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Preterm Labour

• Textbook of Family Medicine 9e; Morgan and Mikhail's Clinical Anesthesiology 7e

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Epidemiology

• Affects approximately 8% of live-born infants in the United States
• Accounts for the majority of neonatal morbidity and mortality
• Racial disparities are significant: Black women have persistently higher rates of preterm birth than White women, even when controlling for socioeconomic factors

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Risk Factors

Strongest predictors

Maternal factors

• Extremes of age
• Low BMI or, at very early gestations (<28 wks), obesity
• Inadequate prenatal care
• Smoking (RR ~1.3-1.5 for preterm birth)
• Infections: urinary tract, bacterial vaginosis (BV), chorioamnionitis
• African American race
• Short interpregnancy interval
• Prior cervical procedures (LEEP, cone biopsy)
• Stress, physical overexertion

Fetal/uterine factors

• Multiple gestation
• Polyhydramnios
• Uterine malformation
• Fetal anomaly or aneuploidy
• Placental abruption

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Prediction

1. Transvaginal Ultrasound (TVU) Cervical Length

• 50th percentile: ~40 mm
• 10th percentile: ~30 mm
• 3rd percentile: ~25 mm

2. Fetal Fibronectin (fFN)

• Collected from cervicovaginal secretions at 22-35 weeks
• Negative result (most clinically useful): Predicts the woman will NOT deliver for at least 7-10 days - high negative predictive value (~99%)
• Positive result warrants closer surveillance or tocolytic consideration
• Contamination from digital exam, intercourse, or blood renders the test invalid - always collect BEFORE digital exam

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Assessment of a Woman with Suspected Preterm Labour

1. Monitoring: Continuous CTG for contractions + FHR in left lateral position
2. History and exam: Identify treatable causes; check contraindications to tocolysis
3. Speculum exam if membrane rupture suspected - nitrazine test, ferning, GBS/chlamydia/GC cultures
4. fFN swab before digital exam (at 22-35 weeks)
5. Urinalysis + culture - treat UTI if present
6. Digital cervical exam for dilation, effacement, consistency
7. Rule out chorioamnionitis: maternal fever, uterine tenderness, leukocytosis, fetal tachycardia

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Management

Step 1 - Corticosteroids (the most important intervention)

• Indicated at 24-34 weeks of gestation when preterm delivery is anticipated
• Enhances fetal lung maturity by stimulating surfactant production
• Reduces: RDS (respiratory distress syndrome), intraventricular hemorrhage, necrotizing enterocolitis, neonatal death
• A single rescue course may be given if >2 weeks since original course and <34 weeks

Step 2 - GBS Prophylaxis

Step 3 - Tocolysis

• Chorioamnionitis
• Abruptio placentae / heavy vaginal bleeding
• Fetal demise or severe fetal compromise
• Severe or uncontrolled hypertension
• Maternal haemodynamic instability

• Indomethacin risk of ductal constriction is mostly reversible on stopping the drug; generally avoid after 32 weeks
• Hypokalaemia with β-agonists is usually due to intracellular shift and rarely requires treatment, but increases sensitivity to muscle relaxants
• Maintenance tocolysis beyond the initial 48-hour window does not improve outcomes and is not recommended

Step 4 - Magnesium for Neuroprotection (separate from tocolysis)

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Prevention

Progesterone therapy

• Vaginal progesterone (200 mg/night or 90 mg gel daily): Recommended for singletons with short cervix ≤25 mm at 16-24 weeks without prior PTB. Reduces rate of PTB by ~40-45%.
• 17-hydroxyprogesterone caproate (17-OHPC) IM: Previously recommended for patients with prior spontaneous PTB. Recent large trial (PROLONG) failed to show benefit; use is now debated. Notably, 17-OHPC is less effective in women with BMI ≥30 kg/m².
• Neither formulation is recommended for multifetal gestations.

Cervical cerclage

1. History-indicated cerclage: 3+ second-trimester pregnancy losses or prior PTBs due to cervical insufficiency - placed at 12-14 weeks
2. Ultrasound-indicated cerclage: Singleton + prior PTB + current cervical length <25 mm at 16-23+6 weeks
3. Physical/emergency cerclage: Dilated, prolapsing membranes on speculum exam

Lifestyle / Screening

• Smoking cessation
• Treatment of asymptomatic bacteriuria
• Routine screening and treatment for BV in low-risk women does not reliably reduce PTB
• Activity restriction / bed rest: Evidence does NOT support benefit and may increase risk of PTB

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Complications of Prematurity

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Preterm Premature Rupture of Membranes (PPROM)

• <34 weeks: Expectant management, corticosteroids, antibiotics (latency antibiotics - ampicillin + erythromycin/azithromycin), GBS prophylaxis, MgSO4 neuroprotection if <32 weeks
• ≥34 weeks: Delivery generally preferred
• Tocolysis in PPROM is generally not recommended beyond allowing corticosteroid effect

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Anesthesia Considerations in Preterm Labour

• Epidural/spinal anesthesia promotes pelvic relaxation and is preferred for vaginal delivery
• Aim for slow, controlled delivery with minimal maternal expulsive effort; episiotomy and low forceps may assist
• Residual β-agonist effects may complicate general anaesthesia: use ketamine, ephedrine, and isoflurane cautiously
• Magnesium potentiates non-depolarising muscle relaxants - reduce doses accordingly
• Hypokalaemia from β-agonists increases muscle relaxant sensitivity

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Principles in Management of Preterm Labour

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Principle 1: Confirm the Diagnosis Before Intervening

• Diagnosis requires: Regular uterine contractions plus documented cervical change (≥2 cm dilation, ≥80% effacement, or progression on serial exams)
• Contractions without cervical change do not warrant tocolytic therapy; initiating tocolysis for unconfirmed preterm labour is actively discouraged
• Assess with: CTG, digital cervical exam (after excluding PROM), and fetal fibronectin (fFN) swab at 22-35 weeks before digital exam
  • Negative fFN = delivery within 7-10 days extremely unlikely (very high NPV) - can safely avoid treatment
• Exclude PROM with sterile speculum exam, nitrazine, and ferning before digital exam

"Initiation of tocolytic therapy for potential but unconfirmed preterm labor is discouraged." - Mulholland & Greenfield's Surgery 7e

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Principle 2: Identify and Treat Reversible Causes

• Supplemental oxygen - uterine hypoxia can itself drive contractions
• IV crystalloid hydration (500 mL) - dehydration is a common precipitant; can reduce contraction frequency
• Left lateral decubitus position - improves uterine and placental perfusion
• Urinalysis + culture - treat UTI/pyelonephritis promptly
• Rule out chorioamnionitis: fever, uterine tenderness, maternal/fetal tachycardia, leukocytosis, purulent discharge
• Screen for GBS, Chlamydia, GC, bacterial vaginosis
• If contractions persist after these measures and cervical change is confirmed, proceed to pharmacologic therapy

"Because uterine, cervical, or urinary tract infections account for 20% to 40% of cases of preterm labor, search for a specific cause and treat infections appropriately." - Roberts & Hedges' Clinical Procedures in Emergency Medicine

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Principle 3: Assess Contraindications to Labour Arrest

• Vaginal spotting from cervical effacement is acceptable, but anything beyond light spotting must prompt exclusion of abruption and praevia
• In extreme prematurity with borderline haemorrhage, short-term tocolysis to gain corticosteroid benefit may occasionally be considered with caution

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Principle 4: Delay Delivery by 48-72 Hours (the actual goal of tocolysis)

1. Administer antenatal corticosteroids (which need ~24 hours to work)
2. Transfer the mother to a tertiary facility with neonatal ICU capability
3. Administer MgSO4 for neuroprotection

"Although tocolytic agents delay delivery in approximately 80% of women, they neither prevent premature births nor improve adverse fetal outcomes such as respiratory distress syndrome." - Goodman & Gilman's Pharmacological Basis of Therapeutics

"The goal of delaying delivery is to enable administration of antenatal corticosteroids for lung maturation and magnesium sulfate for neuroprotection, as well as to permit maternal transport to a tertiary facility." - Roberts & Hedges' Clinical Procedures in Emergency Medicine

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Principle 5: Administer Antenatal Corticosteroids (the single most important intervention)

• Betamethasone 12 mg IM every 24 hours x 2 doses, OR
• Dexamethasone 6 mg IM every 12 hours x 4 doses

• Consider also at 34-36+6 weeks (late preterm) if not previously given
• A single rescue course may be given if >2 weeks have passed since original course and gestation is still <34 weeks

• Reduced RDS (hyaline membrane disease)
• Reduced intraventricular haemorrhage (IVH)
• Reduced necrotising enterocolitis (NEC)
• Reduced periventricular leukomalacia
• Reduced neonatal death
• Maximum benefit seen for births between 22-25 weeks

"Corticosteroids not only increase surfactant secretion in the fetal lung but also induce morphologic development of pulmonary epithelial cells and increase lung compliance... decreasing the incidence of NEC, IVH, periventricular leukomalacia, and death." - Mulholland & Greenfield's Surgery 7e

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Principle 6: Choose Tocolytic Agent Thoughtfully

First-line: Nifedipine (Calcium Channel Blocker) - WHO preferred

• Mechanism: blocks calcium entry into myometrial smooth muscle cells, reducing actin-myosin interaction
• Dosing: 10-20 mg oral loading dose, repeated every 3-6 hours until contractions settle, then 30-60 mg long-acting every 12-24 hours for 48 hours
• Advantages: oral, convenient, fewer maternal side effects than β-mimetics
• Cochrane evidence: effective in delaying delivery >48 hours; better neonatal outcomes and fewer maternal side effects vs β-mimetics
• Caution: avoid in hypotension, cardiac disease; do NOT combine with MgSO4 (risk of skeletal muscle blockade) or β-mimetics (cardiovascular interaction)
• Avoid doses >60 mg total in acute phase; do not chew short-acting tablets

Second-line options:

Key prescribing rules:

• Do NOT combine nifedipine + MgSO4 (neuromuscular blockade)
• Do NOT combine nifedipine + IV β-mimetics (cardiovascular)
• Do not initiate tocolysis for unconfirmed labour
• Cochrane evidence favours nifedipine > β-mimetics > MgSO4 for tocolytic efficacy

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Principle 7: Magnesium Sulphate for Fetal Neuroprotection (<32 weeks)

• Typical regimen: 4-6 g IV bolus + 1-2 g/h infusion until delivery
• Monitor for toxicity: respiratory depression (patellar reflexes lost at ~7-10 mEq/L, respiratory arrest at >12 mEq/L)
• Antidote: calcium gluconate 1 g IV

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Principle 8: GBS Prophylaxis

• First-line: Penicillin G 5 million units IV, then 2.5-3 million units q4h until delivery
• Penicillin allergy (low risk): Ampicillin 2 g IV, then 1 g q4h
• Penicillin allergy (high risk / anaphylaxis): Clindamycin or vancomycin (based on sensitivities)

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Principle 9: Do NOT Use Maintenance Tocolysis

• Cochrane reviews of oral β-mimetics, terbutaline pump, oxytocin antagonists, and calcium channel blockers all found no evidence of reduced preterm birth rate with maintenance therapy
• One study found infants exposed to maintenance calcium channel blockers had significantly longer NICU stays (mean 14 extra days)
• Outpatient uterine contraction monitoring and associated care did not improve delivery rates or birth weight

"Continued suppression of contractions after acute tocolysis (maintenance tocolysis) does not reduce the rate of preterm birth." - Creasy & Resnik's Maternal-Fetal Medicine

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Principle 10: Plan for Delivery and Neonatal Care

• Mode of delivery: Aim for slow, controlled vaginal delivery with minimal maternal expulsive effort; episiotomy and low forceps may be used for head protection
• Breech at <34 weeks: Caesarean section is generally preferred - soft cranium and cord prolapse risk
• Fetal indications for CS: Fetal distress, IUGR, failure to progress, malpresentation
• Analgesia: Epidural/spinal preferred - promotes pelvic relaxation and allows slow delivery
• Neonatal team: Alert NICU/paediatrics team for resuscitation; very preterm infants (<30 weeks) need immediate respiratory support
• Avoid: Prolonged cord compression; manage PROM with vigilance for ascending infection

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Summary Framework

Suspected preterm labour
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Confirm diagnosis (cervical change + contractions)
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Exclude PROM, infection, contraindications to tocolysis
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Basic measures: O₂, hydration, left lateral position, treat UTI
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Give CORTICOSTEROIDS (betamethasone 12 mg IM x 2 doses over 24h)
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Give GBS prophylaxis if delivery likely
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Tocolysis (48-hour window only):
  First-line → Nifedipine
  <32 weeks → Add MgSO₄ for neuroprotection
  <32 weeks → Consider indomethacin
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Arrange maternal transfer to tertiary centre if <34 weeks
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No maintenance tocolysis after 48 hours
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Plan delivery: mode, analgesia, NICU team

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CASE SHEET

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PATIENT IDENTIFICATION

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OBSTETRIC DETAILS

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CHIEF COMPLAINT

• Lower abdominal pain since 6 hours (on the day of admission)

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HISTORY OF PRESENTING ILLNESS

• Onset: Sudden / gradual (to be elicited)
• Character: Intermittent, cramping in nature (suggestive of uterine contractions)
• Duration of each episode: Approximately 20-45 seconds per contraction (to be confirmed by CTG)
• Frequency: To be assessed on CTG monitoring
• Radiation: To the back (to be elicited)
• Associated symptoms:
  • Watery vaginal discharge / leaking per vaginum - to be asked (to rule out PROM)
  • Bleeding per vaginum - to be asked (to rule out placenta praevia / abruption)
  • Decreased fetal movements - to be asked
  • Fever / chills - to be asked (to rule out chorioamnionitis / UTI)
  • Dysuria / frequency - to be asked (to rule out UTI as a precipitant)
  • Vomiting / nausea - to be asked
• Relieving / aggravating factors: To be elicited

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MENSTRUAL HISTORY

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PAST OBSTETRIC HISTORY

• Primigravida - no previous pregnancies, no history of prior preterm birth, miscarriage, or cervical procedure

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ANTENATAL HISTORY (Current Pregnancy)

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PAST MEDICAL HISTORY

• Hypertension: No (to be confirmed)
• Diabetes mellitus: No (to be confirmed)
• Cardiac disease: No
• Thyroid disorder: No
• Asthma: No
• Tuberculosis: No
• Surgeries: None
• Blood transfusions: None
• Allergies: None known

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FAMILY HISTORY

• No known history of multiple gestations, inherited disorders, or preterm births in family

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PERSONAL HISTORY

• Diet: Mixed / Vegetarian
• Sleep: Adequate
• Bowel/Bladder: Regular
• Tobacco / Alcohol / Substance use: Nil (to be confirmed)
• Stress / Physical exertion: To be elicited

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GENERAL PHYSICAL EXAMINATION

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SYSTEMIC EXAMINATION

Cardiovascular System

• S1 S2 heard, no murmurs

Respiratory System

• Bilateral air entry equal, no added sounds

Central Nervous System

• Conscious, oriented, no focal deficits

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OBSTETRIC EXAMINATION

Abdominal Examination

• Abdomen distended corresponding to approximately 32 weeks of gestation
• Linea nigra present
• Striae gravidarum present
• Umbilicus - everted / flat
• Fetal movements visible / not visible

• Fetal Heart Rate (FHR): bpm (normal 110-160 bpm)

Sterile Speculum Examination

• Liquor pooling: Present / Absent
• Nitrazine test: Positive (turns blue) / Negative
• Ferning: Positive / Negative
• Cervical os: Open / Closed
• Bleeding: Present / Absent
• Discharge: Character, colour, odour

Digital Vaginal Examination

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INVESTIGATIONS

Mandatory

Obstetric Investigations

If Chorioamnionitis Suspected

• Blood culture
• Amniocentesis (in selected cases) - WBC, glucose, culture

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DIAGNOSIS

G1P0L0A0 with preterm labour at 32 weeks of gestation

1. Primigravida with 32 weeks of gestation (LMP 22 July 2024, EDD 29 April 2025)
2. Lower abdominal pain since 6 hours - suggestive of uterine contractions
3. Gestational age <37 weeks = preterm

• Uterine contractions on CTG (≥4/hour)
• Cervical change: ≥2 cm dilatation OR ≥80% effacement OR documented progression

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MANAGEMENT

Immediate (Emergency measures)

1. Admit to labour ward / antenatal ward
2. IV access - 18G cannula
3. Continuous CTG monitoring - confirm contractions and FHR
4. Left lateral position - improves uteroplacental perfusion
5. IV crystalloid - Ringer's lactate 500 mL over 30 minutes (treat dehydration)
6. Supplemental oxygen - if SpO2 <95%
7. NPO in case delivery is imminent

Step 1 - Rule out contraindications to tocolysis

• Chorioamnionitis (fever + uterine tenderness + leukocytosis)
• PROM (sterile speculum exam)
• Abruption (bleeding + uterine rigidity)
• Fetal compromise (CTG - non-reassuring pattern)
• Placenta praevia

Step 2 - Antenatal Corticosteroids (most important)

Betamethasone 12 mg IM - first dose immediately; second dose after 24 hours

• Indication: 32 weeks gestation, risk of preterm delivery
• Accelerates fetal lung maturity - reduces RDS, IVH, NEC, death
• Maximum benefit after 24 hours - tocolysis aims to buy this window

Step 3 - GBS Prophylaxis

Injection Penicillin G 5 million units IV stat, then 2.5 million units IV every 4 hours until delivery

• If penicillin allergy: Ampicillin IV
• Reduces neonatal early-onset GBS sepsis

Step 4 - Tocolysis (to allow 48 hours for corticosteroids)

• Tab. Nifedipine 10-20 mg oral loading dose
• Repeat 10-20 mg every 3-6 hours until contractions settle
• Then Tab. Nifedipine SR 30-60 mg every 12-24 hours for 48 hours
• Monitor: BP (hypotension), FHR

• 50-100 mg loading dose oral/rectal
• 25-50 mg every 6 hours for maximum 48 hours
• Monitor: liquor volume (oligohydramnios), ductus arteriosus (fetal echo after 48 hours)
• Do not use beyond 32 weeks due to ductal constriction risk

Step 5 - Magnesium Sulphate for Neuroprotection

Inj. MgSO4 4-6 g IV bolus over 20-30 min, then 1-2 g/hour IV infusion until delivery or 24 hours

• Indication: <34 weeks - reduces risk of cerebral palsy in surviving preterm infant
• Monitor: respiratory rate, patellar reflexes (absent = toxicity), urine output
• Antidote: Calcium gluconate 1 g IV

Step 6 - Monitoring

Step 7 - Supportive

• Bed rest (left lateral)
• Hydration
• Treat UTI if present (empirical: oral nitrofurantoin / cephalexin - pending culture)
• Anaemia correction if Hb <10 g/dL: oral/IV iron
• Psychological support and counselling to patient and family

Step 8 - If Tocolysis Fails / Delivery Proceeds

• Alert Neonatology / NICU team for preterm baby of ~32 weeks
• Mode of delivery: Vaginal if vertex presentation; CS if breech, fetal distress, failure to progress
• Slow, controlled delivery with epidural analgesia
• Episiotomy and low forceps may be used to protect soft preterm head
• Do not give maternal maintenance tocolysis after 48 hours

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PROGNOSIS

• Fetal prognosis at 32 weeks with timely corticosteroids and NICU support: generally good; survival rate >95%
• Neonatal risks: RDS, IVH, NEC, hypothermia, hypoglycaemia, feeding difficulties
• Maternal prognosis: Good if no sepsis or underlying disease

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DISCUSSION

Overview

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Why 32 Weeks is a Critical Gestational Age

• Pulmonary: Surfactant production begins around 20 weeks but is inadequate before 34-35 weeks; RDS is a major cause of neonatal death
• Neurological: High risk of IVH and periventricular leukomalacia leading to cerebral palsy
• Gastrointestinal: NEC risk is significant
• Thermoregulation: Poor subcutaneous fat → hypothermia

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Significance of Primigravida Status

• Primigravidae have no prior obstetric history to suggest risk; this makes it critical to identify precipitating causes
• A prior preterm birth is the strongest single risk factor for recurrence (RR 2-5x); here it is absent, so other causes must be sought: UTI, BV, physical exertion, dehydration
• Cervical incompetence is less common in primigravidae but cannot be entirely excluded
• Advanced maternal age (32 years) combined with primigravida status is itself a mild risk factor

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Calculating Gestational Age - Clinical Importance

• LMP: 22 July 2024
• EDD (Naegele's rule): Add 1 year, subtract 3 months, add 7 days → 29 April 2025 (confirmed by the slide)
• At presentation with "8 months pregnancy": ~32 weeks
• This lies in the period where all four major interventions (tocolysis, betamethasone, GBS prophylaxis, MgSO4 neuroprotection) are indicated

Accurate gestational age is critical: corticosteroids are indicated at 24-34 weeks; indomethacin is safe only <32 weeks; MgSO4 neuroprotection is given <34 weeks.

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Pathophysiology of Preterm Labour

• Rise in prostaglandins (PGE2, PGF2α) - stimulate myometrial contractions
• Oxytocin receptor upregulation
• Cervical ripening (collagen breakdown, prostaglandin-mediated)
• Gap junction formation between myometrial cells (electrical coupling)

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Why Each Management Step is Justified in This Case

1. Confirm the diagnosis

2. Antenatal corticosteroids

• Stimulates surfactant production by type II pneumocytes
• Induces morphological maturation of pulmonary epithelial cells
• Reduces RDS by 50%, IVH by 40%, NEC by 50%
• Maximum effect appears within 24 hours and lasts 7 days
• Both doses should be completed before delivery if at all possible - hence tocolysis is used to buy this window

3. Tocolysis with nifedipine

• Oral route - convenient and safe
• Cochrane reviews confirm it delays delivery >48 hours and improves neonatal outcomes compared to β-mimetics
• At 32 weeks, indomethacin could also be considered (within the <32-week cut-off), but nifedipine is safer beyond 30 weeks
• Tocolysis does NOT prevent preterm birth - it only buys time (48-72 hours in ~75-80% of patients)
• Maintenance tocolysis after 48 hours provides NO benefit and may increase NICU stay - it should not be continued

4. GBS prophylaxis

5. Magnesium sulphate for neuroprotection

• Stabilises neuronal membranes
• Reduces glutamate excitotoxicity
• Multiple RCTs confirm reduced risk of cerebral palsy when given <34 weeks before preterm delivery
• This is given in addition to (not instead of) tocolysis, and is a separate indication

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Special Considerations for This Patient

Primigravida + Advanced age (32 years)

• No prior obstetric history to guide risk stratification
• Baseline pre-delivery workup especially important: USS biometry, Doppler, AFI
• Psychological impact of a preterm birth in a primigravida - may be profound; counselling needed

Residing in Bheemili (semi-rural area)

• Access to tertiary NICU care may be limited locally
• Maternal transport to a tertiary facility with NICU should be arranged if tocolysis is successful and delivery is not imminent
• A 32-weeker requires Level III NICU support (ventilation, TPN, monitoring)

Middle socioeconomic class

• Compliance with follow-up and medications is likely reasonable
• Financial counselling regarding NICU costs should be initiated early

No known risk factors

• In the absence of infection, abruption, or PROM: this may represent idiopathic preterm labour, which comprises ~50% of cases
• Investigate for occult UTI, BV, or subclinical chorioamnionitis

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Differential Diagnoses

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Complications if Untreated / If Delivery Occurs at 32 Weeks

Neonatal

• Respiratory Distress Syndrome (RDS) - surfactant deficiency; requires CPAP/ventilation
• Intraventricular Haemorrhage (IVH) - immature germinal matrix; risk of hydrocephalus, cerebral palsy
• Necrotising Enterocolitis (NEC) - immature gut; surgical emergency
• Hypothermia - poor thermoregulation
• Hypoglycaemia - limited glycogen stores
• Retinopathy of Prematurity (ROP) - especially if oxygen therapy needed
• Neonatal sepsis - immature immune system
• Prolonged NICU stay - feeding difficulties, apnoeas

Maternal

• Chorioamnionitis if labour prolonged
• PPH (particularly if prolonged tocolytic use)
• Psychological trauma / postnatal depression in a primigravida experiencing preterm birth

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Outcome and Follow-up

• Discharge after 48-72 hours if contractions settled and cervix stable
• Outpatient follow-up at 1 week
• Serial TVU cervical length monitoring
• Avoid strenuous activity, coitus (debated)
• Oral tocolytics: NOT recommended as maintenance
• Repeat corticosteroids: single rescue course if >2 weeks from first course and <34 weeks
• Plan delivery at a tertiary centre

• NICU team to be present at delivery
• Neonatal resuscitation readiness
• Delayed cord clamping (60 seconds) - improves neonatal Hb and reduces IVH
• Kangaroo mother care and breastfeeding support

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Key Takeaways from This Case

1. Gestational age at 32 weeks means all four major interventions apply: corticosteroids, tocolysis (48h only), GBS prophylaxis, and MgSO4 neuroprotection
2. Tocolysis is a bridge - its only goal is 48 hours for steroids and/or maternal transfer; it does not prevent preterm birth
3. Corticosteroids are the single most important intervention - they should never be omitted
4. Confirm the diagnosis first - overtreatment of Braxton-Hicks contractions is common; fFN and TVU cervical length are the most useful diagnostic tools
5. Primigravida at 32 weeks with no identifiable risk factor = likely idiopathic; investigate thoroughly for treatable causes (UTI, BV, dehydration)
6. Arrange NICU transport early if tertiary facilities are not locally available

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