Preterm laborMANAGEMENT

OBSTETRIC PRESENTATIONS · 12 SECTIONS

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508 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Eclampsia Ectopic Pregnancy (Ruptured)Ectopic Pregnancy (Unruptured)HELLP Syndrome Hyperemesis gravidarum Placenta previa Placental abruption Postpartum Endometritis Postpartum hemorrhage Postpartum infection Preeclampsia Preeclampsia:eclampsia Preterm labor Spontaneous Abortion (Incomplete)Spontaneous Abortion (Missed)Spontaneous Abortion (Threatened)Threatened:inevitable:incomplete abortion

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp53

Immediate priorities

›Maternal fetal stabilization

›Airway breathing circulation stability

›If hypotension, isotonic crystalloid bolus then reassessment

›If shock, massive hemorrhage pathway consideration

›Maternal vital signs

›If fever, sepsis evaluation and antibiotics pathway

›If severe hypertension, preeclampsia pathway

›Fetal status

›Continuous fetal heart rate monitoring if viable gestational age

›If nonreassuring tracing, immediate obstetrics notification

›Gestational age confirmation

›If less than viability threshold per local policy, individualized goals of care

›If 24 to 36 weeks 6 days, preterm labor pathway

Key decisions

›Delivery versus delay decision points

›Contraindications to delaying delivery

›Intraamniotic infection suspicion

›Placental abruption suspicion

›Nonreassuring fetal status persistent

›Severe preeclampsia or eclampsia

›Significant maternal hemorrhage

›Benefit of delay

›Antenatal corticosteroid window completion

›Maternal transfer to higher level neonatal care

›Magnesium sulfate neuroprotection completion

Monitoring and access

›Monitoring setup

›Two large bore IV access if moderate to high risk

›If ongoing bleeding, type and crossmatch

›Urine output tracking

›If magnesium infusion, hourly urine output target

›Continuous pulse oximetry if respiratory risk

Initial therapeutics bundle

›Time sensitive therapies

›If gestational age 24 to 33 weeks 6 days and likely delivery within 7 days, antenatal corticosteroids

›Betamethasone IM regimen

›Dexamethasone IM regimen

›If gestational age less than 32 weeks and likely delivery within 24 hours, magnesium sulfate neuroprotection

›Loading dose then maintenance dose protocol

›If tocolysis candidate and gestational age less than 34 weeks, short course tocolysis

›Nifedipine protocol

›Indomethacin protocol if early gestational age

›If group B streptococcus status unknown and preterm labor with risk of delivery, intrapartum prophylaxis plan

›Penicillin regimen

›Allergy alternatives

PITFALLS

›Common misses

›Cervical exam before placenta location confirmation in bleeding patient

›Ultrasound placenta assessment first if bleeding and unknown placenta location

›Preterm labor mimic

›Urinary tract infection

›Dehydration

›Abruption

›Appendicitis

›Under recognition of infection

›Maternal fever absent in early intraamniotic infection

›Uterine tenderness and fetal tachycardia as early clues

02History/hx58

Focused obstetric history

›Pregnancy timeline and dating

›Gestational age by earliest reliable ultrasound

›Estimated due date source

›Prior preterm birth history

›Spontaneous preterm birth gestational age

›Indicated preterm birth reason

›Cervical procedures history

›LEEP

›Cone biopsy

›Presenting symptoms

›Contractions pattern

›Frequency

›Duration

›Intensity progression

›Vaginal fluid loss

›Gush versus intermittent leakage

›Color and odor

›Vaginal bleeding

›Quantity

›Clots

›Pelvic pressure

›Rectal pressure

›Low back pain

›Fetal movement change

›Decreased movement

›Infection risk

›Fever or chills

›Recent illness

›Dysuria or urinary frequency

›Flank pain

›Vaginal discharge change

›Pruritus

›Odor

›Recent sexually transmitted infection exposure

›Untreated infection history

›Maternal comorbidities

›Hypertensive disorders symptoms

›Headache

›Visual changes

›Right upper quadrant pain

›Diabetes status

›Insulin use

›Thromboembolism risk

›Anticoagulant use

›Medication and substance history

›Current medications

›Progesterone use

›Tocolytic use prior

›Substance use

›Nicotine

›Stimulants

›Obstetric complications this pregnancy

›Placenta previa known

›Prior ultrasound findings

›Fetal growth restriction

›Prior estimated fetal weight percentile

›Multiple gestation

›Chorionicity if known

03Physical Exam/exam52

Maternal assessment

›Maternal status

›Temperature

›Fever threshold per local policy

›Blood pressure

›Severe range threshold identification

›Heart rate

›Maternal tachycardia as infection marker

›Respiratory status

›Pulmonary edema signs if tocolytics planned

›Abdominal exam

›Uterine tenderness

›Intraamniotic infection clue

›Fundal tone

›Abruption clue

›Contraction palpation

›Frequency estimate

›Pelvic exam strategy

›Sterile speculum exam first if rupture of membranes concern

›Pooling

›Cervical dilation visualization

›Bleeding source evaluation

›Digital cervical exam timing

›If placenta previa suspected or unknown and bleeding, ultrasound placenta location before digital exam

›If rupture of membranes suspected, minimize repeated digital exams

Cervical assessment

›Cervical findings

›Dilation

›Change over time interval

›Effacement

›Progressive change

›Station

›Fetal presenting part

›Cervical consistency and position

›Favorability trend

Fetal assessment

›Fetal monitoring

›Baseline fetal heart rate

›Fetal tachycardia as infection marker

›Variability

›Reduced variability risk pattern

›Accelerations

›Reassuring sign

›Decelerations

›Recurrent late decelerations trigger escalation

›Leopold maneuvers

›Presentation

›Breech suspicion

›Estimated fetal size

›Large for gestational age suspicion

PITFALLS

›Exam hazards

›Digital exam with unknown placenta location and bleeding

›Hemorrhage risk

›Missed cord prolapse risk

›If rupture of membranes and high presenting part, immediate assessment

04Differential Diagnosis/ddx40

Obstetric causes

›Preterm labor with cervical change

›ICD-10 O60.0

›SNOMED CT preterm labor

›Preterm premature rupture of membranes

›Fluid leakage with positive rupture testing

›Placental abruption

›Painful bleeding

›Uterine tenderness

›Placenta previa

›Painless bleeding

›Known low lying placenta

›Cervical insufficiency

›Painless dilation

›Membranes bulging

›Intraamniotic infection

›Maternal fever

›Uterine tenderness

›Fetal tachycardia

›Uterine overdistension

›Multiple gestation

›Polyhydramnios

Non obstetric mimics

›Urinary tract infection

›Cystitis

›Pyelonephritis

›Gastrointestinal causes

›Appendicitis

›Gastroenteritis

›Musculoskeletal pain

›Round ligament pain

›Back strain

›Nephrolithiasis

›Flank pain

›Hematuria

›Ovarian torsion

›Acute unilateral pelvic pain

Cervicitis and vaginitis

›Sexually transmitted infection

›Chlamydia

›Gonorrhea

›Bacterial vaginosis

›Discharge odor change

05Laboratory Tests/lt36

Core maternal labs

›Maternal baseline evaluation

›Complete blood count for infection or bleeding concern

›Leukocytosis interpretation limited in pregnancy

›Hemoglobin trend for hemorrhage

›Blood type and antibody screen

›If Rh negative and bleeding, anti D prophylaxis plan

›Urinalysis with culture for urinary infection

›Ketones as dehydration marker

›Comprehensive metabolic panel for preeclampsia differential

›Creatinine baseline

›Liver enzymes

Infection testing

›Genital infection workup

›Group B streptococcus culture if unknown status

›If imminent delivery, treat empirically per protocol

›Gonorrhea and chlamydia NAAT if risk

›Treatment impacts preterm risk

›Vaginal wet mount if discharge

›Bacterial vaginosis markers

Preterm labor risk stratification tests

›Adjunct tests for symptomatic patients

›Fetal fibronectin if gestational age appropriate and membranes intact

›If negative, low short term delivery risk

›If positive, limited specificity

›Amniotic fluid rupture testing if fluid leakage

›If positive, manage as rupture pathway

Hemorrhage labs

›If bleeding moderate to severe

›Coagulation studies

›Fibrinogen low as abruption severity marker

›Type and crossmatch units

›Transfusion readiness

Preeclampsia labs

›If hypertensive symptoms or severe range blood pressure

›Platelet count

›Thrombocytopenia threshold

›Urine protein testing per protocol

›Protein creatinine ratio approach

›Lactate dehydrogenase

›Hemolysis marker

06Diagnostic Tests/dt37

Scoring Systems

›Clinical classification tools

›Preterm labor definition

›Regular contractions plus cervical change

›Cervical dilation threshold context

›Cervical dilation progression

›Change over 2 hours as higher risk marker

›Fetal fibronectin plus cervical length combined risk

›Cervical length greater than 30 mm with negative fibronectin as low near term delivery risk

›Cervical length short with positive fibronectin as higher near term delivery risk

MRI

›Limited role in acute preterm labor

›Maternal abdominal pathology evaluation if ultrasound nondiagnostic

›Appendicitis in pregnancy consideration

›Contraindications and access limitations

›Unstable patient not suitable

›Rare use in pregnancy for preterm labor evaluation

›Maternal life threatening diagnosis evaluation

›Pulmonary embolism workup pathway

›Abdominal catastrophe pathway

›Radiation counseling and shielding per protocol

›Benefit risk documentation

Ultrasound

›Obstetric ultrasound applications

›Transvaginal cervical length

›Short cervix threshold supports preterm risk

›Dynamic funneling note

›Placenta location

›Previa exclusion before digital exam in bleeding patient

›Fetal presentation

›Breech identification impacts delivery planning

›Amniotic fluid assessment

›Oligohydramnios suggests rupture

›Estimated fetal weight

›Growth restriction affects delivery threshold decisions

›POCUS adjuncts

›Maternal volume status

›IVC assessment limitations in pregnancy

›Lung ultrasound if pulmonary edema concern

›B lines as fluid overload marker

07Disposition/dispo28

Level of care decisions

›Admission versus discharge framework

›Admission indicators

›Cervical change over observation interval

›Cervical dilation at or above local threshold

›Rupture of membranes confirmed

›Vaginal bleeding concerning for abruption

›Nonreassuring fetal monitoring

›Suspected infection

›Transfer indicators

›Gestational age within neonatal intensive care benefit range and higher level nursery needed

›Anticipated delivery within 24 hours at non tertiary site

›Maternal complication requiring higher acuity care

›Discharge indicators

›No cervical change after observation

›Reassuring fetal monitoring

›No rupture of membranes evidence

›No significant bleeding

›Pain controlled with supportive care

Observation pathway

›Short interval reassessment

›Repeat cervical exam timing per protocol

›Avoid frequent exams if rupture suspected

›Contraction response to hydration and rest

›Persistent regular contractions as higher risk

Follow up planning

›Outpatient follow up

›Obstetrics follow up within 24 to 72 hours if discharged

›Cervical length surveillance plan if short cervix

›Return precautions reinforced

›Contraction frequency threshold

08Treatment/t111

Supportive measures

›Maternal comfort and triggers

›Oral hydration if tolerated

›Dehydration correction

›IV fluids if unable to hydrate orally

›Avoid fluid overload if tocolytics planned

›Analgesia options

›Acetaminophen dosing per pregnancy safe regimen

›Avoid routine bed rest

›Thromboembolism risk

Antenatal corticosteroids

›Fetal lung maturation therapy

›Indications

›Gestational age 24 to 33 weeks 6 days with likely delivery within 7 days

›Consider 34 to 36 weeks 6 days with high likelihood of delivery within 7 days per local protocol

›Betamethasone IM

›12 mg IM once

›Second dose 12 mg IM at 24 hours

›Total 2 doses

›Dexamethasone IM

›6 mg IM once

›Repeat 6 mg IM every 12 hours

›Total 4 doses

›Evidence

›Reduction in neonatal respiratory distress syndrome

›Reduction in intraventricular hemorrhage

Magnesium sulfate neuroprotection

›Neuroprotection protocol

›Indications

›Gestational age less than 32 weeks with likely delivery within 24 hours

›Dosing

›Initiate magnesium sulfate IV 4 g loading dose over 20 to 30 minutes

›Continue 1 g per hour maintenance infusion

›Stop after 24 hours if undelivered

›Stop at delivery

›Monitoring

›Deep tendon reflexes

›If absent reflexes, stop infusion and check magnesium level

›Respiratory rate

›If respiratory depression, stop infusion and give calcium gluconate

›Urine output

›If oliguria, dose adjustment or stop infusion

›Antidote

›Calcium gluconate IV 10 percent 10 mL over 10 minutes for toxicity

Tocolysis

›Short term uterine relaxation

›Goals

›Delay delivery 48 hours for corticosteroid completion

›Facilitate maternal transfer

›Candidate criteria

›Gestational age less than 34 weeks

›Intact membranes or individualized decision with rupture

›No maternal fetal contraindications

›Contraindications

›Intraamniotic infection suspicion

›Significant hemorrhage or abruption suspicion

›Nonreassuring fetal status requiring delivery

›Severe preeclampsia or eclampsia

›Maternal hemodynamic instability

›Lethal fetal anomaly or fetal demise

›Nifedipine PO

›Initiate 20 mg PO loading dose

›If contractions persist after 30 minutes, additional 10 mg PO

›Maintenance 10 mg to 20 mg PO every 4 to 6 hours

›Maximum 180 mg per day

›Adverse effects

›Hypotension risk

›Headache

›Cautions

›Concomitant magnesium increases hypotension risk

›Indomethacin PR or PO

›Initiate 50 mg PR loading dose

›Alternative 50 mg PO loading dose

›Maintenance 25 mg PO every 6 hours

›Typical duration limit 48 hours

›Gestational age limits

›Prefer less than 32 weeks due to ductus arteriosus risk later gestation

›Adverse effects

›Oligohydramnios risk

›Ductus arteriosus constriction risk

›Terbutaline SC

›Initiate 0.25 mg SC once

›Repeat dosing per protocol if needed with monitoring

›Adverse effects

›Tachycardia

›Hyperglycemia

›Arrhythmia risk

Group B streptococcus prophylaxis

›Intrapartum antibiotic plan

›Indications

›Unknown GBS status with preterm labor and delivery risk

›Known GBS positive

›Penicillin G IV

›Initiate 5 million units IV loading dose

›Continue 2.5 to 3 million units IV every 4 hours until delivery

›Ampicillin IV alternative

›Initiate 2 g IV loading dose

›Continue 1 g IV every 4 hours until delivery

›Severe penicillin allergy alternatives

›Clindamycin IV if susceptibility documented

›900 mg IV every 8 hours until delivery

›Vancomycin IV if clindamycin not suitable

›20 mg per kg IV every 8 hours

Infection treatment

›If intraamniotic infection suspected

›Broad spectrum antibiotics per protocol

›Ampicillin plus gentamicin regimen option

›Add anaerobic coverage if cesarean anticipated

›Delivery planning

›Tocolysis avoidance

Rh immunoprophylaxis

›If Rh negative and bleeding or procedures

›Anti D dosing per gestational age and local policy

›Kleihauer Betke or flow cytometry for large fetomaternal hemorrhage concern

Evidence level notes

›Guideline aligned therapies

›Antenatal corticosteroids as Class I recommendation in threatened preterm birth within window

›Magnesium sulfate neuroprotection as Class I recommendation for early preterm imminent delivery

›Tocolysis as Class IIa recommendation for short term delay in appropriate candidates

09Special Populations/sp25

Pregnancy

›Pregnancy specific considerations

›Gestational age thresholds drive therapy selection

›Viability threshold per local neonatal capability

›Less than 34 weeks as typical tocolysis window

›Less than 32 weeks as magnesium neuroprotection window

›Multiple gestation considerations

›Higher baseline preterm risk

›Cervical length interpretation differences

›Placenta previa considerations

›Avoid digital exam until placenta location confirmed

›Prior cesarean considerations

›Trial of labor eligibility impacts disposition

Geriatric

›Advanced maternal age considerations

›Higher risk comorbidities

›Hypertension screening emphasis

›Diabetes screening emphasis

›Medication adverse effect sensitivity

›Tocolytic hypotension monitoring

Pediatrics

›Adolescent pregnancy considerations

›Higher risk of delayed prenatal care

›Dating uncertainty frequency

›Safeguarding and support needs

›Social work involvement triggers

›Consent and confidentiality per jurisdiction

›Care pathway alignment

10Background/b29

Epidemiology

›Population burden

›Preterm birth as leading cause of neonatal morbidity and mortality

›Earlier gestational age correlates with higher morbidity

›Spontaneous preterm labor proportion of preterm births

›Common pathway including infection and inflammation

›Recurrence risk

›Prior spontaneous preterm birth increases future risk

Pathophysiology

›Mechanisms

›Uterine activation pathways

›Inflammatory cytokines

›Decidual hemorrhage

›Cervical remodeling

›Collagen breakdown and shortening

›Funneling and dilation progression

›Membrane and decidual factors

›Microbial invasion

›Sterile inflammation

Therapeutic Considerations

›Why therapies matter

›Corticosteroids

›Surfactant production acceleration

›Reduced intraventricular hemorrhage risk

›Magnesium sulfate

›Reduced cerebral palsy risk in early preterm infants

›Tocolysis

›Short term delay benefits

›No proven long term pregnancy prolongation

›Antibiotics

›Indicated for infection or GBS prophylaxis

›Not routine for intact membranes without infection

11Patient Discharge Instructions/pdi22

copy discharge instructions

›Preterm labor precautions

›Return now for contractions

›Regular contractions every 10 minutes or more often for 1 hour

›Contractions getting stronger or closer together

›Return now for fluid leakage

›Gush or continuous leaking from vagina

›Wet underwear repeatedly

›Return now for bleeding

›More than light spotting

›Clots

›Return now for decreased fetal movement

›Marked decrease from usual pattern

›Return now for fever or illness

›Fever or chills

›Severe abdominal pain

›Activity guidance

›Hydration goal with water intake

›Avoid substance triggers

›Sexual activity guidance per obstetrics plan

›Follow up plan

›Obstetrics appointment timing provided

›Medication instructions if prescribed

12References/r17

Clinical guidelines and evidence

›Key guidance sources

›ACOG practice guidance on management of preterm labor

›Antenatal corticosteroid indications and regimens

›Tocolysis candidate selection and contraindications

›SMFM guidance on late preterm corticosteroids

›Candidate selection for 34 to 36 weeks 6 days

›International consensus on magnesium sulfate neuroprotection

›Less than 32 weeks dosing and monitoring

Evidence based sources

›Landmark evidence themes

›Randomized trials supporting antenatal corticosteroids for neonatal outcomes

›Respiratory distress syndrome reduction

›Intraventricular hemorrhage reduction

›Meta analyses supporting magnesium sulfate neuroprotection

›Cerebral palsy risk reduction

›Trials and systematic reviews on tocolytics

›Short term delay benefit

›Maternal adverse effect profiles

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.