Preterm labour

Rationale

Preterm birth (prior to 37 weeks gestation) is the leading cause of perinatal morbidity and mortality in developed countries. Rates of preterm birth are rising with increasing maternal age and growing use of assisted reproductive technologies. Medical management of preterm labour can significantly impact maternal and neonatal outcomes.

Causal Conditions

(list not exhaustive)

1. Fetal (e.g., multiple gestation, congenital anomalies)
2. Placental (e.g., abruption, placental insufficiency)
3. Uterine (e.g., cervical anomalies)
4. Maternal (e.g., substance abuse, chronic illness, infection)
5. Iatrogenic (indicated induction of labour e.g., eclampsia, intrauterine growth restriction, premature rupture of membranes)

Key Objectives

Given a patient with preterm labour, the candidate will investigate the cause, determine the level of maternal and fetal risk, and initiate an appropriate initial management plan. Particular attention should be paid to the identification of patients requiring immediate transfer to a centre with appropriate neonatal intensive care facilities.

Enabling Objectives

Given a patient with preterm labour, the candidate will

1. list and interpret critical clinical findings, including those based on
   1. risk factors (e.g., maternal age, smoking, prior preterm deliveries);
   2. status of current pregnancy (e.g., gestational age, contractions, spontaneous rupture of membranes);
   3. results of an appropriate physical examination (e.g., maternal blood pressure, speculum examination with swabs for culture and sensitivity (C and S) and fetal fibronectin);
2. list and interpret critical investigations, including
   1. assessment of fetal well-being (e.g., ultrasound, fetal monitoring);
   2. identification of contributing factors requiring treatment (e.g., urine C and S, Group B Streptococcus status);
3. construct an effective initial management plan, including
   1. initiating appropriate medical therapy (e.g., antenatal steroids, group B streptococcal prophylaxis, tocolysis);
   2. referring the patient for specialized care and/or transfer to an appropriate facility, if necessary;
   3. counselling the parents about relevant immediate and long-term health problems encountered by premature infants;
   4. referring the patient for assistance with social and economic issues related to preterm labour, if necessary.