Guideline sources The following summarized guidelines for the evaluation and management of preterm labor are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2022), the American College of Obstetricians and Gynecologists (ACOG 2021; 2020; 2017; 2016), and the World Health Organization (WHO 2015). 1 2 3 4 5 6 Guidelines 1. Diagnostic investigations Cervical ultrasound: recognize that eliciting short cevix on ultrasound alone has low positive predictive value for preterm labor. Do not use the finding of short cervix on ultrasound exclusively to direct management in patients with acute symptoms. B Fetal fibronectin: recognize that positive fFN results alone have low positive predictive value for preterm labor. Do not use fFN results exclusively to direct management in patients with acute symptoms. B 2. Medical management Corticosteroids: https://web.pathway.md/diseases/recM19dfgg6phSXGu 1/4 6/29/23, 11:28 PM Preterm labor Pathway As per ACOG 2017 guidelines, administer a single course of corticosteroids in pregnant patients between 24 0/7 and 33 6/7 weeks of gestation at risk of preterm delivery within 7 days, including patients with ruptured membranes and multiple gestations. E Show 8 more As per ACOG 2016 guidelines, administer a single course of corticosteroids in pregnant patients at 24-34 weeks of gestation at risk of delivery within 7 days. A Show 3 more As per WHO 2015 guidelines, administer antenatal corticosteroids in patients at 24-34 weeks of gestation at risk of preterm birth when the following conditions are met: gestational age assessment can be accurately undertaken preterm birth is considered imminent no clinical evidence of maternal infection adequate childbirth care is available (including the capacity to recognize and safely manage preterm labor and birth) the preterm infant can receive adequate care if needed (including resuscitation, thermal care, feeding support, infection treatment and safe oxygen use). A Show 4 more Tocolytics: As per ACOG 2016 guidelines, administer -adrenergic agonists, CCBs, or NSAIDs as first- line tocolytic therapy for short-term prolongation of pregnancy (up to 48 hours) to allow the administration of antenatal corticosteroids. A Show 3 more As per WHO 2015 guidelines: Do not use tocolytics (acute and maintenance treatments) in patients at risk of imminent preterm birth to improve infant outcomes. D Administer magnesium sulfate in patients at risk of imminent preterm birth before 32 weeks of gestation to prevent cerebral palsy in the infant and child. A Antibiotics: As per ACOG 2016 guidelines, do not use antibiotics to prolong gestation or improve neonatal outcomes in patients with preterm labor and intact membranes. D As per WHO 2015 guidelines, do not use routine antibiotics during preterm labor in patients with intact amniotic membranes and without clinical signs of infection. D Show 3 more 3. Therapeutic procedures Mode of delivery: do not perform routine C-section to improve preterm infant outcomes, regardless of cephalic or breech presentation. D Umbilical cord clamping: As per SOGC 2022 guidelines, delay cord clamping for 60-120 seconds in both preterm (< 37 weeks) and extremely preterm (< 28 weeks) singletons because it decreases newborn mortality and morbidity and improves hematological outcomes after the neonatal period. https://web.pathway.md/diseases/recM19dfgg6phSXGu 2/4 6/29/23, 11:28 PM Preterm labor Pathway Delay cord clamping for at least 30 seconds over clamping immediately when cord clamping cannot be deferred for a full 60-120 seconds. Delay cord clamping with the infant at or below the level of the introitus or at the level of the Cesarean incision. A Show 11 more As per ACOG 2020 guidelines, perform delayed umbilical cord clamping in preterm infants as it is associated with significant neonatal benefits, including improved transitional circulation, better establishment of RBC volume, decreased need for blood transfusion and lower incidence of necrotizing enterocolitis and intraventricular hemorrhage. E Show 2 more 4. Preventative measures Bed rest: as per ACOG 2016 guidelines, do not advise routine bed rest and hydration for the prevention of preterm birth. D Clinical findings Symptoms Past medical history Abdominal cramps Preterm premature membrane rupture Vaginal bleeding Vaginal discharge Gynecologic exam Past obstetric history Progressive cervical dilation Progressive cervical effacement Multiple gestation Regular uterine contractions at 20-37 weeks of gestation Premature labor Short cervical length Studies 2017 APTS In fetuses from women who were expected to deliver before 30 weeks of gestation, delayed cord clamping was not superior to immediate cord clamping with respect to death or major morbidity at 36 weeks of postmenstrual age. William Tarnow-Mordi et al. N Engl J Med. 2017 Dec 21. References 1. American College of Obstetricians and Gynecologists Committee on Practice Bulletins Obstetrics. Practice Bulletin No. 171 Management of Preterm Labor. Obstet Gynecol. 2016 Oct;128 4):e155 64. Open 2. No authors listed. WHO Recommendations on Interventions to Improve Preterm Birth Outcomes. Geneva: World Health Organization; 2015. Open https://web.pathway.md/diseases/recM19dfgg6phSXGu 3/4 6/29/23, 11:28 PM Preterm labor Pathway 3. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins Obstetrics. Prediction and Prevention of Spontaneous Preterm Birth: ACOG Practice Bulletin, Number 234. Obstet Gynecol. 2021 Aug 1;138 2):e65-e90. Open 4. No authors listed. Delayed Umbilical Cord Clamping After Birth: ACOG Committee Opinion Summary, Number 814. Obstet Gynecol. 2020 Dec;136 6 1238 1239. Open 5. Sarah D McDonald, Michael Narvey, William Ehman et al. Guideline No. 424 Umbilical Cord Management in Preterm and Term Infants. J Obstet Gynaecol Can. 2022 Mar;44 3 313 322.e1. Open 6. Committee on Obstetric Practice. Committee Opinion No. 713 Antenatal Corticosteroid Therapy for Fetal Maturation. Obstet Gynecol. 2017 Aug;130 2):e102-e109. Open 7. Schmitz T, Maillard F, Bessard-Bacquaert S et al. Selective use of fetal fibronectin detection after cervical length measurement to predict spontaneous preterm delivery in women with preterm labor. Am J Obstet Gynecol. 2006 Jan;194 1 138 43. Open 8. Praveen Kumar, Committee on Fetus and Newborn, American Academy of Pediatrics. Use of inhaled nitric oxide in preterm infants. Pediatrics. 2014 Jan;133 1 164 70. Open 9. Andrew Shennan, Lisa Story, Bo Jacobsson et al. FIGO good practice recommendations on cervical cerclage for prevention of preterm birth. Int J Gynaecol Obstet. 2021 Oct;155 1 19 22. Open 10. Stefania Ronzoni, Isabelle Boucoiran, Mark H Yudin et al. Guideline No. 430 Diagnosis and management of preterm prelabour rupture of membranes. J Obstet Gynaecol Can. 2022 Nov;44 11 1193 1208.e1. Open https://web.pathway.md/diseases/recM19dfgg6phSXGu 4/4