Pre-term Labour Care Guidelines

Pre-term Labour

• Pre-term labour is defined as birth occurring between 20 and 37 weeks gestation.
• If birth is not imminent, the mother should be transferred to the nearest obstetric unit or ED with obstetrics onsite.
• If the gestation is unknown, but the woman appears visibly pregnant and/or the fundus is palpable at the umbilicus, the gestation is likely to be over 20 weeks.
• Any pregnancy over 20 weeks without antenatal care requires safeguarding referral through EBS.
• Signs of pre-term labour include:
  • Regular contractions or tightenings
  • Period-type pain or pressure in the vagina
  • Membrane rupture (waters breaking)
  • Backache
  • Bleeding (greater than 20 weeks is a RED FLAG)
• If birth is imminent, prepare for birth on-scene:
  • Update EOC, request additional resources
  • Prepare for NLS, warm environment
• If birth is not imminent, pre-alert the receiving hospital and continuously reassess the mother en route.
• Survival-focused care is recommended for pregnancies at or below 21+6 weeks gestation.
• Comfort care is recommended for pregnancies at or above 22 weeks gestation, or for any pregnancy with unknown gestation and fused eyes.
• Comfort care is also recommended for pregnancies with unknown gestation and non-fused eyes.

Cord Prolapse

• Cord prolapse occurs when the umbilical cord protrudes out of the vagina before the baby.
• It most often occurs with membrane rupture and is more likely in pre-term labour, breech presentation, or with multiple births.
• It is a TIME-CRITICAL EMERGENCY.
• Inspect the vaginal opening for the cord with consent.
• Cord prolapse causes fetal hypoxia by compression of the cord by the presenting part, or by vasospasm as the cord is exposed.
• Pre-alert the nearest obstetric unit (unless birth is imminent, the mother will require an emergency cesarean section).
• Minimise handling of the cord. Gently replace the cord to the vulva using a clean dry pad and do not re-insert the cord into the vagina.
• Assist the mother into an exaggerated SIMS position for transporting to the ambulance.
• If there is any delay in transferring the mother to the ambulance, a knees-chest position can be used.

Multiple Births

• Have a lower threshold for conveyance in cases of multiple births.
• If birth is not imminent, transport the mother to the nearest obstetric unit as quickly as possible.
• Clamp the cord of the first twin immediately after birth on-scene.
• Thermoregulation is even more important in multiple births as babies are likely to be premature and smaller.
• There may be a delay of minutes to hours between the birth of the first baby and the subsequent babies, so do not delay on-scene.

Breech Birth

• Breech birth is when the buttocks or feet are presenting first.
• It is more common in pre-term births and with multiple births.
• The longer the delay from the birth of the buttocks until complete delivery, the greater the risk of hypoxic injury.
• If the baby is not delivered within 30 minutes, the obstetrician will need to intervene.
• Be prepared for NLS and/or PPH.
• If the feet come out first and are not immediately followed by the buttocks, this is an emergency and requires rapid transport (Footling breech).
• Use the Maternity Action Tool checklist to guide management.
• Call for help (second crew/APP-CC/CTM/IRO).
• Have hands poised to intervene/receive the baby.
• Set a timer for delivery of the baby. A delay means intervention is required.

Shoulder Dystocia

• Shoulder dystocia occurs when the baby's head is born and the shoulders become stuck on the mother's pelvic bone, preventing delivery of the baby's body.
• Diagnosis occurs when the head of the baby is born and the body is not born within the next two contractions.
• It is an emergency.
• Use the Maternity Action Tool checklist to guide management.
• Prepare for NLS and PPH.
• Early pre-alert is essential.
• Document the time of delivery of the head and any maneuvers performed.
• Avoid encouraging the woman to push or applying excessive traction.

General Notes

• Birth complications can be difficult to predict, so call for help early.
• Use the JRCALC+ maternal assessment and obstetric emergencies cards to guide management.
• Do not call a midwife during an obstetric emergency, this will delay care (unless the patient declines transfer).
• Datix all birth complications.