Preterm Labour

Pregnancy is a time of anticipation and joy, but it can also be a source of anxiety, especially when complications arise. Preterm labour, defined as the onset of labour before 37 weeks of gestation, is one such complication that can cause concern for expectant parents. While medical advancements have significantly improved outcomes for premature babies, preterm birth remains a leading cause of infant mortality and morbidity worldwide.

This comprehensive guide aims to shed light on preterm labour, covering its causes, symptoms, diagnosis, and treatment options. We will also explore risk factors, potential complications, prevention strategies, and tips for managing preterm labour. Additionally, we'll address common misconceptions and offer guidance on when to seek immediate medical attention.

Preterm labour is defined as the occurrence of regular uterine contractions accompanied by cervical changes (softening, thinning, and dilation) before 37 completed weeks of pregnancy. It can lead to the premature birth of a baby, which means the baby is born before the organs are fully developed. The earlier a baby is born, the greater the risk of health complications.

A full-term pregnancy typically lasts about 40 weeks. Babies born between 37 and 42 weeks are considered full-term. However, babies born before 37 weeks are premature, and their degree of prematurity is further categorized:

• Extremely preterm: Born before 28 weeks
• Very preterm: Born between 28 and 32 weeks
• Moderate to late preterm: Born between 32 and 37 weeks

Preterm birth is a global concern, and its prevalence varies across different regions and populations.

• Worldwide: An estimated 13.4 million babies were born preterm in the year 2020. And complications arising due to preterm birth are the major cause of death among children below 5.
• India: India has one of the highest numbers of preterm births in the world, with an estimated 3.5 million preterm babies born each year. This accounts for approximately 24% of all births in the country. 

These statistics highlight the significant impact of preterm birth and the need for focused efforts on prevention and management, especially in regions with high prevalence rates like India.

While preterm labour itself is not categorized into distinct types, it's important to understand that it can occur due to different underlying causes, which can influence its management and prognosis. These causes can be broadly classified as:

• Spontaneous preterm labour: This occurs without any identifiable cause and accounts for the majority of preterm births.
• Indicated preterm labour: This is when labour is induced or a caesarean section is performed due to medical reasons affecting the mother or the baby, such as pre-eclampsia, fetal growth restriction, or placental abruption.

The exact cause of spontaneous preterm labour is often unknown, but several factors can increase the risk. These include:

• Previous preterm birth: Women who have had a previous preterm birth are at a higher risk of experiencing it again.
• Multiple pregnancies (twins, triplets, etc.): Carrying more than one baby increases the risk of preterm labour.
• Infections: Infections of the amniotic fluid, placenta, or reproductive tract can trigger preterm labour.
• Cervical insufficiency: A weak cervix that starts to open prematurely can lead to preterm labour.
• Placental problems: Issues with the placenta, such as placenta previa (placenta covering the cervix) or placental abruption (placenta separating from the uterus), can increase the risk.
• Chronic health conditions: Conditions like diabetes, high blood pressure, or autoimmune diseases can increase the risk of preterm labour.
• Lifestyle factors: Smoking, substance abuse, and poor nutrition can contribute to preterm labour.
• Social and economic factors: Stress, low socioeconomic status, and lack of access to prenatal care can also increase the risk.

Recognizing the signs and symptoms of preterm labour is crucial for prompt medical intervention. These may include:

• Regular contractions: Sensations of abdominal tightening or hardening that occur regularly, even if they are not painful.
• Backache: A persistent low, dull backache that may be different from your usual back pain.
• Pelvic pressure: A feeling of pressure in your pelvis or lower abdomen.
• Changes in vaginal discharge: An increase in vaginal discharge that may be watery, mucus-like, or bloody.
• Vaginal bleeding: Light bleeding or spotting.
• Abdominal cramps: Mild abdominal cramps, with or without diarrhoea.
• Rupture of membranes: Leaking of amniotic fluid (water breaking).

It's important to note that some of these symptoms can also occur in normal pregnancies. However, if you experience any of these signs, especially before 37 weeks, contact your healthcare provider immediately.
 

Diagnosing preterm labour involves a thorough evaluation to confirm the presence of contractions and cervical changes. This may include:

• Medical history and physical examination: Your doctor will ask about your symptoms and perform a physical examination to assess your cervix.
• Pelvic examination: This allows the doctor to assess the dilation and effacement (thinning) of your cervix.
• Fetal monitoring: This measures the baby's heart rate and uterine contractions.
• Ultrasound: An ultrasound can measure the length of your cervix, which can help predict the risk of preterm birth.
• Laboratory tests: Tests may be done to check for infections or other potential causes of preterm labour.

The primary goal in managing preterm labour is to delay delivery for as long as possible, allowing the baby more time to develop within the womb. The specific treatment approach will depend on several factors, including how far along the pregnancy is, the severity of the preterm labour, the mother's overall health, and the presence of any underlying conditions. Here's a closer look at the common interventions:

Initial Measures and Monitoring

• Close Observation: When preterm labour is suspected, close monitoring is essential. This typically involves hospitalization to observe the frequency and intensity of contractions, assess cervical changes, and monitor the baby's well-being.
• Bed Rest: While strict bed rest is not always necessary, reducing activity and getting plenty of rest can help decrease uterine activity and potentially slow down or stop labour.
• Hydration: Dehydration can sometimes contribute to uterine contractions. Ensuring adequate hydration through intravenous fluids or encouraging oral fluid intake can be helpful.

Medications

• Tocolytics: These medications are specifically designed to suppress uterine contractions and delay labour. They work through various mechanisms, such as relaxing the uterine muscles or blocking the actions of hormones that stimulate contractions. Commonly used tocolytics include:   
  • Nifedipine: This calcium channel blocker is often the first-choice tocolytic. It helps to relax the uterine muscles and decrease contractions.   
  • Indomethacin: This non-steroidal anti-inflammatory drug (NSAID) can also be effective in suppressing preterm labour, particularly when used for short periods.   
  • Magnesium sulfate: This medication is often used in cases of severe preterm labour or when other tocolytics are not effective. It can help to relax the uterus and also provide neuroprotection for the baby's brain.   
  • Tocolytics are generally most effective in delaying delivery for a short period (typically 48 hours), providing time for other interventions, such as corticosteroids, to take effect.
• Hydroxyprogesterone Caproate: Progesterone plays a crucial role in maintaining pregnancy and preventing premature birth. Synthetic forms of progesterone, like hydroxyprogesterone caproate (Brand Available: Proluton), are used to reduce the risk of preterm labour in women with a history of previous preterm birth. 

The injectable is typically given weekly, starting in the second trimester, to women who have had a previous spontaneous preterm birth. It helps to support the pregnancy and reduce the risk of recurrence.   

• Corticosteroids: If preterm birth appears likely, corticosteroids are a crucial intervention. These medications are given to the mother to help accelerate the development of the baby's lungs. Corticosteroids reduce the risk of respiratory distress syndrome (RDS), a serious breathing problem common in premature babies.   
  • Betamethasone: This is a commonly used corticosteroid given in two injections, 24 hours apart. It is most effective when administered between 24 and 34 weeks of gestation.
  • Corticosteroids are a significant advancement in the care of preterm infants, significantly improving their chances of survival and reducing the severity of respiratory complications.   
• Antibiotics: If an infection is suspected or confirmed as a contributing factor to preterm labour, antibiotics will be given to treat the infection. This can help to reduce inflammation and potentially stop the labour.

Important Note: It's crucial to remember that any medication use during pregnancy should be under the guidance of a healthcare professional. They will assess the individual's situation and prescribe the most appropriate medication and dosage based on the specific circumstances.

Cervical Cerclage

• In cases of cervical insufficiency (a weak cervix that opens prematurely), a cervical cerclage may be performed. This is a surgical procedure in which a strong stitch is placed around the cervix to help keep it closed and prevent premature opening. 
  • Cervical cerclage is typically done in the second trimester (between 12 and 24 weeks) and is usually removed later in pregnancy, close to the due date, or if labour begins.
  • This procedure can be an effective way to prolong pregnancy and reduce the risk of preterm birth in women with cervical insufficiency.

Other Considerations

• Managing Underlying Conditions: If any underlying medical conditions, such as diabetes or high blood pressure, are contributing to preterm labour, these conditions need to be carefully managed.
• Emotional Support: Experiencing preterm labour can be stressful and anxiety-provoking. Providing emotional support and counseling can help women cope with the situation and make informed decisions about their care.
• Delivery Planning: If preterm birth appears imminent, the healthcare team will discuss delivery plans with the parents, including the potential need for neonatal intensive care for the baby.

It's important to remember that the management of preterm labour is individualized and dynamic. The healthcare team will continuously assess the situation and adjust the treatment plan as needed to ensure the best possible outcome for both the mother and the baby.

While there is limited scientific evidence to support their effectiveness, some women may explore complementary therapies to manage stress and promote relaxation during preterm labour. These may include:

• Prenatal yoga: Gentle breathing exercises can help reduce stress and promote relaxation.
• Massage therapy: Massage can help relieve muscle tension and promote relaxation.

It's crucial to discuss any alternative therapies with your healthcare provider before trying them, as some may not be safe during pregnancy.

Several factors can increase a woman's risk of preterm labour:

• Previous preterm birth
• Multiple pregnancies
• History of cervical surgery
• Short cervix
• Infections
• Placental problems
• Chronic health conditions
• Lifestyle factors (smoking, substance abuse, poor nutrition)
• Age (younger than 17 or older than 35)
• Low socioeconomic status
• Stress
• Domestic violence

Preterm birth can lead to various complications for the baby, including:

• Breathing problems: Premature babies often have underdeveloped lungs and may require respiratory support.
• Feeding difficulties: Premature babies may have difficulty sucking and swallowing, requiring tube feeding.
• Temperature regulation problems: Premature babies have difficulty maintaining their body temperature and may need to be kept in an incubator.
• Brain bleeds: Bleeding in the brain can occur in premature babies and may lead to developmental problems.
• Infections: Premature babies are more susceptible to infections.
• Long-term health problems: Premature babies may have an increased risk of developmental delays, cerebral palsy, vision problems, and hearing problems.

If you are experiencing preterm labour, it's important to follow your healthcare provider's instructions carefully. Here are some additional tips:

• Stay hydrated: Drink plenty of fluids to prevent dehydration.
• Rest: Avoid strenuous activities and get plenty of rest.
• Monitor your baby's movements: Pay attention to your baby's movements and contact your doctor if you notice any changes.
• Educate yourself: Learn about preterm labour and the potential complications.
• Connect with other parents: Talk to other parents who have experienced preterm labour or have premature babies.

Preterm labour always leads to preterm birth.

While preterm labour increases the risk of preterm birth, it doesn't always result in a premature baby. With appropriate medical care, labour can sometimes be delayed or stopped.

Preterm labour is always obvious.

Some women may experience subtle symptoms of preterm labour, so it's important to be aware of any changes in your body and contact your doctor if you have any concerns.

There's nothing you can do to prevent preterm labour.

While some risk factors are unavoidable, there are steps women can take to reduce their risk, such as getting regular prenatal care and maintaining a healthy lifestyle.

If you experience any signs or symptoms of preterm labour, such as regular contractions, backache, pelvic pressure, changes in vaginal discharge, or vaginal bleeding, contact your healthcare provider immediately. Don't hesitate to seek medical attention, even if you're unsure whether your symptoms are serious.

• What are the potential causes of my preterm labour?
• What are my treatment options?
• What are the risks and benefits of each treatment?
• What are the potential complications for my baby?
• What can I do to reduce my risk of preterm birth?

If someone you know is experiencing preterm labour, you can offer support by:

• Being a good listener: Allow them to express their fears and concerns.
• Offering practical help: Assist with household chores, errands, or childcare.
• Providing emotional support: Offer encouragement and reassurance.
• Educating yourself: Learn about preterm labour and the potential complications.
• Respecting their privacy: Avoid asking intrusive questions or offering unsolicited advice.

Preterm labour is a serious complication of pregnancy that can pose risks to the baby. However, with early detection, appropriate medical care, and a supportive environment, many women can delay labour and deliver healthy babies. By understanding the causes, symptoms, and prevention strategies, women can take proactive steps to reduce their risk of preterm labour and ensure the best possible outcome for themselves and their babies.