Premature Labor

If a pregnant woman is experiencing some of the following signs or symptoms before her 37th week of pregnancy, she may be facing premature labor:

• Pressure in the pelvis or lower belly, as if the baby is pushing down
• Menstrual-type cramps
• Constant or low back pain
• Contractions occurring more than 6 times an hour, continuously at intervals of ten minutes apart
• Painful or hard uterus
• Increasing pressure in the vagina
• Vaginal secretion, spotting, or light bleeding
• Blurred or troubled vision
• Swelling in the hands, feet, and face
• Preterm rupture of the membranes surrounding the baby
• Decreased fetal movements
• Nausea, vomiting, and diarrhea

What are Braxton Hicks contractions?

Braxton Hicks contractions are mild, irregular, and infrequent contractions, often referred to as 'false' or 'practice' contractions. They feel like tightness in the abdomen and are relatively less painful. These contractions usually stop on their own or with a change in position, resting, or walking. In contrast, labor contractions typically occur at regular intervals, increase in duration over time, and are much more painful.

In cases where labor starts spontaneously before 37 weeks, it is often difficult to determine the exact cause. However, several factors can increase the risk of premature birth, as discussed in the following section.

There are several risk factors for premature labor and birth, including some that researchers have not yet identified. A few of them are discussed below:

• Age: Mothers younger than 18 years and older than 35 years are at a high risk of having preterm infants.
• History of Preterm Labor: Women with a history of delivering preterm or who have experienced preterm labor during previous pregnancies are considered at high risk for preterm labor and birth.
• Multiple Pregnancy: A multiple pregnancy, where a woman is carrying more than one baby, is associated with a higher risk of preterm labor and birth. Research shows that over 50% of twin births occur preterm, compared to only 10% of single infant deliveries.
• Short Interpregnancy Interval: An interpregnancy interval of less than 6 months increases the risk of preterm birth. The longer the interval between pregnancies, the lower the risk.
• Anomalies of the Reproductive Organs: Women with certain anomalies, such as a shorter or incompetent cervix, are at increased risk for preterm labor.
• Certain Medical Conditions: Medical conditions that may elevate the risk for preterm labor and delivery include:
  • Sexually Transmitted Diseases (STDs)
  • Urinary Tract Infections (UTIs)
  • Bacterial Vaginosis (infection of the vagina)
  • Hypertension (High Blood Pressure)
  • Being underweight or obese before pregnancy
  • Diabetes (high blood sugar)
  • Gestational diabetes (diabetes that occurs during pregnancy)
  • Blood clotting problems
  • Certain developmental anomalies in the fetus
  • Placenta previa (the placenta grows in the lowest part of the uterus and covers all or part of the opening to the cervix)
  • Polyhydramnios (excessive amniotic fluid surrounding the baby)
  • Premature rupture of the fetal membranes (PROM)
  • Intrahepatic cholestasis of pregnancy (ICP)
  • Placental abruption (the placenta starts to separate from the womb wall)
  • Antiphospholipid syndrome (APS)
• Smoking: Maternal exposure to smoke during pregnancy is a significant modifiable risk factor for premature birth, stillbirth, and miscarriage.
• Drinking Alcohol: Women who consume seven or more drinks per week have a significantly increased risk of very premature delivery compared to non-drinking women.
• Disruption of the Internal Clock: Disruption in the 24-hour circadian rhythm increases the risk of miscarriages, preterm birth, and low birth weights.
• Air Pollution: Research indicates a significant relationship between exposure to air pollution, particularly sulfur dioxide, and preterm birth.
• Stress: Stress may increase the risk of preterm birth by leading to high blood pressure during pregnancy, which further raises the risk of preeclampsia and premature birth.
• Lack of Social Support: Insufficient social support can exacerbate mental stress, anxiety, and depression, sometimes leading to premature labor.
• Domestic Violence: Women facing physical, sexual, or emotional abuse are at a doubled risk of preterm labor and low birth weight infants, with the risk increasing further for those experiencing multiple types of domestic violence during pregnancy.

The doctors monitor the signs and symptoms that indicate that labor may be taking place before the baby’s due date.

Physical Examination

The doctor will assess the signs and symptoms to determine if the woman is entering labor and decide whether to watch and wait or allow labor to progress naturally if she is 34 to 37 weeks pregnant.

A pelvic examination may be performed to evaluate:

• The firmness and tenderness of the uterus
• The baby's size and position
• Whether the cervix has begun to open
• Any uterine bleeding

Lab and Imaging Tests

Ultrasound: This test, also called a sonogram, uses high-frequency sound waves to check for any problems with the baby or placenta, confirm the baby's position, assess the level of amniotic fluid, and estimate the baby's weight.

Transvaginal ultrasound: This imaging scan is performed to measure cervical length and is essential in assessing the risk of preterm labor and delivery. It is considered the gold standard for women at high risk of preterm birth.

Monitor contractions: If a woman is experiencing contractions, the doctor uses an instrument called a tocodynamometer to monitor and record uterine contractions before and during labor.

Fetal Fibronectin Screening: Fetal fibronectin is a protein that helps the amniotic sac stay attached to the lining of the uterus. Its presence in vaginal discharge during the second and third trimesters signals a high risk of labor. The doctor may swab the cervix and test the secretions for fetal fibronectin protein.

Urine tests: If symptoms of labor are experienced before week 37 of pregnancy, the doctor may request a urine sample to check for bladder or urinary tract infections, which can lead to preterm contractions.

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A full-term pregnancy is 40 weeks. The baby's important organs develop towards the end of pregnancy, and a full-term baby faces fewer health issues at the time of birth.

While preterm labor cannot be prevented in all cases, its risk can be reduced by following these guidelines:

• Lead a healthy lifestyle.
• Eat a well-balanced, nutritious diet.
• Keep yourself hydrated.
• Take all prescribed supplements on time.
• Gain a healthy amount of weight.
• Try to stay active every day; walking is always a good idea.
• Avoid strenuous activities that put pressure on the abdomen and cause significant fatigue.
• Ensure adequate rest and allow your body to adjust during pregnancy.
• Manage stress levels by engaging in physical and spiritual activities.
• Maintain a healthy relationship with your partner.

Say goodbye to these vices:

• Do not drink alcohol while trying to conceive and during the entire pregnancy.
• Quit tobacco, smoking, e-cigarettes, and vaping.
• Avoid recreational drugs and non-prescribed medications.

Seek prenatal care:

• Seek prenatal care early in the pregnancy, particularly if you have risk factors for preterm birth, such as a history of premature birth or issues related to your uterus or cervix.
• Consult with your doctor immediately if you experience any signs of premature labor.
• If both the mother and baby are healthy, it is best to wait until at least 39 weeks and allow labor to begin on its own.

Know the signs of preterm labor before it becomes too late. Consult your pregnancy care physician immediately if you experience:

• Contractions, cramping, or tightening of the uterus.
• Abdominal cramps, with or without diarrhea.
• Pressure in the vagina or pelvic region.
• Lower backache.
• Increased vaginal discharge.

Prenatal Probiotics - A Breakthrough in Preventing Preterm Birth?

Abnormal vaginal microbes and bacterial vaginosis are significant risk factors for premature labor.

Various studies have shown that administering probiotics containing Lactobacillus rhamnosus GR1 and Lactobacillus reuteri RC14 in pregnant women restores normal vaginal flora and maintains optimum vaginal pH.

Probiotics containing these strains have the potential to reduce vaginal infections and, consequently, the incidence of preterm births.

They are beneficial and safe for use in pregnancy to prevent preterm birth if administered at or before 20 weeks of pregnancy.

Management is implemented based on the symptoms and the baby’s gestational age at which the mother presents to the hospital. The doctor might recommend the following medications and procedures to delay or manage early labor:

Medications

• Antibiotics: If a urine test during preterm labor reveals a bladder, kidney, or urinary tract infection (UTI), the doctor may prescribe antibiotics. Sometimes, managing the infection stops premature labor. Examples include:
  • Azithromycin
  • Erythromycin
  • Ceftriaxone
  • Clarithromycin
  • Metronidazole
• Tocolytic Agents: These drugs are designed to inhibit contractions of smooth muscles and thus inhibit premature labor. If a woman is showing signs of preterm labor and is less than 34 weeks pregnant, the doctor may administer a tocolytic medication to suppress labor and give the baby’s lungs more time to mature. They may be given intravenously. Examples include:
  • Atosiban
  • Magnesium sulfate
  • Indomethacin
  • Nifedipine
  • Ritodrine

  Note: Tocolytics should not be prescribed to women with certain health conditions, such as severe bleeding, which may be caused by placental abruption (placenta detaching from the wall of the uterus).

• Corticosteroids: If a woman is less than 34 weeks pregnant and experiencing symptoms of labor, corticosteroids are injected to help promote the baby's lung maturity. Examples include:
  • Betamethasone
  • Dexamethasone

  Note: These corticosteroids also benefit patients with PPROM (Preterm premature rupture of the membranes) and those with hypertensive syndromes. However, repeated courses of corticosteroids are not recommended.

• Progesterone Therapy: This therapy reduces the risk of spontaneous preterm labor in women who are at increased risk based on a history of previous spontaneous preterm labor. Progesterone supplementation is beneficial for women starting at 16 to 24 weeks gestation and continuing through 34 weeks gestation. Example: Hydroxyprogesterone caproate.

  Note: Progesterone is not beneficial in multiple gestation pregnancies.

Surgical Procedures

• Cervical Cerclage: This surgical procedure might be recommended for women with a short cervix (less than 25 mm) and a history of early premature birth. This procedure is performed around 12-14 weeks of pregnancy by closing the cervix with strong sutures that are removed at around 37 weeks.
• Cervical Pessary: This is a simple, less invasive procedure that involves closing the cervix with a silicone ring that is removed at around 37 weeks. This procedure does not require anesthesia and might replace the invasive cervical stitch operation.

A developing baby needs a full term in the uterus to develop. Growth happens throughout the pregnancy, including the final months and weeks. For example, the brain, lungs, and liver need the final weeks of pregnancy to develop completely. Hence, premature labor and birth can pose many complications discussed below:

Neonatal Complications

• Prematurely born babies tend to have heart, brain, lung, or liver issues.
• They are prone to breathing difficulties, pneumonia, infections, anemia, jaundice, bleeding in the brain, sepsis, and vision problems, among other complications.
• However, with improved obstetric and neonatal care facilities, the rate of complications in preterm births has reduced.

Infant Complications

• Infants can have breathing problems, feeding difficulties, impaired cognitive abilities, cerebral palsy, learning disabilities, developmental delays, and vision and hearing problems.
• Behavioral issues such as anxiety, depression, autism spectrum disorders, and ADHD (Attention Deficit Hyperactivity Disorder) are also associated with preterm labor.

Maternal Complications

• Studies have shown that preterm labor has been associated with an increased risk for cardiac complications, typically years after delivery.
• Women delivering preterm babies can experience significant emotional impacts, leading to anxiety, postpartum depression, and post-traumatic stress disorder.

Some alternative therapies have shown promising results in preventing preterm labor and delivery:

• Prenatal Yoga: Prenatal yoga focuses on positions specifically designed for pregnant women's bodies. These yoga postures should be performed under the guidance of a trained instructor. This practice can improve flexibility and enhance blood circulation, promoting the health of both the baby and mother, thereby reducing the chances of preterm labor.
• Massage Therapy: Massage therapy during pregnancy provides numerous benefits, including a sense of wellness, improved relaxation, and better sleep. This therapy helps reduce stress, anxiety, and emotional disturbances faced by pregnant women, thereby lowering the risk of preterm labor.
• Warm Baths: Warm baths help calm the body and relax the muscles. This practice is an excellent way to de-stress and promote relaxation.

If a woman is at risk of premature labor, she may feel scared or anxious about the pregnancy, especially if she has a history of preterm labor. In such cases, it is advisable to consult your doctor at each step to stay relaxed and calm.

If a woman is feeling anxious or depressed, it is important that she is accompanied by a loved one or caretaker while visiting the doctor. This provides moral support and a sense of protection.

It is essential to ask multiple questions from the doctor. Do not hesitate or feel fearful about inquiring anything regarding your condition.

Premature delivery of a baby also involves high medical expenditure. Therefore, it is important to plan finances accordingly.