This will depend on gestation due to the specialist facilities needed for extremely premature births. Babies <35 weeks may benefit from specialist neonatal facilities with those born at 24–28 weeks requiring intensive care.

Some preterm babies are born unplanned at home or in a hospital with limited facilities and will need prompt transfer to appropriate neonatal services. Transfer is advisable for women with threatened preterm labour; however, it is usually unsafe to transfer if:

• The birth is imminent
  
• Her condition is unstable, e.g. bleeding or severe pre-eclampsia.

If transfer is required, decide whether a midwife is needed to accompany the woman. Any escorting staff must be trained to assist in transfer (CESDI, 2003).

Preterm, prelabour rupture of membranes (PPROM) is associated with 40% of preterm births and can cause significant neonatal mortality and morbidity, with one-third of women testing positive to infection (RCOG, 2006).

• If PPROM occurs at 24–34 weeks gestation, 50% of women will deliver within 4 days and 70–80% within 1 week (Walkinshaw, 2001).
  
• The three causes of neonatal death associated with PPROM are prematurity, sepsis and pulmonary hypoplasia (RCOG, 2006).
  
• Antibiotics following PPROM significantly reduce chorioamnionitis, neonatal infection, abnormal cerebral ultrasound and can extend the pregnancy (RCOG, 2006).
  
• Erythromycin (250 mg orally 6 hourly) should be given for 10 days following the diagnosis of PPROM (Co-amoxiclav is not recommended) (RCOG, 2006).

Infection

Infection is a major cause of preterm labour, and infants born with sepsis have a mortality rate four times higher than those without sepsis (RCOG, 2006).

The ORACLE trial (Kenyon et al., 2001a) suggests that:

• If infection is suspected/diagnosed or PPROM confirmed, commence antibiotics as quickly as possible.
  
• If there is no sign of infection or PPROM then antibiotics are of no benefit.

Signs and symptoms of maternal infection

Early signs of infection:

• Slight maternal pyrexia
  
• Fetal tachycardia
  
• General malaise

Advanced signs of infection:

• Feeling very unwell
  
• High pyrexia
  
• Maternal and/or fetal tachycardia
  
• Uterine tenderness and an offensive smelling vaginal discharge/liquor
  
• Baby ill at birth
  
• Intrauterine death

Screening and assessment:

• Obstetric referral
  
• Maternal temperature, pulse rate and urinalysis
  
• Fetal heart rate (FHR) auscultation
  
• Two sets of blood cultures
  
• Depending on history and clinical picture, send urgent and repeated bacterial specimens (Department of Health (DOH) 2001) e.g. vaginal/cervical swabs, urine specimen and maybe throat swab, sputum sample and faeces for culture

Diagnosing preterm labour

It can be difficult to distinguish threatened from actual preterm labour at the outset. Every area should have clear guidelines for the diagnosis and management of preterm labour. Any woman reporting preterm regular painful contractions or suspected ruptured membranes should be assessed in a consultant unit.

A careful history should be taken. Abdominal palpation and FHR auscultation should be performed. Perform a speculum rather than digital vaginal examination (VE) to take swabs and attempt to visualise the cervix (RCOG, 2006). Avoid digital VE if possible, or keep to a minimum, as it can introduce infection, cause prostaglandin release and augment labour (Atalla et al., 2000).

Digital VE is contraindicated in cases of suspected infection or PPROM (CESDI, 2003; RCOG, 2006).

Tocolysis

Tocolytic drugs are sometimes used to delay preterm delivery. RCOG (2002) suggests that there is no clear evidence that they improve the outcome, but a few days may be gained if necessary to complete a course of corticosteroids, or transfer in utero.

Tocolytic drugs have serious side effects, and if used, nifedipine (not licensed for this use in the UK) or atosiban is effective and has fewer adverse effects than ritodrine.

The use of tocolytics should be avoided in the following:

• Fetal death or fetal abnormality incompatible with life
  
• Fetal or maternal condition requiring urgent delivery
  
• Active vaginal bleeding (as tocolytics relax the uterus)
  
• Preterm rupture of the membranes and/or infection

Use of corticosteroids

A single course of corticosteroids should be administered ≤34 weeks to women at risk of preterm birth. Antenatal corticosteroids encourage the release of pulmonary surfactant in fetal lungs, reducing the risk of respiratory distress syndrome, cerebroventricular haemorrhage, systemic infection <48 hours of age, necrotising enterocolitis and death (Roberts & Dalziel, 2007).

Fetal heart rate monitoring

National Institute for Health and Clinical Excellence (NICE) (2007) lists preterm labour as one indication for continuous electronic fetal monitoring (EFM). However, Cochrane review found that EFM in preterm labour appears to have no advantage over intermittent auscultation (IA) and increases maternal morbidity, caesarean section (CS) and possibly cerebral palsy (Alfirevic et al., 2007).

Preterm EFM is an unreliable tool for predicting future neurodevelopmental impairment of premature infants of very low birth weight (Nisenblat et al., 2006). Very premature, small babies can be difficult to monitor continuously, and preterm fetal heart rates may be difficult to interpret as they differ from those at term (Atalla et al., 2000). So if continuous cardiotocography (CTG) monitoring is performed, it is likely to be more easily interpretable in older preterm babies than very early ones. Preterm (particularly very preterm) CTGs tend to have a higher baseline (sometimes 170 bpm) and decelerations which are not necessarily truly pathological, and Atalla et al. (2000) suggests that most preterm babies with unsatisfactory CTG traces will not be acidotic. However, once a CTG is performed it is natural that clinicians will have a low threshold for action in a preterm labour. If it is decided to perform IA, it should be carried out scrupulously (see Chapter 3).

First stage of labour

Most care and support will be the same as for any labour (see Chapter 1):

• Continuous, supportive, one-to-one midwifery care is proved to reduce interventions and improves maternal and fetal outcomes (Hodnett et al., 2007).
  
• Discuss with the parents what may occur at the birth and immediately afterwards: who will be present, what type of resuscitation is anticipated and the likelihood of their baby needing special care.
  
• Minimise environmental stress. Try to reduce external stressful stimuli of bright lights, noise, interruptions and lack of privacy.
  
• Liaise with colleagues. Ensure that neonatal intensive care units (NICU) are well briefed. Ideally the delivery suite coordinator will keep the relevant clinicians updated so the midwife can remain with the mother.
  
• Encourage mobility and upright position to aid optimal fetal positioning, progress and descent. As with any labour, avoid the supine position as it may cause FHR abnormalities, increased duration of second stage, episiotomy and instrumental delivery (Gupta et al., 2004). A non-supine position also improves outcomes in women with epidurals (Roberts et al., 2005).
  
• Monitor the FHR.
  
• Minimise digital VEs. Always consider what is to be gained by them. They may lead to ascending vaginal infection, especially if the membranes have ruptured.
  
• Eating and drinking is not contraindicated, although it may be wise to administer regular antacids/hydrogen ion inhibitors, e.g. ranitidine or cimetidine, in case an emergency anaesthetic is required (Johnson et al., 2000).
  
• Avoid narcotic analgesia, e.g. pethidine: it can cause neonatal respiratory depression, drowsiness and depressed reflexes, including the suck reflex (NICE, 2007) which is more of a problem for a preterm baby.
  
• Artificial rupture of the membranes (ARM) is not recommended since any potential cord compression may be particularly serious for a preterm baby and there is a risk of exacerbating ascending infection/chorioamnionitis.
  
• Fetal blood sampling is contraindicated <34 weeks (NICE, 2007) and has not been shown to hold an advantage over CTG without fetal blood sampling (Alfirevic et al., 2007).
  
• Prepare the resuscitaire. Check equipment. Provide baby clothes, hat and warm towels. Preterm labours can progress rapidly, so be prepared.

Second stage of labour

• Keep the room warm. Shut windows and switch off fans when birth is close.
  
• Avoid forced pushing. Prolonged breath holding and closed glottis pushing is associated with fetal compromise, forceps delivery and lower Apgars (Keirse, 2000) which can have more serious consequences for a preterm infant. Let the woman push at her own pace.
  
• Avoid episiotomy. The only indications for an episiotomy are acute fetal compromise and, if absolutely necessary, an unyielding perineum (Keirse, 2000). This procedure does not protect the fetal head.
  
• Ventouse delivery is not recommended in gestations <34 weeks due to the baby’s soft skull (Keirse, 2000).
  
• Forceps delivery may damage the fetal head (Keirse, 2000) and the old practice of preterm elective forceps delivery has been abandoned.

Mode of delivery

Mode of delivery for preterm infants remains controversial. Almost 50% preterm infants are delivered by CS (RCOG, 2001) despite no clear evidence of advantages of a CS over a vaginal birth (Keirse, 2000).

Skin-to-skin contact in preterm infants

Conventional care involves early cutting of the cord and immediate maternal–infant separation possibly including the use of a space blanket or placing the baby in a plastic bag (Vohra et al., 1999) for heat conservation despite evidence of the clinical superiority of a more humane approach.