[CG] Early signs and symptoms of preterm labour

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Definition

Preterm birth, defined as delivery at less than 37 completed weeks of gestation, is the single biggest cause of neonatal morbidity and mortality.

It is estimated that around 1 in 13 babies are born prematurely in the UK every year. This statistic has been largely unchanged over the last 10 years.

Three quarters of these births are due to spontaneous onset labour and not all of these women have risk factors for pre term labour.

What is the importance of early diagnosis of pre-term labour?

Early diagnosis of pre-term labour can allow time to potentially- Early diagnosis can allow time to implement antenatal optimisation bundle checklist. Do you use this at RAH? Its two simple infographics which could be utilised here?

  • Delay delivery in order to administer antepartum steroids and Magnesium sulphate to reduce morbidity by up to 30% (1).
  • Early diagnosis may also permit transfer of the fetus in-utero to a centre where neonatal intensive care unit facilities are available.

Can we recognise pre-term labour?

Women can experience a range of subtle and non-specific symptoms during the prodromal period leading up to pre-term labour. These symptoms can develop over days to weeks prior to established pre-term labour(3). (Reference numbers will need changed as one missing)

Although with low predictive value, these symptoms cause women to present themselves to health care services providing the opportunity for early diagnosis.

Signs and symptoms may include (4) (Please refer to attached infograph)

  • Abdominal Cramps- with or without diarrhoea
  • Backache- low, dull constant
  • Contractions >1 painful contraction every 10mins for a period of > 30 mins - (I would keep it just at contractions and delete the rest)
  • Vaginal Discharge (increase in the amount of discharge) or bleeding
  • un-Easiness- feeling “not right”
  • Fetal movements /urine Frequency– changed
  • Gush of fluid loss - preterm rupture of membranes
  • Heaviness or pelvic pressure—the feeling that the baby is pushing down

Subtle changes in uterine activity patterns have been detected a few days to several weeks before overt pre-term labour (5). Uterine activity may or not be perceived by patients at all and are not necessarily painful. It has been observed that only about half of women can feel painful uterine activity in the days preceding pre-term labour. About a third of patients can report no uterine contractions (3). One in five patients admitted with suspected pre-term uterine activity go on to develop established pre-term labour.

What are the obstacles to diagnosis?

  • Delay in presentation as women can attribute their symptoms to stress or normal discomfort of pregnancy. Pre-term labour is often not recognised by the patient as a possible cause of their symptoms.
  • Not “piecing it together” a woman who has had recurrent presentations with non-specific symptoms- attention to pattern and progress of symptoms can help triage these patients appropriately.

What can we improve?

The first presentation to health care by the patient is dependent on them perceiving their symptoms to be concerning. It will be helpful to make patients aware of possible association of the non-specific symptoms with threated pre-term labour particularly if they are persistent or progressive.

It will be advisable to arrange an obstetric medical review (ST3+ or clinically experienced ST2)for women with symptoms so that a speculum examination can be done. There should be an awareness of red flags for pre-term labour.

Appendix: Infographic - The 'A-H' of Pre-term Labour

References
  1. Antenatal Optimisation for Preterm Infants less than 34 weeks:A Quality Improvement Toolkit.
  2. Cooper, R. L., Goldenberg, R. L., Davis, R. O., Cutter, G. R., DuBard, M. B., Corliss, D. K., & Andrews, J. B. (1990). Warning symptoms, uterine contractions, and cervical examination findings in women at risk for preterm delivery. American Journal of Obstetrics and Gynecology, 162, 748-754.
  3. Weiss M, Saks N, Harris S.(2002).Resolving the uncertainty of preterm symptoms: women's experiences with the onset of preterm labor. J Obstet Gynecol Neonatal Nurs. Jan-Feb 2002;31(1):66-76.
  4. Maloni, J. A. (2000). Preventing preterm birth: Evidence-based interventions shift toward prevention. AWHONN Lifelines, 4(4), 26-33.
  5. Iams, J. D., Stilson, R., Johnson, F. F., Williams, R. A., & Rice, R. (1990). Symptoms that precede preterm labor and preterm premature rupture of the membranes. American Journal of Obstetrics and Gynecology, 162, 486-490.

Last reviewed: 31 December 2021

Next review: 31 July 2025

Author(s): Dr Harkiran Narang/Julie Murphy/ Fiona Hendry

Version: 1

Approved By: Obstetric Guideline Group

Document Id: 1037