Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Information and support

1.1.1 When giving information and support to women at increased risk of preterm labour, or with suspected, diagnosed or established preterm labour, or having a planned preterm birth (and their family members or carers as appropriate):

  • ensure this is given as early as possible, taking into account the likelihood of preterm birth and the status of labour

  • follow the principles in NICE's guideline on patient experience in adult NHS services

  • bear in mind that the woman (and their family members or carers) may be particularly anxious

  • give both oral and written information

  • describe the symptoms and signs of preterm labour

  • explain about the care that may be offered. [2015]

1.1.2 For women who are having a planned preterm birth or are offered treatment for preterm labour in line with the sections on tocolysis, maternal corticosteroids and magnesium sulfate for neuroprotection (and their family members or carers as appropriate), provide information and support that includes:

  • information about the likelihood of the baby surviving and other outcomes (including long-term outcomes) and risks for the baby, giving values as natural frequencies (for example, 1 in 100)

  • explanation of the neonatal care of preterm babies, including location of care

  • explanation of the immediate problems that can arise when a baby is born preterm

  • explanation of the possible long-term consequences of prematurity for the baby (how premature babies grow and develop)

  • ongoing opportunities to talk about and state their wishes about resuscitation of the baby

  • an opportunity to tour the neonatal unit

  • an opportunity to speak to a neonatologist or paediatrician. [2015]

1.1.3 Be aware that, according to the 2021 Mothers and babies: reducing risk through audits and confidential enquiries across the UK (MBRRACE-UK) report on perinatal mortality, women from some minority ethnic backgrounds or who live in deprived areas have an increased risk of stillbirth and may need closer monitoring and additional support. The report showed that across all births (not just those which are preterm):

  • compared with white babies (32 out of 10,000), the stillbirth rate is:

    • more than twice as high in black babies (72 out of 10,000)

    • around 50% higher in Asian babies (51 out of 10,000)

  • compared with the least deprived areas (23 out of 10,000), the still birth rate is twice as high in the most deprived areas (47 out of 10,000). [2022]

Care of women at risk of preterm labour

1.2 Prophylactic vaginal progesterone and prophylactic cervical cerclage

1.2.1 Offer a choice of prophylactic vaginal progesterone or prophylactic cervical cerclage to women who have both:

  • a history of spontaneous preterm birth (up to 34+0 weeks of pregnancy) or loss (from 16+0 weeks of pregnancy onwards), and

  • results from a transvaginal ultrasound scan carried out between 16+0 and 24+0 weeks of pregnancy that show a cervical length of 25 mm or less.

    Discuss the risks and benefits of both options with the woman, and make a shared decision on which treatment is most suitable.

    In August 2019, this was an off-label use of vaginal progesterone. See NICE's information on prescribing medicines. [2019, amended 2022]

1.2.2 Consider prophylactic vaginal progesterone for women who have either:

  • a history of spontaneous preterm birth (up to 34+0 weeks of pregnancy) or loss (from 16+0 weeks of pregnancy onwards), or

  • results from a transvaginal ultrasound scan carried out between 16+0 and 24+0 weeks of pregnancy that show a cervical length of 25 mm or less.

    In August 2019, this was an off-label use of vaginal progesterone. See NICE's information on prescribing medicines. [2019, amended 2022]

1.2.3 When using vaginal progesterone, start treatment between 16+0 and 24+0 weeks of pregnancy and continue until at least 34 weeks. [2019]

1.2.4 Consider prophylactic cervical cerclage for women when results of a transvaginal ultrasound scan carried out between 16+0 and 24+0 weeks of pregnancy show a cervical length of 25 mm or less, who have had either:

1.2.5 If prophylactic cervical cerclage is used, ensure a plan is made and documented for removal of the suture. [2019, amended 2022]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on prophylactic vaginal progesterone.

Full details of the evidence and the committee's discussion are in evidence review A: clinical effectiveness of prophylactic progesterone in preventing preterm labour.

1.3 Diagnosing preterm prelabour rupture of membranes (P-PROM)

1.3.1 In a woman reporting symptoms suggestive of P‑PROM, offer a speculum examination to look for pooling of amniotic fluid and:

1.3.2 If the results of the insulin-like growth factor binding protein‑1 or placental alpha-microglobulin‑1 test are positive, do not use the test results alone to decide what care to offer the woman, but also take into account her clinical condition, medical and pregnancy history and gestational age, and either:

1.3.3 If the results of the insulin-like growth factor binding protein‑1 or placental alpha-microglobulin‑1 test are negative and no amniotic fluid is observed:

  • do not offer antenatal prophylactic antibiotics

  • explain to the woman that it is unlikely she has P‑PROM, but that she should return for reassessment if there are any further symptoms suggestive of P‑PROM or preterm labour. [2015, amended 2022]

1.3.4 Do not use nitrazine to diagnose P‑PROM. [2015]

1.3.5 Do not perform diagnostic tests for P‑PROM if labour becomes established in a woman reporting symptoms suggestive of P‑PROM. [2015]

1.4 Antenatal prophylactic antibiotics for women with P-PROM

1.4.1 As prophylaxis for intrauterine infection, offer women with P-PROM oral erythromycin 250 mg 4 times a day for a maximum of 10 days or until the woman is in established labour (whichever is sooner). [2015, amended 2022]

1.4.2 For women with P‑PROM who cannot tolerate erythromycin or in whom erythromycin is contraindicated, consider an oral penicillin for a maximum of 10 days or until the woman is in established labour (whichever is sooner). [2015, amended 2019]

1.4.3 Do not offer women with P‑PROM co‑amoxiclav as prophylaxis for intrauterine infection. [2015]

1.5 Identifying infection in women with P-PROM

1.5.1 Use a combination of clinical assessment and tests (C‑reactive protein, white blood cell count and measurement of fetal heart rate using cardiotocography) to diagnose intrauterine infection in women with P‑PROM. [2015]

1.5.2 Do not use any one of the following in isolation to confirm or exclude intrauterine infection in women with P‑PROM:

  • a single test of C‑reactive protein

  • white blood cell count

  • measurement of fetal heart rate using cardiotocography. [2015]

1.5.3 If the results of the clinical assessment or any of the tests are not consistent with each other, continue to observe the woman and consider repeating the tests. [2015]

1.6 Emergency cervical cerclage

1.6.1 Do not offer emergency cervical cerclage to women with:

  • signs of infection, or

  • active vaginal bleeding, or

  • uterine contractions. [2015, amended 2022]

1.6.2 Consider emergency cervical cerclage for women between 16+0 and 27+6 weeks of pregnancy with a dilated cervix and exposed, unruptured fetal membranes. Also:

  • take into account gestational age (being aware that the benefits are likely to be greater for earlier gestations) and the extent of cervical dilatation

  • discuss with a consultant obstetrician and consultant paediatrician. [2015, amended 2022]

1.6.3 If emergency cervical cerclage is being considered, explain to the woman (and their family members or carers, as appropriate):

  • about the risks of the procedure

  • that it aims to delay the birth, and so increase the likelihood of the baby surviving and of reducing serious neonatal morbidity [2015, amended 2022]

1.6.4 If emergency cervical cerclage is used, ensure that a plan is made and documented for removal of the suture. [2019, amended 2022]

For a short explanation of why the committee made the 2019 recommendation and how it might affect practice, see the rationale and impact section on emergency cervical cerclage.

Care of women with suspected or established preterm labour

1.7 Diagnosing preterm labour for women with intact membranes

1.7.1 Explain to women reporting symptoms of preterm labour who have intact membranes (and their family members or carers, as appropriate):

  • about the clinical assessment and diagnostic tests that are available

  • how the clinical assessment and diagnostic tests are carried out

  • what the benefits, risks and possible consequences of the clinical assessment and diagnostic tests are, including the consequences of false-positive and false-negative test results and taking into account gestational age. [2015]

1.7.2 Offer a clinical assessment to women reporting symptoms of preterm labour who have intact membranes. This should include:

1.7.3 If the clinical assessment suggests that the woman is in suspected preterm labour and she is 29+6 weeks pregnant or less, advise treatment for preterm labour as described in the sections on tocolysis and maternal corticosteroids. [2015]

1.7.4 If the clinical assessment suggests that the woman is in suspected preterm labour and she is 30+0 weeks pregnant or more, consider transvaginal ultrasound measurement of cervical length as a diagnostic test to determine likelihood of birth within 48 hours. Act on the results as follows:

  • if cervical length is more than 15 mm, explain to the woman that it is unlikely to be preterm labour and:

    • think about alternative diagnoses

    • discuss with her the benefits and risks of going home compared with continued monitoring and treatment in hospital

    • advise her that if she does decide to go home, she should return if symptoms suggestive of preterm labour persist or recur

  • if cervical length is 15 mm or less, view the woman as being in diagnosed preterm labour and offer treatment as described in the sections on tocolysis and maternal corticosteroids. [2015]

1.7.5 Consider fetal fibronectin testing as a diagnostic test to determine likelihood of birth within 48 hours for women who are 30+0 weeks pregnant or more if transvaginal ultrasound measurement of cervical length is indicated, but is not available or not acceptable. Act on the results as follows:

  • if fetal fibronectin testing is negative (concentration 50 ng/ml or less), explain to the woman that it is unlikely she is in preterm labour and:

    • think about alternative diagnoses

    • discuss with her the benefits and risks of going home compared with continued monitoring and treatment in hospital

    • advise her that if she decides to go home, she should return if symptoms suggestive of preterm labour persist or recur

  • if fetal fibronectin testing is positive (concentration more than 50 ng/ml), view the woman as being in diagnosed preterm labour and offer treatment as described in the sections on tocolysis and maternal corticosteroids. [2015]

1.7.6 If a woman in suspected preterm labour who is 30+0 weeks pregnant or more does not have transvaginal ultrasound measurement of cervical length or fetal fibronectin testing to exclude preterm labour, offer treatment consistent with her being in diagnosed preterm labour (see the sections on tocolysis and maternal corticosteroids). [2015]

1.7.7 Do not use transvaginal ultrasound measurement of cervical length and fetal fibronectin testing in combination to diagnose preterm labour. [2015]

1.7.8 Ultrasound scans should be performed by healthcare professionals with training in, and experience of, transvaginal ultrasound measurement of cervical length. [2015]

1.7.9 For guidance on the use of other biomarker tests used for the diagnosis of preterm labour, see NICE's diagnostics guidance on biomarker tests to help diagnose preterm labour in women with intact membranes. [2019]

1.8 Tocolysis

1.8.1 Take the following factors into account when making a decision about whether to start tocolysis:

  • whether the woman is in suspected or diagnosed preterm labour

  • other clinical features (for example, bleeding or infection) that may suggest that stopping labour is contraindicated

  • gestational age at presentation

  • likely benefit of maternal corticosteroids (see the section on maternal corticosteroids)

  • availability of an appropriate level of neonatal care (if there is need for transfer to another unit). See also NHS England's guidance on saving babies' lives care bundle version 2 (recommendation 5.9).

  • the preference of the woman. [2015, amended 2022]

1.8.2 Consider nifedipine for tocolysis for women between 24+0 and 25+6 weeks of pregnancy who have intact membranes and are in suspected preterm labour.

In November 2015, this was an off-label use of nifedipine. See NICE's information on prescribing medicines. [2015]

1.8.3 Offer nifedipine for tocolysis to women between 26+0 and 33+6 weeks of pregnancy who have intact membranes and are in suspected or diagnosed preterm labour.

In November 2015, this was an off-label use of nifedipine. See NICE's information on prescribing medicines. [2015]

1.8.4 If nifedipine is contraindicated, offer oxytocin receptor antagonists for tocolysis. [2015]

1.8.5 Do not offer betamimetics for tocolysis. [2015]

1.9 Maternal corticosteroids

In June 2022 this was an off-label use of betamethasone and dexamethasone. See NICE's information on prescribing medicines.

1.9.1 For women between 22+0 and 23+6 weeks of pregnancy who are in suspected or established preterm labour, are having a planned preterm birth or have P‑PROM (see the section on diagnosing P-PROM), discuss with the woman (and her family members or carers, as appropriate) and the multidisciplinary team the use of maternal corticosteroids in the context of her individual circumstances. [2015, amended 2022]

1.9.2 Offer maternal corticosteroids to women between 24+0 and 33+6 weeks of pregnancy who are in suspected, diagnosed or established preterm labour, are having a planned preterm birth or have P‑PROM. [2015, amended 2019]

1.9.3 Consider maternal corticosteroids for women between 34+0 and 35+6 weeks of pregnancy who are in suspected, diagnosed or established preterm labour, are having a planned preterm birth or have P‑PROM. [2015]

1.9.4 Consider a single repeat course of maternal corticosteroids for women less than 34+0 weeks of pregnancy who:

  • have already had a course of corticosteroids when this was more than 7 days ago, and

  • are at very high risk of giving birth in the next 48 hours.

    Where the woman is less than 30+0 weeks pregnant or if there is suspected growth restriction, take into account the possible impact on fetal growth of a repeat course of maternal corticosteroids. [2022]

1.9.5 Do not give more than 2 courses of maternal corticosteroids for preterm birth. [2022]

1.9.6 When offering or considering maternal corticosteroids, discuss the benefits and risks with the woman (and her family members or carers, as appropriate). [2015, amended 2022]

1.9.7 For guidance on the use of corticosteroids in people with diabetes, see NICE's guideline on diabetes in pregnancy. [2019]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on repeat courses of maternal corticosteroids.

Full details of the evidence and the committee's discussion are in evidence review B: effectiveness of repeat courses of maternal corticosteroids for fetal lung maturation.

1.10 Magnesium sulfate for neuroprotection

In August 2019, the use of intravenous magnesium sulfate in recommendations 1.10.1 to 1.10.3 was off label. See NICE's information on prescribing medicines.

This guideline does not recommend using magnesium sulfate beyond 24 hours. But if uncertainty around exact timing of delivery results in repeat administration, follow the MHRA safety advice on the prolonged or repeated use of magnesium sulfate in pregnancy.

1.10.1 For women between 23+0 and 23+6 weeks of pregnancy who are in established preterm labour or having a planned preterm birth within 24 hours, discuss with the woman (and her family members or carers, as appropriate) the use of intravenous magnesium sulfate for neuroprotection of the baby, in the context of her individual circumstances. [2019]

1.10.2 Offer intravenous magnesium sulfate for neuroprotection of the baby to women between 24+0 and 29+6 weeks of pregnancy who are:

  • in established preterm labour, or

  • having a planned preterm birth within 24 hours. [2015]

1.10.3 Consider intravenous magnesium sulfate for neuroprotection of the baby for women between 30+0 and 33+6 weeks of pregnancy who are:

  • in established preterm labour, or

  • having a planned preterm birth within 24 hours. [2015]

1.10.4 Give a 4 g intravenous bolus of magnesium sulfate over 15 minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours (whichever is sooner). [2015]

1.10.5 For women on magnesium sulfate, monitor for clinical signs of magnesium toxicity at least every 4 hours by recording pulse, blood pressure, respiratory rate and deep tendon (for example, patellar) reflexes. [2015]

1.10.6 If a woman has or develops oliguria or other evidence of renal failure:

  • monitor more frequently for magnesium toxicity

  • reduce or stop the dose of magnesium sulfate. [2015, amended 2022]

1.12 Fetal monitoring

Monitoring options: cardiotocography and intermittent auscultation

1.12.1 Discuss with women in suspected, diagnosed or established preterm labour (and their family members or carers, as appropriate):

  • the purpose of fetal monitoring and what it involves

  • the clinical decisions it informs at different gestational ages

  • if appropriate, the option not to monitor the fetal heart rate (for example, at the threshold of viability). [2015]

1.12.2 Involve a senior obstetrician in discussions about whether and how to monitor the fetal heart rate for women who are between 23+0 and 25+6 weeks pregnant. [2015]

1.12.3 Explain the different fetal monitoring options to the woman (and her family members or carers, as appropriate), being aware that:

  • there is limited evidence about the usefulness of specific features to suggest hypoxia or acidosis in preterm babies

  • the available evidence is broadly consistent with that for babies born at term (see the section on monitoring during labour in NICE's guideline on intrapartum care)

  • a normal cardiotocography trace is reassuring and indicates that the baby is coping well with labour, but an abnormal trace does not necessarily indicate that fetal hypoxia or acidosis is present. [2015]

1.12.4 Explain that there is an absence of evidence that using cardiotocography improves the outcomes of preterm labour for the parent or the baby compared with intermittent auscultation. Include family members or carers in the discussion, as appropriate. [2015]

1.12.5 In established preterm labour with no other risk factors (see the section on monitoring during labour in NICE's guideline on intrapartum care), offer a choice of fetal heart rate monitoring using either:

  • cardiotocography using external ultrasound or

  • intermittent auscultation. [2015]

1.12.6 For guidance on using intermittent auscultation for fetal heart rate monitoring, see the section on monitoring during labour in NICE's guideline on intrapartum care. [2015]

Fetal scalp electrode

1.12.7 Do not use a fetal scalp electrode for fetal heart rate monitoring if the woman is less than 34+0 weeks pregnant unless all of the following apply:

  • it is not possible to monitor the fetal heart rate using either external cardiotocography or intermittent auscultation

  • it has been discussed with a senior obstetrician

  • the benefits are likely to outweigh the potential risks

  • the alternatives (immediate birth, intermittent ultrasound and no monitoring) have been discussed with the woman and are unacceptable to her. [2015]

1.12.8 Discuss with the woman (and her family members or carers, as appropriate) the possible use of a fetal scalp electrode between 34+0 and 36+6 weeks of pregnancy if it is not possible to monitor the fetal heart rate using either external cardiotocography or intermittent auscultation. [2015]

Fetal blood sampling

1.12.9 Do not carry out fetal blood sampling if the woman is less than 34+0 weeks pregnant. [2015]

1.12.10 Discuss with the woman the possible use of fetal blood sampling between 34+0 and 36+6 weeks of pregnancy if the benefits are likely to outweigh the potential risks. [2015]

1.12.11 When offering fetal blood sampling, advise the woman that if a blood sample cannot be obtained a caesarean section is likely. Also see the advice on fetal blood sampling in the NICE guidelines on intrapartum care for women with existing medical conditions or obstetric complications and their babies and intrapartum care for healthy women and babies. [2015, amended 2020]

1.13 Mode of birth

1.13.1 Discuss the general benefits and risks of caesarean birth and vaginal birth with women in suspected, diagnosed or established preterm labour and in P‑PROM (and their family members or carers, as appropriate). See the section on planning mode of birth in NICE's guideline caesarean birth. [2015]

1.13.2 Explain to women in suspected, diagnosed or established preterm labour and women with P‑PROM about the benefits and risks of caesarean birth that are specific to gestational age. In particular, highlight the difficulties associated with performing a caesarean birth for a preterm birth, especially the increased likelihood of a vertical uterine (classical) incision and the implications of this for future pregnancies. [2015, amended 2022]

1.13.3 Explain to women in suspected, diagnosed or established preterm labour that there are no known benefits or harms for the baby from caesarean birth, but the evidence is very limited. [2015]

1.13.4 Consider caesarean birth for women presenting in suspected, diagnosed or established preterm labour between 26+0 and 36+6 weeks of pregnancy with breech presentation. [2015]

1.14 Timing of cord clamping for preterm babies (born vaginally or by caesarean birth)

1.14.1 Wait at least 60 seconds before clamping the cord of preterm babies unless there are specific maternal or fetal conditions that need earlier clamping. [2015, amended 2022]

1.14.2 Position the baby at or below the level of the placenta before clamping the cord. [2015]

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline. For other definitions see the NICE glossary and the Think Local, Act Personal Care and Support Jargon Buster.

Cervical trauma

Physical injury to the cervix including surgery; for example, previous cone biopsy (cold knife or laser), large loop excision of the transformation zone (LLETZ; any number) or radical diathermy.

Diagnosed preterm labour

A woman is in diagnosed preterm labour if she is in suspected preterm labour and has had a positive diagnostic test for preterm labour.

Emergency cervical cerclage (previously known as 'rescue')

Cervical cerclage performed as an emergency procedure for premature cervical dilatation, often with exposed fetal membranes.

Established preterm labour

A woman is in established preterm labour if she has progressive cervical dilatation from 4 cm with regular contractions (see the definition of the established first stage of labour in NICE's guideline on intrapartum care).

MBRRACE-UK

Mothers and babies: reducing risk through audits and confidential enquiries across the UK (MBRRACE-UK) is a series of audits carried out with the aim of identifying causes of maternal and perinatal death and morbidity and making recommendations to inform maternity care and so reduce these poor outcomes.

Preterm prelabour rupture of membranes (P‑PROM)

A woman is described as having P‑PROM if she has ruptured membranes before 37+0 weeks of pregnancy but is not in established labour.

Suspected preterm labour

A woman is in suspected preterm labour if she has reported symptoms of preterm labour and has had a clinical assessment (including a speculum or digital vaginal examination) that confirms the possibility of preterm labour, but rules out established labour.

Symptoms of preterm labour

A woman has presented before 37+0 weeks of pregnancy reporting symptoms that might be indicative of preterm labour (such as abdominal pain), but no clinical assessment (including speculum or digital vaginal examination) has taken place.

  • National Institute for Health and Care Excellence (NICE)