Preterm birth, birth before 37 completed weeks of pregnancy, affects an estimated 13 million babies a year, according to WHO, and complications of preterm birth are the leading cause of death among children under five worldwide. Many of these deaths are preventable with proven, affordable interventions. Nurses and midwives can make a huge difference by recognising preterm labour early and making sure the right treatments are given at the right time.
Risk factors
- Previous preterm birth or late miscarriage.
- Multiple pregnancy (twins, triplets).
- Infections: urinary tract infection, bacterial vaginosis, malaria, HIV, chorioamnionitis.
- Pre-eclampsia, diabetes, high blood pressure.
- Cervical surgery or a short cervix.
- Very young or older maternal age, short interval between pregnancies.
- Smoking, substance use, poor nutrition, stress, domestic violence.
Recognising threatened preterm labour
- Regular contractions or tightenings.
- Lower back ache, period-like cramps, pelvic pressure.
- A change in vaginal discharge, a “show” (mucus with blood).
- Leaking fluid: possible preterm prelabour rupture of membranes (PPROM).
- Vaginal bleeding: needs urgent assessment.
Many women with symptoms are not actually in labour. Assessment may include speculum examination, cervical length scanning, or tests such as fetal fibronectin where available. Gestational age should be confirmed as accurately as possible.
Key interventions
Antenatal corticosteroids
Steroids such as dexamethasone or betamethasone, given to the mother by intramuscular injection, help the baby’s lungs mature and reduce death and breathing problems. WHO recommends them for women at risk of imminent preterm birth from 24 to 34 weeks when: gestational age can be accurately assessed, preterm birth is considered imminent, there is no clinical evidence of maternal infection, adequate childbirth care is available, and the preterm newborn can receive adequate care (including resuscitation, thermal care, feeding support, infection treatment and safe oxygen). These conditions matter: in settings without adequate newborn care, steroids may not bring the same benefits.
Magnesium sulfate for neuroprotection
Magnesium sulfate given to the mother before early preterm birth (WHO: before 32 weeks) reduces the risk of cerebral palsy in the baby. Monitor the mother as for magnesium in pre-eclampsia: respiratory rate, reflexes, urine output. See our magnesium sulfate guide.
Tocolysis
Medicines to slow contractions (such as nifedipine) may be used for a short time, mainly to allow steroids to work or to transfer the woman to a facility with neonatal care. They don’t improve outcomes on their own over the longer term.
Antibiotics for PPROM
For preterm prelabour rupture of membranes, antibiotics (commonly erythromycin) reduce infection and improve outcomes. Co-amoxiclav is avoided because of an association with necrotising enterocolitis in the baby. Watch closely for signs of chorioamnionitis: maternal fever, tachycardia, uterine tenderness, offensive discharge, fetal tachycardia.
Transfer in utero
If possible, very preterm babies should be born in a facility with appropriate neonatal care. Transferring the mother before birth is safer than transferring a sick baby afterwards.
Preparing for birth
- Alert the neonatal team; prepare resuscitation equipment and a warm environment. See our neonatal resuscitation guide.
- Delayed cord clamping (at least 60 seconds where the baby doesn’t need immediate resuscitation) benefits preterm babies.
- Thermal care: preterm babies lose heat rapidly. Plastic wraps or bags for very preterm babies, skin-to-skin and kangaroo mother care.
- Early breastfeeding or expressed breast milk.
Supporting the family
Preterm labour is frightening. Keep the woman and her partner informed, involve them in decisions, and prepare them for what to expect in the neonatal unit. Parents of preterm babies are at higher risk of anxiety and depression; check on their wellbeing.
Based on WHO recommendations for interventions to improve preterm birth outcomes (2022), WHO preterm birth fact sheet and NICE NG25 (Preterm labour and birth). Educational content: follow local protocols.