Preterm contractions are one of the most difficult situations for a pregnant woman to cope with. First, is the stress of wondering if the contractions are labor contractions, uterine irritability, or just Braxton Hicks contractions. Second, we know that preterm contractions are overtreated in the United States, yet we don’t have really good tools for determining when treatment is necessary and when it is not. Third, none of our interventions for preterm contractions–with the exception of steroids to mature the baby’s lungs–has really been proven effective. It is a frustrating situation for both mother and provider.
Many women will have preterm contractions–also called Braxton Hicks contractions–which can be frequent and regular for periods of time. Keep in mind that while most preterm contractions do not lead to premature labor and birth, it is unwise to simply ignore them until you know that they are not leading to labor. This does not mean, however, that you need to rush to the hospital with the first contractions you feel. Some steps you can take when you experience contractions prior to 37 weeks of pregnancy:
1. The vast majority of the time, contractions that are causing cervical dilation will be regular, 10 minutes or less apart, and progressively getting stronger and lasting longer. They may be felt in the back, lower abdomen, or occasionally in the thighs. While many women will experience regular Braxton-Hicks contractions which may be close together, they do not get progressively stronger and longer, as real labor contractions do. If you are feeling contractions, change your activity for a half hour and see if the contractions change, too. If you have been active and on your feet, lie down or take a warm bath. If you’ve been lying down, get up and move around a little, or sit in a comfortable chair for a while.
2. Drinking a large glass of water may help if you are dehydrated.
3. A warm bath or shower can relax contractions.
Real labor contractions are rarely stopped by any of these measures. So if you think it’s the real thing, what types of intervention might you expect at the hospital?
1. IV fluids: these are fairly routine, even though the Cochrane Review states that IV fluids are not beneficial in stopping labor unless the woman is dehydrated.¹
2. A fetal fibronection test (FFN) and vaginal cultures for bacterial vaginosis and group B strep. The Cochrane Review did not find the FFN to be beneficial in predicting/preventing preterm labor², nor did they find treatment of bacterial vaginosis to prevent preterm labor.³ Another review, however, indicated that screening and treatment of lower genital tract infection may be helpful in prevention and preterm labor.4
3. Tocolytics will likely be given. Tocolytics are drugs that relax the muscle of the uterus, calming preterm contractions. The Cochrane Review states that there is not evidence supporting the benefit of tocolytics beyond the first 48 hours of preterm labor. The benefit of using them in the first 48 hours is allowing time to administer corticosteroid medication to the mother in order to mature the baby’s lungs, an evidence-based beneficial intervention.5 Tocolytics have all been shown to have potential adverse side effects to both mother and baby, but continue to be routinely used, simply because we don’t have any better treatment at this time.
4. The mother will likely be placed on bedrest. This is not an evidence-based intervention. Most providers continue to use it in order to “feel like we’re doing everything we can”. In other words, it’s more of a liability protection, rather than something that will truly benefit mother and baby. Yes, most women will experience more contractions when they are moving around, but contractions triggered by activity are most often Braxton Hicks contractions. Bedrest has not been shown to prevent true preterm labor from occuring.
5. If preterm labor is due to a problem with shortening/dilating of the cervix too soon, a purse-string type of stitch can be placed in the cervix, tying it closed. This is done under anesthetic and has been shown to be beneficial in preventing preterm labor, but only in cases which were caused by what is termed “incompetent cervix”. This term refers to a cervix which thins out and then dilates, often painlessly, prematurely.
What then, can be done to preserve the normal process of labor and birth if one is experiencing contractions? I would recommend the following steps, if you have not experienced a premature birth before:
1. After following the suggestions above, changing activity, drinking water, etc., if contractions are continuing to be regular and noticeably stronger and lasting longer, call your provider.
2. At the hospital, there should be no need for IV fluids unless you are dehydrated and unable to drink water.
3. Before accepting treatment with tocolytics, ask for two cervical exams one to two hours apart, and performed by the same person. Preterm labor cannot be diagnosed in the absence of cervical change. If your cervix is not dilating, you are not in labor, regardless of how many contractions you are feeling.
4. If you do have cervical change, or if your first cervical exam indicates premature changes, tocolysis for the first 48 hours is evidence based. A popular tocolytic, Terbutaline, probably has more perceptible side effects for the mother than Nifedipine, which is also used for tocolysis. If I were in premature labor, I would prefer to take Nifedipine first before using Terbutaline.
5. Accept two injections of betamethasone, 24 hours apart. This has been shown to improve outcomes for infants born early.
6. Bedrest has not been shown to improve outcomes or halt premature labor. A reasonable amount of rest is desirable, but you should be able to have light activity.
7. After 48 hours, consider discontinuing tocolytics, even if you have contractions when you stop them. Many, many women have taken tocolytics until their 36th week of pregancy, only to go overdue in their pregnancy. This indicates that many women are taking tocolytics unnecessarily, while running the risk of the side effects that can go with them. Have your provider monitor your cervix periodically for changes, and as long as your cervix is not changing prematurely, you don’t have to worry about contractions. A partner may also be taught how to check the cervix in the case of a woman who has lots of contractions. Cervical exams should not be performed without discretion, however, as they can trigger contractions if not done very gently.
8. If you do have premature labor and birth, there is no evidence that c-section is better than vaginal delivery for a premature baby. There is strong evidence that the premature infant is benefited by delayed cord clamping. Talk with your provider early in the process, requesting this be done for your baby.
9. While not often practiced in the United States, Kangaroo Mother Care is a marvelous way of humanizing preterm birth and neonatal care. While most neonatal intensive care units do not allow touching or physical handling of the premature infant, Kangaroo Mother Care has shown benefit from skin-to-skin contact with even micro-premies (the very smallest babies). I encourage you to visit their website and read their stories and evidence for this practice. Being aware of this information ahead of time will empower you to be able to advocate for yourself and your baby.
Frequent contractions which are not changing the cervix can be uncomfortable, annoying, and frustrating for the woman experiencing them. One remedy I have found effective is WishGarden Herbs Welcome Womb, an herbal tincture designed to calm an “irritable” uterus. In addition to the tincture, resting when you can and keeping a positive attitude are helpful in getting you through those difficult days or weeks.
1. Intravenous fluids for treatment of preterm labor. Retrieved 02/25/2010 from: http://www.cochrane.org/reviews/en/ab003096.html
2. Fetal fibronectin testing for reducing risk of preterm birth. Retrieved 02/25/2010 from: http://www.cochrane.org/reviews/en/ab006843.html
3. Antibiotics for treating bacterial vaginosis in pregnancy. Retrieved 02/25/2010 from: http://www.cochrane.org/reviews/en/ab000262.html
4. Antenatal lower genital tract infection screening and treatment programs for preventing preterm delivery. Retrieved 02/25/2010 from: http://www.cochrane.org/reviews/en/ab006178.html
5. Antenatal corticosteroids for maturing fetal lungs. Retrieved 02/25/2010 from: http://www.cochrane.org/reviews/en/ab004454.html
I was surprised when I first learned that KMC was not standard practice. My middle daughter spent 4 days in a preemie NICU unit after her birth (she was not premature, but the other NICU unit was full). I spent most of those four days sleeping in a chair in the NICU, holding her inside my hospital gown. The unit itself was full of posters extolling the importance of skin-to-skin contact for preemies, and asking for volunteers to hold babies whose mothers could not be there. How sad to think that unit may be an exception, not the rule.
Yes, wouldn’t it be wonderful if every NICU in the country would adopt these practices? The photos on the Kangaroo Mother Care website brought tears to my eyes, as I’ve always been told these micro-premies cannot tolerate contact.
In terms of what might also be done to rule out preterm labor, a urinanalysis/urine culture to rule out the possibility of urinary tract infection – a common cause of preterm contractions…
Also, while fFN does not predict preterm labor, it can quite reliably predict that labor will NOT occur (with a negative fFN).
Thanks for reminding me of this! Absolutely, a urinary tract infection (UTI) can cause preterm contractions, and is one of the things we always rule out first.
As for the fFN (fetal fibronectin test), a recent premature baby I delivered at just under 34 weeks was born to a mom whom I had tested three days prior, and reassured her since we had a negative fFN. The company’s literature does state that a negative fFN is 99.7% accurate in predicting that labor will not occur within two weeks.
Thank you for this. My Mom went into pre-term labor with both me and my older sister at around 7 months and her doctor was not sure why. Labor stopped (probably on its own, though she was on a tocolytic) and I was born a week past my due date. Do you know if pre-term labor is genetic? I sometimes worry if the same will happen to me when I have kids.
Many women will have episodes of “pre-term labor” that stop spontaneously, and are actually Braxton-Hicks contractions. True pre-term labor does not stop on its own, but will progress to delivery unless it can be stopped by medication. If your mom had a preterm birth, you are considered to be at slightly higher risk for a preterm birth as well.
I am having trouble connecting this blog to mine as a favorite so I just got back to looking at it. I read this note and would like to wade in if ok. I have been in ob pradtice for 25 years and really try to keep up with the latest trends. I am not allowed to work with midwifes (wives) per my insurer but I work “around” several, and yes I offer appropriate candidates VBAC. Now to your blog by point. Number 1. Yes, but on your side is actually better than a chair. Remember, warm bath that floats you if possible – not hot as this can vasodilate and worsen ctxs (and cause fainting with standing).
2. The physiology of dehydration and ctxs is based on the renal/vasopressin axis. Overhydration through any means can calm uterine iritability. Irritability can progress to contractions but it is rare!
3. Why is unsure. Maybe because it relaxes mom.
Level two.
1. I am going to pay no attention to the Cochrane review. Just like the WHI it is full of holes and bias. That said, this is correct. We rarely stop true labor for any length of time but there is no way to know which ones we did stop with our over treatment. It is impossible to set up a double blinded pacebo controlled trial on preterm labor. You simply cannot sacrifice a child to see if something worked. The lawyers would love it the rest of us not so much.
2. I do not use FFN’s. The only ones that do in the five delivering hospitals that I am on staff with are friends of the rep.
3.Yep. The steroids do not mature lungs. They seem to get them ready to mature by encouraging development of the type two pneumocyte. Problem with all of this is if you wait until you document cervical change you have already lost. BUT I cannot even start to tell you how many times I see IV whatever being given to a closed primip for ctxs. If one is determined to do something give her some morphine. A least she will get some sleep.
4.yep
5.Wrong. A cerclage is used for incompetent cervix. By definition this is a silent dilation. It is not associated with contractions until very advanced and then is non-fixable (southern word). Also is has to occur before 24 weeks. The old “lash” procedure for later advanced dilation has no proven effectiveness.
third level.
1. YYYEEEEESSSSS
2. Er, then why’d you go to the hospital? Throw me a bone and let me hydrate and sedate. Ok, I do hydrate by mouth too, but I can only take “what ain’t you doing nuthin” for so long.
3. YEEEESSSSS. Labor is defined as cervical change. Not contractions. Kudos
4. But neither are approved. Ask provider for pro/cons.
5. yep
6. yep
7. nope. It is like saying your car made it to 100,000 miles indicating you changed your oil too often. Just becuse you got past the ptl does not mean your treatment was unnecessery. No way to study this. You cannot issue this as a blanket statement. What if the ptl was secondary to uti, mva, flu, partial abruption, etc. Do all these patients have a course of action? And what is wrong with postdates anyway?
8. Depends, but, on the surface, not incorrect.
9. yep, if the children can be safely moved.
Please do not shoot me. I am just trying to clarify. Remember I like this place.
Later
I do not apologize for spelling or syntax. Not required in med school and I cannot find a spell check here.