There is a great deal that the remote health prac­ti­tion­er can do to pre­vent preterm labour (PTL), we cov­er this in detail in both the MEC and MIDUS cours­es, but here is some infor­ma­tion to inform practice. 

First, let’s clar­i­fy some facts about preterm labour. A preg­nan­cy is clas­si­fied as preterm when it is over 20 weeks ges­ta­tion and before 37 weeks ges­ta­tion, thus preterm labour is the onset of labour dur­ing this peri­od. Around 9% of births in Aus­tralia are preterm, this fig­ure is almost dou­ble for First Nations women, and it is much more com­mon in rur­al and remote Aus­tralia, there­fore ear­ly iden­ti­fi­ca­tion and man­age­ment in rur­al and remote envi­ron­ments is imperative.

It is often dif­fi­cult to pre­dict who will go into preterm labour, as around half of preterm labours are spon­ta­neous and unex­plained. There are, how­ev­er, some poten­tial­ly mod­i­fi­able risk fac­tors asso­ci­at­ed with preterm labour. These include:

• Pre­vi­ous preterm birth(15 – 30% recur­rence rate)
• Preterm pre­ma­ture rup­ture of mem­branes (PPROM)
• Mul­ti­ple pregnancy
• Polyhydramnios/​oligohydramnios (too much/​too lit­tle amni­ot­ic fluid)
• Antepar­tum haemorrhage
• Sys­temic infection*
• Sex­u­al­ly trans­mit­ted infec­tions (STIs)/urinary tract infec­tions (UTIs)*
• Smok­ing*
• Mater­nal trauma
• Illic­it drug use*
• Uter­ine abnormalities
• Assist­ed repro­duc­tion e.g. IVF
• Younger (<18) and old­er (>35) mater­nal age
• Eth­nic­i­ty
• Mater­nal stress.

*As you can see, whilst many of the above risk fac­tors can­not be pre­vent­ed, many can be pre­vent­ed, or at least risk managed.

Good ante­na­tal care, a trust­ing rela­tion­ship between women and their car­ers, cul­tur­al­ly safe and women-cen­tred care all go a long way to pre­vent­ing many com­pli­ca­tions of preg­nan­cy, includ­ing preterm labour.

Many preterm births (15 – 20%) are also the result of a mater­nal com­pli­ca­tion (i.e. Hyper­ten­sion or fetal growth restric­tion) which may lead to a deci­sion to induce labour ear­li­er than 37 weeks.

But: what hap­pens if some­one does present to your health clin­ic with PTL?

Women in preterm labour may present with vary­ing symp­toms, including:

• a gen­er­al feel­ing of being unwell
• con­trac­tions
• low­er back pain
• a ​‘sense’ that all is not right.

A woman’s pre­sen­ta­tion to the clin­ic for care may not be for signs of preterm labour but for symp­toms of the cause of the preterm labour. For exam­ple, she may have been involved in a minor car acci­dent and she now has some inter­mit­tent abdom­i­nal pain and con­se­quent trau­ma or bleed­ing. Or, she may have a uri­nary tract infec­tion (UTI) which has trig­gered labour. There­fore, an impor­tant part of the assess­ment and man­age­ment of the woman is to deter­mine the cause of the preterm labour, and appro­pri­ate treat­ment of the cause where possible.

The goals of man­age­ment of preterm labour in a rural/​remote set­ting are:

• Ear­ly recog­ni­tion of preterm labour.
• Ear­ly con­sul­ta­tion with the refer­ring DMO/​retrieval team/​local con­sul­ta­tion & refer­ral path­way for man­age­ment and medications.
• Med­ica­tions ordered may include: steroids to assist the baby’s lungs to mature, med­ica­tions to stop the labour, or antibi­otics if there are clin­i­cal signs
  of infec­tion (UTI/​STI/​other).
• Assess­ment of and treat­ment for the cause of preterm labour.
• Trans­fer to high­er lev­el care pri­or to birth (the safest way for a preterm baby to be trans­ferred is in utero).

As soon as you have gath­ered a his­to­ry from the woman and have done a thor­ough phys­i­cal assess­ment, you will need to dis­cuss the find­ings with the DMO or anoth­er refer­ral path­way and decide on a plan for man­age­ment and retrieval.

If the baby is born in your set­ting, the impor­tant key points are:

• Resus: util­is­ing the ANZ­COR guide­lines sec­tion 13 https://www.anzcor.org/home/né… in par­tic­u­lar 13.8 which con­tains the infor­ma­tion rel­e­vant to preterm infants.
• Keep the infant warm (if less than 32 weeks can con­sid­er plas­tic bag/​wrap). See ANZ­COR Guide­line 13.8 – The Resus­ci­ta­tion of the New­born in Spe­cial Circumstances.
• Obser­va­tion for and man­age­ment of Res­pi­ra­to­ry Dis­tress Syndrome.
• Check­ing for hypo­gly­caemia and man­ag­ing blood glu­cose lev­el accord­ing to local pro­to­col. Try to gain some colostrum if the baby can­not go to the breast (prem babies may not be able to), or pro­vide some calo­ries via oral glu­cose or for­mu­la, once again fol­low your local pro­to­col and med­ical orders.
• Prem babies can be quite vig­or­ous ini­tial­ly but can tire quick­ly so require con­stant vig­i­lance and monitoring.

Ref­er­ences

Aus­tralian Gov­ern­ment – Depart­ment of Health and Aged Care (2019) Risk of preterm birth. https://​www​.health​.gov​.au/reso…

Aus­tralian Preterm Birth Pre­ven­tion Alliance (n.d.) Caus­es of Preterm Birth. https://​www​.preter​malliance​.com​.au/​A​b​o​u​t​-​P​r​e​t​e​r​m​-​B​i​r​t​h​/​C​a​u​s​e​s​-​O​f​-​P​r​e​t​e​r​m​-​Birth

Aus­tralian Preterm Birth Pre­ven­tion Alliance (n.d.) Preterm Birth in Abo­rig­i­nal Pop­u­la­tions. https://​www​.preter​malliance​.co…

RANZCOG (2021) Term Prelabour Rup­ture of Mem­branes (Term PROM). https://​ranzcog​.edu​.au/​w​p​-​c​o​n​t​e​n​t​/​u​p​l​o​a​d​s​/​2​0​2​2​/​0​5​/​T​e​r​m​-​P​r​e​l​a​b​o​u​r​-​R​u​p​t​u​r​e​-​o​f​-​M​e​m​b​r​a​n​e​s​-​T​e​r​m​-​P​R​O​M.pdf

Safer Care Vic­to­ria (2018) Preterm labour. https://​www​.bet​ter​safer​care​.vi…

Remote Pri­ma­ry Health Care Man­u­als. (2022). Women’s Busi­ness Man­u­al. (7^th edi­tion). Alice Springs, NT: Flinders Uni­ver­si­ty

AIHW Moth­ers & Babies Report 2023. https://​www​.aihw​.gov​.au/​r​eport…

ANZ­COR (2023). Guide­line 13.8 – The Resus­ci­ta­tion of the New­born in Spe­cial Cir­cum­stances. https://www.anzcor.org/home/né…