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GCC Nursing Guide — Preterm Labour & Prematurity
Obstetrics & Neonatology GCC Context NICE / WHO / RCOG Guidelines Updated Apr 2026
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Definition of Preterm Labour

Regular uterine contractions (at least 4 in 20 minutes) with progressive cervical change before 37 completed weeks of gestation.

Classification by Gestational Age

Extremely Preterm<28 weeks
Very Preterm<32 weeks
Moderate Preterm32–33+6 weeks
Late Preterm34–36+6 weeks
Term37–41+6 weeks
⚠️

Late preterm (34–36+6 wks) accounts for ~70% of all preterm births. Often underestimated — these infants still face significant morbidity: feeding difficulties, hypoglycaemia, respiratory distress, temperature instability.

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Risk Factors

Highest Risk
Previous preterm birth Cervical insufficiency Multiple pregnancy

Previous preterm birth is the single strongest predictor — risk doubles with one prior preterm birth.

Moderate Risk
Uterine anomaly Genital tract infection Short cervix <25mm Bacterial vaginosis Low BMI / undernutrition Smoking
GCC-Specific Context
  • Higher multiple pregnancy rates due to IVF uptake across GCC
  • Consanguinity associated with some structural anomalies
  • Older primigravidas more common in urban GCC populations
  • Anaemia, nutritional deficiencies in migrant worker populations
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Diagnostic Investigations

Cervical Length (TVU)

Transvaginal ultrasound is the gold standard. Cervical length <25mm at 16–34 weeks = high risk for preterm birth. CL >30mm is reassuring. Used in symptomatic and asymptomatic (screening) patients.

Fetal Fibronectin (fFN)

Glycoprotein at choriodecidual interface. Collected by cervicovaginal swab at 22–34 weeks. High negative predictive value (>99%) — negative fFN makes delivery within 7–14 days very unlikely. Positive result has poor positive predictive value alone.

Digital Cervical Assessment

Assess cervical dilation, effacement, consistency, position (Bishop score). Cervical dilatation >3cm with contractions = active preterm labour. TVU preferred for objective measurement.

Note: Avoid vaginal examination if PPROM suspected until TVU performed.

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True Preterm Labour vs Braxton Hicks

Feature Braxton Hicks True Preterm Labour
RegularityIrregular, variableRegular, increasing frequency
IntensityDo not intensifyProgressive intensification
Cervical changeNo changeProgressive dilatation/effacement
fFN testUsually negativeMay be positive (>50ng/mL)
Cervical length>30mm (reassuring)<25mm (high risk)
Response to hydrationOften settlePersist despite hydration
Show / liquorAbsentBloody show or liquor possible
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Admission Criteria & Nursing Assessment

Admit if ANY of the following
  • Gestational age <37 weeks with regular contractions
  • Cervical dilatation ≥2cm or effacement ≥80%
  • Cervical length <25mm on TVU
  • Positive fFN with symptoms
  • PPROM (any gestational age)
  • Suspected chorioamnionitis
On Admission
  1. IV access, bloods: FBC, CRP, MSU, HVS, Group & Save
  2. Continuous CTG monitoring — assess contraction frequency and FHR
  3. Vaginal swabs (GBS screen if not done)
  4. TVU cervical length if not contraindicated
  5. Notify neonatology/NICU team of gestation
  6. Assess for contraindications to tocolysis
Continuous CTG — What to Look For

Assess for contraction frequency (aim to quantify). Normal baseline FHR 110–160 bpm. Fetal tachycardia (>160 bpm) may indicate infection. Loss of variability or decelerations require immediate obstetric review.

🔴

Fetal tachycardia + maternal pyrexia = suspect chorioamnionitis. Do not delay delivery in favour of completing steroid course in this situation.

ℹ️

In-utero transfer: Consider transfer to tertiary centre with appropriate NICU level BEFORE active labour if gestational age <28 weeks and delivery is not imminent.

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Principles of Tocolysis

Indications
  • Gestational age <34 weeks
  • To allow 48-hour window for antenatal corticosteroids to take effect
  • To facilitate in-utero transfer to appropriate centre
  • True preterm labour with intact membranes
⚠️

Key message for patients: Tocolytics do NOT improve neonatal outcomes beyond 48 hours. The purpose is to buy time for steroids and transfer — not to stop labour indefinitely. Explain this clearly.

Contraindications to Tocolysis
Absolute Contraindications
  • PPROM with signs of chorioamnionitis
  • Significant placental abruption
  • Severe pre-eclampsia or eclampsia
  • Fetal distress (non-reassuring CTG)
  • Fetal death or lethal anomaly
  • Maternal haemodynamic instability
Relative Contraindications
  • Cervical dilatation >5cm
  • Gestational age >34 weeks
  • IUGR with abnormal Dopplers
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Tocolytic Drugs — Nursing Reference

Nifedipine (Adalat)
Calcium Channel Blocker (CCB) — First-line in most GCC centres
Route: Oral / sublingual
Dose: 20mg orally, then 10–20mg every 4–6 hours (max 160mg/day). Some protocols: 10mg SL q20min x3 then maintenance.
Mechanism: Blocks L-type calcium channels in myometrium — reduces intracellular calcium and contraction force.
Nursing monitoring: BP and pulse every 30 min during loading, then hourly. Flushing, headache, palpitations common. Maternal hypotension is main risk — hold if SBP <90mmHg.
Important: Do NOT combine with MgSO4 — synergistic hypotension and neuromuscular blockade risk.
Atosiban (Tractocile)
Oxytocin/Vasopressin Receptor Antagonist — Preferred in cardiac disease
Route: IV infusion (three-phase protocol)
Dose: 6.75mg IV bolus over 1 min, then 300mcg/min x3hr, then 100mcg/min for up to 45hr.
Mechanism: Competitive antagonist at myometrial oxytocin receptors — prevents contraction signalling.
Nursing monitoring: BP, pulse, RR every 30 min. Fewer systemic side effects than nifedipine. Expensive — used where nifedipine contraindicated or in cardiac disease.
GCC context: Widely available across GCC tertiary centres; preferred by some units due to fewer maternal side effects.
Indomethacin
COX Inhibitor (NSAID) — Use <32 weeks only, short course
Route: Oral or rectal suppository
Dose: 50–100mg loading, then 25mg every 6 hours for maximum 48 hours.
Mechanism: Inhibits prostaglandin synthesis via COX pathway — reduces uterine contractility.
Nursing monitoring: Amniotic fluid index (AFI) — oligohydramnios risk after 48hr use. Fetal renal function monitoring. Avoid after 32 weeks (premature ductus arteriosus closure risk). Monitor maternal renal function. Avoid with pre-existing renal impairment or NSAID sensitivity.
Magnesium Sulphate (MgSO4)
Fetal Neuroprotection — <30 weeks (NOT primarily a tocolytic)
Important distinction: MgSO4 in preterm labour context is primarily given for FETAL NEUROPROTECTION (reducing cerebral palsy risk), not as a tocolytic agent. See Tab 3 for full protocol and monitoring.
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Monitoring During Tocolysis — Nursing Checklist

Maternal Observations (during infusion)
  1. BP and pulse every 30 minutes
  2. Respiratory rate every 30 minutes
  3. Temperature every 4 hours (infection surveillance)
  4. Urine output (especially with MgSO4 — >25mL/hr)
  5. Assess for side effects: headache, flushing, palpitations
  6. IV site assessment hourly
Fetal Monitoring
  1. Continuous CTG from admission
  2. FHR baseline, variability, accelerations, decelerations
  3. Contraction frequency and duration — reassess q1h
  4. If no CTG improvement after 1hr — reassess diagnosis and management
  5. Ultrasound for fetal presentation and wellbeing
  6. Doppler assessment if IUGR concern
ℹ️

Expectation setting: Tocolysis success means buying 48 hours for corticosteroids, not stopping preterm birth. If contractions settle, ongoing bed rest has no evidence base — mobilisation can be encouraged cautiously once stabilised.

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Antenatal Corticosteroids

Standard Protocol
Betamethasone 12mg IM
Preferred agent — reduced neonatal breathing problems vs Dexamethasone
Dose: 12mg IM x2 doses, 24 hours apart
Course complete: 24 hours after second dose
Maximum benefit: 24 hours to 7 days after first dose
Alternative: Dexamethasone 6mg IM x4 doses, 12 hours apart
Indications
  • Gestational age 24–34 weeks with risk of preterm birth within 7 days
  • Consider at 23 weeks (borderline viability — after counselling)
  • PPROM <34 weeks (in absence of chorioamnionitis)
  • Elective caesarean section at <39 weeks (reduces respiratory morbidity)
Neonatal Benefits (Evidence-Based)
  • Reduces Respiratory Distress Syndrome (RDS) by ~40–50%
  • Reduces Intraventricular Haemorrhage (IVH)
  • Reduces Necrotising Enterocolitis (NEC)
  • Reduces overall neonatal mortality
  • Reduces need for surfactant therapy
Rescue Course

A single rescue course (same protocol) can be given if:

  • Gestational age remains <34 weeks
  • More than 7 days have elapsed since first course
  • Ongoing or renewed risk of preterm delivery
⚠️

Repeated multiple courses are NOT recommended — associated with fetal growth restriction and adrenal suppression. Maximum: first course + one rescue course.

ℹ️

Nursing note: Corticosteroids can cause transient hyperglycaemia — monitor blood glucose in diabetic patients and those with gestational diabetes for 48–72 hours after administration. Adjust insulin as needed.

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Magnesium Sulphate — Fetal Neuroprotection

Indication & Evidence Base

MgSO4 is given to reduce the risk of cerebral palsy in preterm infants born at <30 weeks gestation. Evidence from MAGPIE and ACTOMgSO4 trials demonstrates a 30–35% reduction in cerebral palsy risk.

Standard Protocol
Magnesium Sulphate (MgSO4) 50% solution
Neuroprotection <30 weeks gestation
Loading dose: 4g IV over 20 minutes (dilute 8mL of 50% MgSO4 in 92mL 0.9% saline = 4g in 100mL)
Maintenance: 1g/hour IV infusion
Duration: Until delivery or up to 24 hours
Important: MgSO4 is separate from tocolysis — not primarily a uterine relaxant at these doses (though has mild effect)
Toxicity Monitoring — Hourly
Monitor EVERY HOUR — Three Key Parameters
Respiratory rateMust remain >12 breaths/min
Urine outputMust remain >25 mL/hr
Patellar reflexesMust be PRESENT
🔴

Toxicity Signs (in order of severity):

  • Loss of patellar reflexes (Mg ~7–10 mEq/L)
  • Respiratory depression (Mg ~10–13 mEq/L)
  • Cardiac arrest (Mg >15 mEq/L)
ANTIDOTE — Must Be at Bedside at All Times

Calcium Gluconate 1g IV (10mL of 10% solution)

Give slowly IV over 3 minutes if respiratory arrest or severe toxicity occurs. Displaces Mg from binding sites.

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Steroids vs MgSO4 — Quick Comparison

Feature Corticosteroids Magnesium Sulphate
Primary indicationLung maturationFetal neuroprotection
Gestation24–34 weeks (consider from 23 wks)<30 weeks
Timing benefitMax effect 24hr–7 days post doseActive infusion until delivery
RouteIM injectionIV infusion
Key riskHyperglycaemiaRespiratory depression / cardiac arrest
AntidoteN/ACalcium Gluconate 1g IV (BEDSIDE)
Rescue dose?Yes — once, if >7 days since first course and <34wkRestart if delivery not occurred in 24hr and new delivery episode
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PPROM — Preterm Prelabour Rupture of Membranes

Diagnosis
  • History: Gush or constant trickle of fluid from vagina
  • Speculum examination: Pooling of liquor in posterior fornix
  • Ferning test: Amniotic fluid crystallises in fern pattern on drying
  • IGFBP-1 / AFP tests: AmniSure (PAMG-1), Actim PROM (IGFBP-1) — high sensitivity/specificity
⚠️

Avoid digital vaginal examination in suspected PPROM until speculum confirms diagnosis — digital VE increases infection risk and can precipitate labour.

PPROM vs SROM vs Urinary Incontinence
PPROM<37 weeks, before labour onset
SROM≥37 weeks, before labour onset
AROMArtificial rupture by clinician
Urinary incontinenceAmmonia odour, no pooling, pH test
Vaginal dischargepH acidic, no pooling on speculum

Amniotic fluid: alkaline pH >7.1 (turns nitrazine yellow paper blue). Vaginal secretions: acidic pH 4.5–6.0.

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Expectant Management — Infection Surveillance

Monitoring Frequency
  1. Temperature, pulse, BP — 4-hourly minimum
  2. CTG — twice daily or if maternal pyrexia/concern
  3. FBC and CRP — every 24–48 hours
  • Daily fetal movement assessment
  • AFI (amniotic fluid index) — every 24–48 hours
  • Ultrasound for fetal growth and Dopplers weekly
    • Chorioamnionitis — Signs (DELIVER if diagnosed)
    Clinical Diagnosis (2+ of the following)
    Maternal fever>38.0°C (single reading)
    Maternal tachycardia>100 bpm
    Fetal tachycardia>160 bpm
    Uterine tendernessOn palpation
    Offensive liquorPurulent/malodorous
    LeucocytosisWBC >15 x10⁹/L

    Delivery is the treatment for chorioamnionitis — do not delay for steroids.

    💊

    Latency Antibiotics in PPROM

    Erythromycin (ORACLE Trial — preferred)
    Macrolide — prolongation of latency, reduces neonatal morbidity
    Dose: 250mg orally four times daily x10 days (or until delivery if sooner)
    Evidence: ORACLE I trial — erythromycin significantly prolonged pregnancy and reduced neonatal morbidity in PPROM.
    🔴

    Co-amoxiclav (Augmentin) is CONTRAINDICATED in PPROM — ORACLE trial showed increased risk of Necrotising Enterocolitis (NEC) in neonates. Do not use even if erythromycin resistance suspected.

    GBS Prophylaxis in Labour

    If GBS-positive swab or unknown GBS status in preterm labour with PPROM, administer intrapartum IV penicillin G (or ampicillin) for GBS prophylaxis. Benzylpenicillin 3g IV STAT then 1.5g 4-hourly until delivery.

    Corticosteroids in PPROM

    Administer betamethasone as per standard protocol if <34 weeks. Steroids are appropriate in PPROM provided there are no clinical signs of chorioamnionitis.

    Oligohydramnios Monitoring

    Daily AFI assessment. Severe oligohydramnios (AFI <2cm) — assess fetal renal function, pulmonary hypoplasia risk, cord compression risk on CTG.

    📊

    Gestational Age Management Thresholds in PPROM

    Gestation Management Approach Key Considerations
    <23 weeksDetailed counselling re: viability. Shared decision-making with parents.High risk neonatal death/disability. Pulmonary hypoplasia risk with prolonged PPROM. Palliative care vs active management discussion.
    23–27+6 weeksActive management — expectant with close monitoring if infection-free.Steroids, MgSO4. Neonatology counselling. NICU involvement. Latency antibiotics. Daily surveillance for chorioamnionitis.
    28–33+6 weeksExpectant management with surveillance. Aim to continue pregnancy.Steroids. Antibiotics. Twice daily CTG. Deliver for chorioamnionitis or fetal compromise.
    34–36+6 weeksDelivery generally recommended vs expectant — individualised.NICE/RCOG: consider delivery after confirming gestational age and excluding infection. Neonatal support for late preterm.
    >37 weeks (SROM)Induction of labour if not in labour within 12–24 hours.GBS prophylaxis, continuous CTG in labour.
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    Delivery Suite Preparation

    Pre-delivery Checklist
    1. Notify NICU/neonatology team — state exact gestational age, indication, any maternal medication
    2. Prepare resuscitaire — test suction, oxygen, warm environment
    3. Set up warming mattress (activated chemical warming pad)
    4. Prepare surfactant (Poractant alfa/Beractant) — ready for administration
    5. Polythene wrap/bag for <32 weeks — prevents hypothermia
    6. Pulse oximeter probe — apply to right hand (pre-ductal reading)
    Thermoregulation — Critical for <32 Weeks
    Polythene Wrap Protocol
    • Immediately wrap body and head (except face) in polythene bag/wrap
    • Do NOT dry first — wrap wet
    • Place on warm mattress or under radiant warmer
    • Target temperature on NICU admission: 36.5–37.5°C
    • Hypothermia (<36°C) increases mortality, IVH, NEC, infection risk
    ⚠️

    Delivery room temperature should be raised to 26°C minimum before extremely preterm birth. Warm towels, hat, warm humidified resuscitation gases where available.

    🫁

    Respiratory Support & Surfactant

    Respiratory Distress Syndrome (RDS)

    Caused by surfactant deficiency in immature lungs. Clinical features: tachypnoea, grunting, nasal flaring, intercostal/subcostal recession, cyanosis. Chest X-ray: ground-glass pattern, air bronchograms, reduced lung volumes.

    Surfactant Therapy
    Poractant alfa (Curosurf) / Beractant (Survanta)
    Natural surfactant — replaces deficient endogenous surfactant
    Indication: Preterm infant with RDS, <36 weeks, requiring respiratory support
    Timing: Early treatment preferred — within 2 hours of birth
    Route: Intratracheally via endotracheal tube
    Nursing role: Prepare dose per weight, assist with positioning, observe SpO2 improvement post-administration, suction only when necessary
    CPAP vs Intubation Decision
    CPAP First (INSURE approach)

    Non-invasive respiratory support with CPAP (5–8cmH2O) is first-line for most preterm infants with RDS. INSURE = INtubate-SURfactant-Extubate to CPAP.

    Intubation Indicated If:
    • Persistent apnoea unresponsive to CPAP
    • Worsening respiratory failure (FiO2 >0.4 on CPAP)
    • Extreme prematurity (<25 weeks) — often intubated prophylactically
    • Surfactant administration required
    Oxygen Targeting

    For infants <30 weeks: target SpO2 91–95% to reduce retinopathy of prematurity (ROP) while preventing hypoxia. Avoid hyperoxia (>98%).

    🍼

    Nutrition & Feeding

    Expressed Breast Milk (EBM)

    Expressed breast milk is the optimal feed for preterm infants — reduces NEC, infection, improves neurodevelopment. Begin expressing within 1–2 hours of delivery.

    • Colostrum (first milk) — rich in antibodies, even small volumes have immunological benefit
    • Tube feeding via orogastric/nasogastric tube for infants <34 weeks
    • Fortify EBM once establishing feeds for extremely preterm
    • Donor breast milk where available if maternal EBM insufficient
    🔴

    Avoid formula in very preterm infants where possible — formula feeding significantly increases NEC risk compared to breast milk. Document feeding type in records.

    Supporting Mothers to Express
    1. Explain the critical importance of breast milk for preterm infant
    2. Initiate skin-to-skin contact as soon as clinically stable
    3. Provide hospital-grade electric pump immediately post-delivery
    4. Hand-express colostrum in first 24–48 hours before milk comes in
    5. Express 8–10 times per 24 hours (including overnight)
    6. Lactation consultant referral — GCC hospitals increasingly offer this service
    GCC Context — Breastfeeding

    Breastfeeding is strongly encouraged by Islamic teachings — a cultural asset in GCC. However, stress, separation, and unfamiliar NICU environment can impede lactation. Psychosocial support is essential.

    🧠

    Neurodevelopmental & Family-Centred Care

    Minimal Stimulation Principles
    • Cluster care activities — minimise handling episodes
    • Dim lighting, noise reduction
    • Containment holding and positioning (nesting, boundaries)
    • Avoid unnecessary painful procedures
    • Sucrose analgesia for painful procedures in NICU
    Kangaroo (Skin-to-Skin) Care

    Skin-to-skin contact between parent and preterm infant. Benefits: thermoregulation, breastfeeding initiation, weight gain, reduced infection, improved neurodevelopment, parental bonding.

    Commence as soon as infant is stable on CPAP or even ventilated (with appropriate staff present).

    Family Involvement
    • Parents at cot-side 24/7 — open visiting
    • Involve parents in nappy changes, temperature measurement
    • Daily bedside multidisciplinary rounds with family inclusion
    • Developmental physiotherapy referral
    • Prepare parents for ROP, hearing, neurodevelopmental screening
    Retinopathy of Prematurity (ROP)

    Abnormal retinal vascular development due to preterm birth and oxygen exposure. Screening: ophthalmology for all infants <30 weeks or <1500g. Begin screening at 4–6 weeks of age or 31 weeks corrected, whichever is later.

    Strict oxygen targeting (<30 weeks: SpO2 91–95%) is the primary prevention strategy.

    Long-Term Outcomes Counselling
    <23 weeksSurvival ~20–40%; major disability common
    23–24 weeksSurvival ~50–60%; significant morbidity
    25–27 weeksSurvival 70–85%; major morbidity still significant
    28–31 weeksSurvival >90%; better outcomes with modern NICU
    34–36+6 weeksSurvival >99%; mostly minor morbidity
    🎯

    MgSO4 Toxicity — Critical Exam Point

    Must Know for DHA / DOH / SCFHS / QCHP Exams
    ParameterSafe LimitToxicity SignAction
    Respiratory rate>12/min≤12/min — STOP infusionStop MgSO4; give Calcium Gluconate 1g IV
    Urine output>25mL/hr<25mL/hr — STOP infusionStop MgSO4; assess renal function
    Patellar reflexPRESENTABSENT — STOP infusionStop MgSO4; check Mg level if available
    AntidoteCalcium Gluconate 1g IV (10mL of 10%) over 3 minMust be at bedside at all times
    💊

    Tocolytic Drug Comparison Table

    Drug Class Route Gestational Limit Key Monitoring Key Contraindication
    Nifedipine CCB Oral/SL <34 weeks BP q30min — hypotension Do NOT combine with MgSO4
    Atosiban Oxytocin antagonist IV infusion <34 weeks BP, pulse q30min — fewer SE Hypersensitivity; <24 or >33+6 wks
    Indomethacin COX inhibitor Oral/PR <32 weeks, max 48hr AFI, fetal renal function >32 weeks (ductal closure); renal impairment
    MgSO4 Neuroprotection IV infusion <30 weeks RR, UO, patellar reflexes q1h Do NOT combine with nifedipine; renal failure
    📋

    Gestational Age Management Thresholds (Exam Format)

    Gestation Corticosteroids MgSO4 Neuroprotection Tocolysis Notes
    <23 weeksNot recommended (individual decision)Not evidence-basedNot indicatedCounselling — viability discussion
    23–23+6 weeksConsider after counsellingConsider after counsellingDiscuss with seniorPeriviable — active management decision
    24–29+6 weeksYESYES (<30 wks)YES (<34 wks)Tertiary NICU care
    30–33+6 weeksYESNOT routine (>30 wks)YES (<34 wks)Level 2 NICU minimum
    34–36+6 weeksConsider 34–35+6NONOT recommendedLate preterm — enhanced monitoring
    ≥37 weeksNot recommendedNONOTerm delivery management
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    Corticosteroid Protocol Quick Reference

    Betamethasone (Preferred)
    Dose12mg IM
    Frequencyx2 doses, 24 hours apart
    Max benefit24hr–7 days post first dose
    RescueOnce if >7 days since first & <34 wks
    BenefitRDS, IVH, NEC reduction
    Dexamethasone (Alternative)
    Dose6mg IM
    Frequencyx4 doses, 12 hours apart
    Total dose24mg over 48 hours
    NoteLess preferred — more IVH vs betamethasone in some studies
    GCC contextUsed in some UAE/KSA centres where betamethasone unavailable
    📝

    GCC Exam High-Yield Questions

    Q: What is the antidote for MgSO4 toxicity? ▼

    Calcium Gluconate 1g IV (10mL of 10% solution) given slowly over 3 minutes. This must be at the bedside at all times during MgSO4 infusion. It acts by displacing magnesium from neuromuscular binding sites.

    Q: Which tocolytic must NOT be given with nifedipine? ▼

    Magnesium Sulphate. The combination causes synergistic hypotension and neuromuscular blockade. If MgSO4 is needed for neuroprotection, switch to atosiban for tocolysis or use MgSO4 alone.

    Q: Why is co-amoxiclav contraindicated in PPROM? ▼

    ORACLE trial (2001) demonstrated that co-amoxiclav (Augmentin) was associated with a significant increase in neonatal Necrotising Enterocolitis (NEC) compared to erythromycin. Erythromycin 250mg QDS x10 days is the recommended latency antibiotic in PPROM.

    Q: What is the purpose of tocolysis? ▼

    Tocolysis is given to delay delivery for 48 hours to allow: (1) antenatal corticosteroids to reach maximum neonatal lung-protective effect, and (2) safe in-utero transfer to an appropriate tertiary unit. Tocolytics do NOT improve neonatal outcomes beyond 48 hours and do not prevent preterm birth.

    Q: When is MgSO4 given for neuroprotection vs tocolysis? ▼

    For neuroprotection: <30 weeks gestation — 4g IV loading over 20 min, then 1g/hr maintenance. This is based on ACTOMgSO4 and MAGPIE trial evidence showing a reduction in cerebral palsy. As a tocolytic, MgSO4 has minimal efficacy and is not recommended for this purpose in modern guidelines.

    Q: What cervical length on TVU indicates high risk for preterm birth? ▼

    Cervical length <25mm on transvaginal ultrasound between 16–34 weeks is the threshold for high risk. Cervical length <15mm carries even higher risk. A cervical length >30mm is reassuring. Combined with a negative fFN test (high NPV), short cervix can help guide management decisions.

    Q: What are the five signs of chorioamnionitis? ▼

    Maternal fever >38°C, maternal tachycardia >100bpm, fetal tachycardia >160bpm, uterine tenderness, and offensive/purulent liquor. Delivery is the definitive treatment — do not delay for corticosteroids. Broad-spectrum IV antibiotics should be commenced immediately (e.g. ampicillin + metronidazole +/- gentamicin per local protocol).

    Q: What is the fFN test, and what is its main clinical value? ▼

    Fetal fibronectin (fFN) is a glycoprotein at the choriodecidual interface. It is detected by cervicovaginal swab at 22–34 weeks. Its main clinical value is its high negative predictive value (>99%) — a negative result makes delivery within 7–14 days very unlikely. This can safely reduce unnecessary hospital admissions and tocolysis. A positive result has poor positive predictive value alone and must be interpreted with clinical findings and cervical length.

    Q: Why is polythene wrap used for infants <32 weeks at delivery? ▼

    Extremely preterm infants have a large surface area relative to body mass, minimal subcutaneous fat, and immature temperature regulation. Polythene wrap (applied wet, without drying) prevents evaporative heat loss and reduces hypothermia risk. Target temperature on NICU admission is 36.5–37.5°C. Hypothermia increases mortality, IVH, NEC, and infection risk in preterm neonates.

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