Implementation: getting started

This section highlights 2 areas of the preterm labour and birth guideline that could have a big impact on practice and be challenging to implement, along with the reasons why we are proposing change in these areas (given in the box at the start of each area). We identified these with the help of stakeholders and Guideline Committee members (see section 9.4 of the manual). The section also gives information on resources to help with implementation.

The challenge: diagnosing preterm labour for women with intact membranes

See recommendations 1.7.4 and 1.7.5.

The evidence reviewed for the guideline indicated that transvaginal ultrasound measurement of cervical length is the best diagnostic test for determining the likelihood of birth within 48 hours for women who are 30+0 weeks pregnant or more with intact membranes who, after clinical assessment, are in suspected preterm labour. Many women thought to be in preterm labour on clinical assessment will not have a preterm birth. Optimal diagnosis in women with symptoms of preterm labour ensures that preterm labour can be correctly identified and the appropriate clinical management started.

If transvaginal ultrasound measurement of cervical length is not available or not acceptable, fetal fibronectin testing should be considered for ruling out preterm birth within 48 hours. This test is useful, although it is not as good a diagnostic tool as ultrasound measurement of cervical length. Fetal fibronectin testing is a simple test that can be carried out by healthcare professionals very quickly.

Increasing availability of transvaginal ultrasound

Using transvaginal ultrasound measurement of cervical length is not part of routine antenatal care, so implementation is likely to lead to an increase in the number of scans needed. Ensuring that women have access to this diagnostic test may be challenging because of a lack of available specialist equipment and/or expertise, and investment in technology and training may be needed. Staff training will be important to ensure that transvaginal ultrasound measurements of cervical length are performed using consistent and standard criteria.

NICE is working with the Royal College of Obstetricians and Gynaecologists (RCOG) to ensure that measuring cervical length using transvaginal ultrasound is included in the ultrasound module for obstetric trainees.

To increase availability, commissioners could:

  • Invest in additional ultrasound equipment, ensuring that images can be stored for audit.

  • Commission a service that is able to provide cervical length scans outside normal working hours. This may be provided by on‑call imaging services and/or by training healthcare professionals in obstetric units so that sufficient expertise is available at all times.

  • Use the NICE resource impact assessment to work out the cost implications.

Promoting the use of fetal fibronectin testing

When transvaginal ultrasound measurement of cervical length is not available, it is not currently routine practice to use fetal fibronectin testing as a diagnostic test for determining likelihood of birth within 48 hours for women who are 30+0 weeks pregnant or more and in suspected preterm labour.

What can obstetric units do to help?

  • Raise awareness of when fetal fibronectin testing should be used and that it is a simple test that can be carried out in 5 minutes by healthcare professionals.

The challenge: using tocolysis

See recommendations 1.8.1–1.8.5.

Giving an effective tocolytic medicine to women with intact membranes who are in suspected or diagnosed preterm labour can delay the birth. This in turn can improve neonatal outcomes.

Promoting the use of tocolysis

Clinical practice varies in terms of which women in preterm labour are offered a tocolytic medicine, when it should be given and the choice of tocolytic. The decision to offer tocolysis should take into account whether neonatal care is available on‑site or whether transfer to another hospital will be needed.

To overcome this, the lead clinician for each obstetric unit could:

  • Update local guidelines on managing preterm labour with regard to which women should be offered tocolytic medicines, and which tocolytics are first‑line treatment.

  • Use the NICE baseline assessment tool to determine current prescribing practice.

  • Use bulletins to raise awareness of these recommendations.

  • National Institute for Health and Care Excellence (NICE)