within 7 within 14 before 34 always be taken into
days days weeks consideration.
<10 1 <2 1.5 Consider alternative diagnoses.
Discharge with routine midwife
10-49 0 <2 8.2
follow-up.
50-199 0 <8 11.5 Consider admission.
Consider corticosteroids.
Tocolysis not recommended.
200-499 14 29 33 Admit.
Administer corticosteroids.
Inform neonatal unit.

≥500 38 46 75 Tocolysis.
MgSO4 if in labour and <30/40.
Antibiotics if in labour.

6. Tocolysis

Tocolysis is to be considered when the risk of preterm delivery outweighs

that of continuing the pregnancy. Tocolysis is only indicated if there is a
need to give corticosteroids. It is reasonable not to use tocolytic drugs as
there is no clear evidence that they improve outcome. However, tocolytics
should be considered if the few days gained would be put to good use:
completing a course or corticosteroids or completing an in-utero transfer.

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

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  other clinical features (for example, bleeding or infection) that 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.

Indication
Consider tocolysis for women between 24+0 and 25+6 weeks of
pregnancy who have intact membranes and are in suspected preterm
labour (fFN ≥200 ng/mL or clinical judgement).

Offer tocolysis to women between 26+0 and 33+6 weeks of pregnancy

who have intact membranes and are in suspected or diagnosed preterm
labour (fFN ≥200 ng/mL or clinical judgement).

Absolute contraindications
Maternal: cardiac shock, aortic stenosis, severe pre-eclampsia
Fetal: severe IUGR, fetal compromise
Obstetric: intra-uterine infection, abruption

Relative contraindications
Maternal: cardiac failure, diabetes mellitus, abnormal liver function,
previous hypotensive reaction
Obstetric: ruptured membranes, cervical dilatation >4cm

Choice of drug
When tocolysis is indicated nifedipine is the drug of choice (calcium
channel blocker, unlicensed for this indication). If nifedipine is
contraindicated an oxytocin-reception antagonist (atosiban) should be
offered.

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Betamimetics (ritodrine) should not be used for tocolysis.

Nifedipine regime
 Loading: 10 mg orally followed by a further 10mg every 20 minutes
for a maximum of 4 doses or until the contractions stop (if sooner).
 Maintenance: Then 4 hours after the first administration give 20 mg
modified release orally 8 hourly for a maximum of 48 hours.
 Discontinue: 48 hours after commencement of regime OR if
significant maternal hypotensive reaction occurs causing severe
maternal symptoms, adverse CTG changes or meconium stained
liquor.
 Side effects: transient hypotension, flushing, palpitations,
headache.

Atosiban regime (second line)

 Bolus: 6.75mg intravenously over 1 minute (using 6.75mg/0.9ml
solution for injection vial)
 Prepare maintenance infusion: remove 10mL from 100mL sodium
chloride 0.9% bag and replace with two 5mL vials of atosiban
37.5mg/5ml concentrate for solution for infusion (total 75mg) to
make up 100mL infusion solution.
 Maintenance: intravenous infusion of 18mg/hour (24mL/hour) for
3 hours followed by 6mg/hour (8mL/hour) for a maximum of 45
hours.
 Replacement infusion bags should be prepared as required and be
used within 24 hours of preparation.
 Duration of treatment should not exceed 48 hours and the total
dose given during the course should not exceed 330mg atosiban.

In certain cases, where there are contraindications to nifedipine and

atosiban, indometacin (NSAID) can be used, but only in the second
trimester as there is a risk of premature closure of the ductus arteriosus

9
in the third trimester. This is an unlicensed indication and must be a
consultant decision.

Indometacin regime (consultant decision, second trimester only)

 100mg suppository PR to be repeated 12-24 hours later.

7. 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 PPROM discuss with the woman and her family the use of
maternal corticosteroids in the context of her individual circumstances.

Offer maternal corticosteroids to women between 24+0 and 33+6 weeks

of pregnancy who are in suspected, diagnosed or established preterm
labour, are having a planned preterm birth or have PPROM.

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 PPROM.

When offering or considering maternal corticosteroids, discuss with the

woman and her family:
 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 the last course, the gestational
age and the likelihood of birth within 48 hours (fFN result).

For guidance on the use of corticosteroids in women with diabetes, see

the diabetes in pregnancy guideline.

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Corticosteroid regime
 Betamethasone 12mg intramuscular, 2 administrations 24 hours
apart.

8. Magnesium sulphate for neuroprotection

For women between 23+0 and 23+6 weeks of pregnancy who are in
established preterm labour or having a planned preterm birth within
24 hours, discuss with the woman and her family the use of intravenous
magnesium sulphate for neuroprotection of the baby, in the context of
her individual circumstances.

Offer intravenous magnesium sulphate for neuroprotection of the baby to

women between 24+0 and 29+6 weeks of pregnancy in the following
circumstances and consider this 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.

When delivery needs to be expedited for maternal or fetal wellbeing

reasons then delivery should not be delayed solely for magnesium
sulphate administration.

Magnesium sulphate infusions should not be used during antenatal in-

utero transfer.

If the infusion is solely given for neuroprotection of the fetus the infusion
should be discontinued at birth.

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Magnesium sulphate regime (unlicensed)
 Bolus: 4g intravenous bolus over 15 minutes. Ideally given 4 hours
prior to delivery.
 Maintenance: intravenous infusion of 1g per hour until the birth or
for 24 hours (whichever is sooner).

For women on magnesium sulphate, monitor for clinical signs of

magnesium toxicity at least every 4 hours by recording pulse, blood
pressure, respiratory rate and deep tendon reflexes.

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

more frequently for magnesium toxicity and think about reducing the
dose of magnesium sulphate.

Antidote
 Calcium gluconate 1g intravenously (10ml of 10% calcium
gluconate in 50ml NaCl 0.9%) given over 10 minutes.

9. In-utero transfer

Women presenting in suspected or established labour between 24+0 and

31+6 weeks gestation or a multiple pregnancy of less than 34+0 weeks
should be cared for in a hospital where level 3 Neonatal Intensive Care is
available.
This assessment should be based on the safety of mother and baby
requiring possible transfer. Tocolysis can be considered during the
transfer, however delivery during transfer needs to be avoided. Therefore
a careful assessment of the stage and progress of labour will have to be
made before the transfer.

The neonatal unit needs to be informed of an admission with suspected

or established preterm labour and discussion between the neonatologist

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and obstetrician should take place whether in-utero transfer is required
and appropriate.

An All Wales in-utero transfer form (see Appendix 2) should be completed

and the transfer should be agreed by neonatal, obstetric and midwifery
team of the receiving unit.

10. Intrapartum antibiotics

The risk of early onset Group B Streptococcal (GBS) disease in infants

delivered prematurely is estimated to be 2.3 per 1000. The risk of GBS
infection is higher with preterm delivery and the mortality rate from
infection is increased (20-30% vs 2-3% at term).

Offer intrapartum antibiotics to women in confirmed preterm labour, with

or without intact membranes.

Intrapartum antibiotics for the prevention of GBS are not recommended

for women having a planned preterm caesarean section with intact
membranes.

If the woman decides to take intrapartum antibiotic prophylaxis, give the

first dose as soon as possible and continue prophylaxis until the birth of
the baby.
Choice of antibiotic
Benzylpenicillin sodium (first line)
 Bolus: 3g intravenous as soon as possible after the onset of labour.
 Maintenance: 1.8g intravenous every 4 hours until delivery.

Penicillin allergy
The antibiotic chosen will depend on the confidence of the diagnosis of
penicillin allergy and the severity of penicillin allergy.

13
If the history suggests that the reaction described is not likely to be
allergic in nature (e.g. vomiting only) then penicillin should be given.

If the history suggests an allergy to beta-lactams, but one that is not

severe (i.e. no anaphylaxis, angioedema, respiratory distress or
urticaria), then a cephalosporin can be administered intravenously:
cefuroxime 1.5g loading dose followed by 750 mg every 8 hours until
delivery.

If the allergy to beta-lactams is severe then intravenous vancomycin 1g

every 12 hours is recommended until delivery.

Pre-dose vancomycin levels are only required if the patient is to receive

more than 4 doses. Contact the Pharmacy Department for advice if
necessary.

Clindamycin can no longer be recommended as the current resistance

rate in the UK is 16%.

11. Fetal monitoring

Discuss with women in suspected, diagnosed or established preterm

labour (and their family):
 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.

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Explain the different fetal monitoring options to the woman and her
family, being aware that:
 there is limited evidence about the usefulness of specific features
to suggest hypoxia or acidosis in preterm babies
 the available evidence is broadly consistent with that for babies
born at term
 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 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 (FSE) 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.

15
Discuss with the woman and her family the possible use of a FSE 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 (FBS) if the woman is less than
34+0 weeks pregnant.

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

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

12. 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 their family).

Explain to women in suspected, diagnosed or established preterm labour

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.

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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.

13. 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.

14. Auditable standards

 Percentage of women presenting in suspected preterm labour that

had a fetal fibronectin test performed before 34 weeks gestation.
 Percentage of women presenting in suspected preterm labour that
had a positive fetal fibronectin test (fFN >199).
 Percentage of women presenting in suspected preterm labour that
had a fetal fibronectin test result between 50-199.
 Percentage of women presenting in suspected preterm labour that
had a positive fetal fibronectin test (fFN >199) and delivered within
2 weeks.

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 Percentage of women with a positive fetal fibronectin test (fFN
>199) before 34 weeks gestation that were offered steroids (100%)
and received steroids (100%).
 Percentage of women with a positive fetal fibronectin test (fFN
>199) before 30 weeks gestation that were offered magnesium
sulphate (MgSO4) (100%) and received MgSO4 prior to delivery
(100%).
 Percentage of women in confirmed preterm labour that were offered
intrapartum antibiotics (100%) and received these (100%).

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15. References

1. NICE Guideline 25: Preterm Labour and Birth, Updated August

2019.
2. RCOG Greentop Guideline 36: Early-Onset Group B Streptococcal
Disease, September 2017.
3. Swansea Bay UHB Guideline: Management of Pre-Term Labour,
November 2018.
4. Cwm Taf UHB Guideline: Guidelines for the use of Fetal
Fibronectin Testing, September 2017.
5. Norfolk and Norwich University Hospitals: Trust Guideline for the
use of Fetal Fibronectin and Actim PROM, June 2019.
6. Cardiff and Vale UHB Guideline: Management of Pre-term labour,
October 2015.
7. Summary of Product Characteristics (SPC) atosiban 37.5mg/5ml.
Ranbaxy (UK) Ltd. Accessed via
https://www.medicines.org.uk/emc/product/3262/smpc#USEHAN
DLING on 25.05.20
8. British National Formulary (BNF On-line). Myometrial relaxants.
Accessed via
https://www.medicinescomplete.com/#/content/bnf/_971671372
on 25.05.20
9. American College of Obstetrics and Gynaecology. Antenatal
corticosteroid Therapy for Fetal Maturation. Committee Opinion.
Number 715. Aug 2017. Reconfirmed 2018.
https://www.acog.org/clinical/clinical-guidance/committee-
opinion/articles/2017/08/antenatal-corticosteroid-therapy-for-
fetal-maturation

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Appendix 1 Fetal Fibronectin (fFN) Test Proforma

Fetal Fibronectin (fFN) Test Proforma

Date:
Addressograph
Test requested by:

Designation:

If previously performed, date of last test: ……/……/……

Only perform fFN test if all of the following criteria are met:

Criteria Please tick if met

24+0 – 33+6 gestation
Intact membranes
Cervix ≤ 3cm dilated
Fetal well-being established
>14 days since last fFN test
Absence of placenta praevia
Absence of cervical cerclage

Moderate or gross vaginal bleeding If result ≥10ng/mL clinical

judgement advised.
Sexual intercourse within 24 hours If result <10 ng/mL interpret
as negative.

Test performed by:

Designation:
Test result sticker
Sign:

Date:

Time:

Management plan Please tick

Discharged and routine follow-up
Steroids given (Specify)?
Admitted for observation
Tocolysis given (Specify)?
Magnesium sulphate given
In-utero transfer

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 Appendix 2 ALL WALES IN- ADDRESSOGRAPH

UTERO TRANSFER
COMMUNICATION
FORM

S MATERNAL DETAILS FETAL DETAILS

I
T
U Gravida …………………….……. Para ……………………………. EDD …………………..
A SROM Y/N Date ……….….. Time…………………………….. Gestation …………
T Blood Group …………………… Rh …………………. Antibodies ……………….. Multiple
I
O
Medication …………………………………………………………………………………………… Pregnancy Y/N
N Comments …………………………………………………………………………………………… No. of fetuses ………
B Previous pre-term birth: Y/N Details ………………………………………………
A
Obstetric History ……………………………………………………………………………… Anomalies Y/N
C
K ………………………………………………………………………………………………………………. Details …………………
G Medical history ………………………………………………………………………………… ……………………………..
R ……………………………………………………………………………………………………………….
O
Has Mother? Safeguarding
U
N  Received health care treatments (inc IVF), in other countries issues Y/N
D outside Wales during last year? Y/N Details …………………
 If yes, details of treatment…………..…..…….Country…………..……………… ……………………………..
 Had any infections/positive screening results during pregnancy Y/N ……………………………..
 If Yes, please specify………………………………………………………………………….
A Pre-Term Labour Test: Pos/Neg fetal fibronectin/Actim Partus Fetal
S
Compromise? Y/N
S
E Vaginal Examination: Date…..Time…….Findings……………………………. Comments…………….
S ………………………………………………………………………………………………………………… ………………………………
S Is Mother? Maternal
M
 Currently infected or colonised with organism/virus that is multi- Steroids? Y/N
E
N resistant or could cause harm to baby? Y/N/Unknown Date………………………
T  If yes, Sensitivities of organism………………………………………………………… Gest………………………
 Currently on any antimicrobial treatment? Y/N USS
 If yes, please specify…………………………………………………………………………. Date………………………
AC………. HC………….
HVS: Y/N Dates/s ……………………… Sensitivities of isolates……………………. FL……….. AFI…………
Doppler…………………
Outstanding Microbiology Results? Y/N Please specify ………………… EFW……………………….
Comments…………….
R TRANSFER FROM: TRANSFER TO:
E
C Consultant Obstetrician Consultant Obstetrician
O
M
SPR: DUTY SPR informed 
M LW Coordinator informed 
E Neonatal Unit informed 
N
D Named midwife for transfer: NB: All must be informed prior to transfer
A
T
I
O Person completing form:
N
NAME: DESIGNATION: SIGNATURE:

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