Threatened Preterm Labour (<37 weeks with contractions, unchanging cervix)
Clinical detail
Additional detail checked 2026-10-17 against the linked sources. This check covers the section below; the rest of the module retains its displayed verification status.
Contractions before 37 weeks need clinical assessment; the test pathway depends on gestation and membrane status.
Assessment & interpretation
- Assess symptoms, observations and the cervix. Take a planned fetal-fibronectin swab before digital examination.
Decisions that change management
- In NICE’s intact-membrane pathway from 30 weeks, cervical length above 15 mm makes birth within 48 hours less likely; 15 mm or less supports diagnosed preterm labour.
- When that scan is unavailable or unacceptable, the guideline offers fetal fibronectin as an alternative.
Follow-up & safety-netting
- A decision to discharge must include instructions to return for persistent or recurrent symptoms.
Admission & discharge
Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.
When admission or continued hospital care is needed
- Admit diagnosed labour, maternal/fetal concerns, membrane rupture, bleeding/infection or an unsafe home situation. If assessment at ≥30 weeks cannot obtain the indicated tests, NICE advises treating as diagnosed preterm labour.
When clinic, day care or home care may be suitable
- For symptomatic women ≥30 weeks, NICE cervical length >15 mm or, when ultrasound is unavailable/unacceptable, negative fetal fibronectin ≤50 ng/mL can support a discussion of home care after full assessment.
- Do not apply these discharge test thresholds as a shortcut to every gestation or presentation.
Before going home
- No cervical progression or complication requiring treatment/monitoring; assessment suggests a low likelihood of imminent birth, and alternatives for symptoms have been considered.
- Document the benefits/risks of home care, return instructions, gestation and neonatal/transfer considerations.
Discharge medicines and treatment changes
- Document any completed/remaining antenatal steroid doses and their arrangements. Do not send an unspecified maintenance tocolytic prescription home.
Tests, pending results and their reviewer
- Record the actual cervical length or fetal fibronectin result and fetal assessment; a negative test does not remove every obstetric risk.
Home care and counselling
- Explain that persistent/recurrent contractions or other new symptoms require reassessment.
Follow-up: when and what to review
| When | Action / responsible service |
|---|---|
At the agreed antenatal review or remaining treatment appointment | Review recurrence and complete any scheduled care. |
Immediately if symptoms persist or return | Contact/attend the maternity unit rather than relying on the previous negative test. |
Return urgently
- Contractions, pelvic pressure, vaginal bleeding, fluid loss, fever or reduced movements require maternity contact.
Open the complete discharge checklist →
Treatment
① Immediate stabilization — first minutes
Not an emergency unless converted to established labour.
③ First-line treatment & drug regimens
- LOW-risk results (>30 mm / negative fFN): discharge with safety-netting after observation period
- HIGH-risk: admit, steroids if <34+0 (consider to 34+6 per GTG74), discuss transfer to neonatal-capable centre
- Cervical cerclage consideration: history-indicated or ultrasound-indicated (<25 mm before 24 wks) per specialist
- Imminent preterm birth within the guideline gestational window; do not delay urgent maternal/fetal delivery
- NICE offers at 24+0–33+6 weeks, considers 34+0–35+6; individual discussion at 22+0–23+6. Repeat: <34 weeks, prior course >7 days ago and very high risk of birth in 48 h.
- Glucose monitoring and an insulin-adjustment plan in diabetes; assess infection and timing of birth
④ Drug treatment detail (3 agents)
- Indication: Selected threatened preterm labour to gain time for steroids/transfer, without infection, major bleeding or a reason for immediate birth
- BP/pulse, contraction frequency and fetal heart rate; stop for hypotension or ischaemic chest pain
- Indication: Alternative fetal-lung-maturation course when appropriate
- Maternal glucose, infection assessment and birth timing; diabetes team plan
- Indication: Imminent preterm birth: NICE offers at 24+0–29+6 weeks and considers at 30+0–33+6 weeks; discuss 23+0–23+6 individually
- Record pulse, BP, respiratory rate and tendon reflexes at least every 4 h; more often if oliguria or renal impairment
Definitive treatment
Prevent conversion: treat reversible drivers (infection), progesterone maintenance where indicated for prior spontaneous PTB (vaginal progesterone 200 mg nocte for short cervix).
Monitoring
- Serial exams only if symptoms evolve
- Re-scan cervical length q1-2 wks in high-risk surveillance
Response assessment
- Contractions settle without change; discharged with clear return instructions
Treatment failure
- Progressive change -> established preterm labour pathway
Escalation
- In-utero transfer BEFORE birth whenever feasible (best neonatal outcomes)
⑮ Complications & their management
Conversion to established labour
Switch pathways
Post-treatment care
- Progesterone continuation plan; follow-up schedule; education on warning symptoms
Diagnosis & assessment
- Cervical change on serial exam -> convert to established pathway
- Rupture of membranes
- Bleeding (abruption!)
- Abnormal CTG
Definition: Uterine activity before 37+0 weeks without documented cervical progression.
Initial assessment
- CTG + maternal obs
- Speculum: membranes intact? cervical length visualised; collect fFN/swabs where available
- TVS cervical length <15 mm high risk; >30 mm low risk (at 24 wks context)
- Exclude causes: infection (urine/cervical), abruption, overdistension (twins/polyhydramnios)
Investigations
| Test | Looking for |
|---|---|
TVS cervical length | Objective risk stratification |
Fetal fibronectin (where available) | <50 ng/mL at 22-35+6 predicts very low 7-day birth risk |
MSU/high vaginal swabs | Asymptomatic bacteriuria/infection triggers |
Principles & follow-up
Management principles
Guideline conflict
MSF nifedipine tocolysis monograph
Advises against combining nifedipine with magnesium sulfate because of hypotension/neuromuscular-blockade concerns.
India NHM CEmONC 2024, chapter 4
States the feared interaction has not been demonstrated in retrospective reviews, while requiring careful BP and pulse monitoring.
Population/setting difference: MSF addresses nifedipine tocolysis; NHM discusses emergency hypertension/eclampsia care. Dose, indication and monitoring setting differ.
Practical India consideration: Magnesium for indicated seizure prevention or fetal neuroprotection has its own priority; do not withhold it merely to continue tocolysis.
Reason: This preserves the source-specific caution and does not turn a monitored emergency-use discussion into blanket permission for coadministration.
Sources (10)
2022-02 · checked 2026-08-23 · pending-verification
Open source ↗
Cited via RCOG GTG73 update note; direct PDF audit pending — flag
2019-06-18 · checked 2026-08-23 · verified-live
Open source ↗
RCOG page incl. June 2022 update note aligning steroids advice with GTG 74 (offer up to 33+6; consider to 35+6 with caution per GTG74 Feb 2022)
20 November 2015 · updated 10 June 2022 · checked 2026-10-18 · verified-live
Open source ↗
Scope: additional clinical-detail explanation for ptl-threatened, ptl-established. Checked the assessment, management-decision and follow-up statements in that section against this source. This does not certify all pre-existing regimens, calculations or recommendations in the module. Additional admi…
· checked 2026-10-17 · verified-live
Open source ↗
10 mg every 15 minutes up to 40 mg loading, 20 mg every 6 hours, 48-hour duration and maternal hypotension/concurrent-drug cautions. This is not the hypertension row.
· checked 2026-10-17 · verified-summary
Open source ↗
Recommendation 1.9/type-and-regimen evidence: IM dexamethasone or betamethasone total 24 mg; four 6 mg dexamethasone doses 12 hours apart or two 12 mg betamethasone doses 24 hours apart. NICE NG25 supplies gestational and repeat-course criteria.
· checked 2026-10-18 · verified-live
Open source ↗
Maternal/newborn transfer assessment, first void and effective feeding, handover, support/safeguarding, first midwife visit within 36 hours after transfer, postnatal danger symptoms. Full recommendations page read.
· checked 2026-10-18 · verified-live
Open source ↗
Normal-delivery discharge not less than 48 hours: full primary SOP PDF normal-delivery/discharge passages read. Corroborated by NHM CEmONC 2024 Part 1, chapter 8. This does not define a universal post-caesarean or complicated-case stay.
· checked 2026-10-18 · verified-live
Open source ↗
Official WHO summary read: at least 24-hour facility care after birth; additional contacts at 48–72 hours, 7–14 days and week 6; individual assessment/support. Summary facts only, not a claim that the full 242-page PDF was reviewed.
· checked 2026-10-18 · verified-live
Open source ↗
Full primary patient recovery page read: pain control, wounds, activity/VTE, urinary/bowel and infection warning signs, adult support and no driving/important decisions during the first 24 hours after general anaesthesia. Used as general recovery/handover principles, not operation-specific discharge…
· checked 2026-10-18 · verified-live
Open source ↗
Full primary recommendations read, focusing on critical-care-to-ward transfer: structured written handover, shared plan, monitoring, rehabilitation and receiving-team capability. Step-down is distinct from home discharge; no universal organ-support discharge cutoff is asserted.