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Preterm labour and birth

About

What is covered

This interactive flowchart covers women in or at risk of preterm labour, or having a planned preterm birth.

Updates

Updates to this interactive flowchart

1 August 2019 Updated on publication of the update of preterm labour and birth (NICE guideline NG25).
29 January 2019 Laparoscopic cerclage for cervical incompetence to prevent late miscarriage or preterm birth (NICE interventional procedures guidance 639) added to preventing preterm labour.
3 July 2018 Biomarker tests to help diagnose preterm labour in women with intact membranes (NICE diagnotics guidance 33) added to diagnosing preterm labour for women with intact membranes.
21 December 2016 Drainage, irrigation and fibrinolytic therapy (DRIFT) for post-haemorrhagic hydrocephalus in preterm infants (interventional procedures guidance 412) added to hydrocephalus in preterm infants.
18 October 2016 Preterm labour and birth (NICE quality standard 135) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in 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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on the care of women in or at risk of preterm labour or having a planned preterm birth in an interactive flowchart

What is covered

This interactive flowchart covers women in or at risk of preterm labour, or having a planned preterm birth.

Updates

Updates to this interactive flowchart

1 August 2019 Updated on publication of the update of preterm labour and birth (NICE guideline NG25).
29 January 2019 Laparoscopic cerclage for cervical incompetence to prevent late miscarriage or preterm birth (NICE interventional procedures guidance 639) added to preventing preterm labour.
3 July 2018 Biomarker tests to help diagnose preterm labour in women with intact membranes (NICE diagnotics guidance 33) added to diagnosing preterm labour for women with intact membranes.
21 December 2016 Drainage, irrigation and fibrinolytic therapy (DRIFT) for post-haemorrhagic hydrocephalus in preterm infants (interventional procedures guidance 412) added to hydrocephalus in preterm infants.
18 October 2016 Preterm labour and birth (NICE quality standard 135) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Preterm labour and birth (2015 updated 2019) NICE guideline NG25
Preterm labour and birth (2016) NICE quality standard 135

Quality standards

Quality statements

Providing information about potential signs and symptoms of preterm labour

This quality statement is taken from the preterm labour and birth quality standard. The quality standard defines clinical best practice in preterm labour and birth and should be read in full.

Quality statement

Pregnant women at increased risk of preterm labour are given information about the potential signs and symptoms.

Rationale

Not all pregnant women at increased risk of preterm labour know what symptoms and signs to look out for. At such a vulnerable time in their lives, women and their families need information about the potential signs and symptoms of preterm labour and the care available that meets their needs and supports shared decision-making, without causing unnecessary anxiety.

Quality measures

Structure
Evidence of local arrangements and clinical protocols to ensure that pregnant women at increased risk of preterm labour are given information about the potential signs and symptoms.
Data source: Local data collection.
Process
Proportion of pregnant women at increased risk of preterm labour who are given information about the potential signs and symptoms.
Numerator – the number in the denominator who are given information about the potential signs and symptoms.
Denominator – the number of pregnant women at increased risk of preterm labour.
Data source: Local data collection.
Outcome
Pregnant women’s satisfaction with the information provided.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that pregnant women at increased risk of preterm labour are given written information about the potential signs and symptoms by healthcare professionals, who also discuss this with them.
Healthcare professionals (such as midwives and obstetricians) give written information to pregnant women at increased risk of preterm labour about the potential signs and symptoms, and discuss this with them.
Commissioners (clinical commissioning groups) commission services that ensure that pregnant women at increased risk of preterm labour are given written information about the potential signs and symptoms by healthcare professionals, who also discuss this with them.
Pregnant women at increased risk of preterm labour (that is, going into labour before the 37th week of pregnancy) are given written information about the signs and symptoms that might suggest preterm labour. A healthcare professional also talks to them about this and the care available.

Source guidance

Preterm labour and birth (2015, updated 2019) NICE guideline NG25, recommendation 1.1.1

Definitions of terms used in this quality statement

Pregnant women at increased risk of preterm labour
Pregnant women who:
  • have a history of:
    • spontaneous preterm birth
    • preterm prelabour rupture of membranes
    • mid-trimester loss
    • cervical trauma (including surgery – for example, previous cone biopsy [cold knife or laser], large loop excision of the transformation zone [LLETZ – any number] and radical diathermy)
  • are considered to be at risk of preterm labour and birth because they have a short cervix (25 mm or less) that has been identified on a transvaginal ultrasound scan and/or bulging membranes in the current pregnancy
  • have preterm prelabour rupture of membranes (P-PROM).
[Adapted from NICE’s full guideline on preterm labour and birth]
Information
Pregnant women should be given oral and written information, and be directed to organisations that can provide further support.
[Adapted from NICE’s full guideline on preterm labour and birth]
Potential signs of preterm labour
Potential signs could include:
  • watery, mucosal or bloody vaginal discharge
  • regular or frequent (often painless) contractions or uterine tightening
  • P-PROM.
[Expert opinion]
Potential symptoms of preterm labour
Potential symptoms could include:
  • pelvic or lower abdominal pressure
  • constant low, dull backache
  • mild abdominal cramps, with or without diarrhoea.
[Expert opinion]

Equality and diversity considerations

Pregnant women at increased risk of preterm labour should have access to information that is understandable if they:
  • have additional needs, such as physical, sensory or learning disabilities
  • do not speak or read English
  • have religious, ethnic or cultural needs.
Interpreters and advocates should be provided if needed.

Prophylactic vaginal progesterone and prophylactic cervical cerclage

This quality statement is taken from the preterm labour and birth quality standard. The quality standard defines clinical best practice in preterm labour and birth and should be read in full.

Quality statement

Women who have had a previous preterm birth or mid-trimester loss and have a cervical length of 25 mm or less measured between 16+0 and 24+0 weeks of pregnancy are offered a choice of either prophylactic vaginal progesteroneAlthough this use is common in UK clinical practice, at the time of publication (August 2019), vaginal progesterone did not have a UK marketing authorisation for this indication. The prescriber should see the summary of product characteristics for the manufacturer’s advice on use in pregnancy. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information. or prophylactic cervical cerclage.

Rationale

Preterm birth causes significant neonatal morbidity and mortality, as well as long-term disability. Therefore strategies for preventing preterm birth are important. Both prophylactic cervical cerclage and prophylactic vaginal progesterone are effective in preventing or delaying preterm birth in women with a short cervix and a history of spontaneous preterm birth (up to 34+0 weeks of pregnancy) or mid-trimester loss (from 16+0 weeks of pregnancy onwards). Which treatment is best for each woman will depend on her individual preferences and circumstances, and women should be given information as part of shared decision making.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that women who have had a previous preterm birth or mid-trimester loss and have a cervical length of 25 mm or less measured between 16+0 and 24+0 weeks of pregnancy are offered a choice of either prophylactic vaginal progesterone or prophylactic cervical cerclage.
Data source: Local data collection.
Process
Proportion of women who have had a previous preterm birth or mid-trimester loss and have a cervical length of 25 mm or less measured between 16+0 and 24+0 weeks of pregnancy who are offered a choice of either prophylactic vaginal progesterone or prophylactic cervical cerclage.
Numerator – the number in the denominator who are offered a choice of either prophylactic vaginal progesterone or prophylactic cervical cerclage.
Denominator – the number of women who have had a previous preterm birth or mid-trimester loss and have a cervical length of 25 mm or less measured between 16+0 and 24+0 weeks of pregnancy.
Data source: Local data collection.
Outcome
Timing of labour and birth.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that women who have had a previous preterm birth or mid-trimester loss and have a cervical length of 25 mm or less measured between 16+0 and 24+0 weeks of pregnancy are offered a choice of either prophylactic vaginal progesterone or prophylactic cervical cerclage, with the choice of treatment depending on the woman’s preferences and circumstances.
Healthcare professionals (such as obstetricians caring for women with high-risk pregnancies) offer women who have had a previous preterm birth or mid-trimester loss and have a cervical length of 25 mm or less measured between 16+0 and 24+0 weeks of pregnancy a choice of either prophylactic vaginal progesterone or prophylactic cervical cerclage, with the choice of treatment depending on the woman’s preferences and circumstances.
Commissioners (clinical commissioning groups) commission services that ensure that women who have had a previous preterm birth or mid-trimester loss and have a cervical length of 25 mm or less measured between 16+0 and 24+0 weeks of pregnancy are offered a choice of either prophylactic vaginal progesterone or prophylactic cervical cerclage, with the choice of treatment depending on the woman’s preferences and circumstances.
Women at increased risk of preterm labour in whom an ultrasound scan has shown that they have a short cervix are offered a treatment to stop the cervix (neck of the womb) opening early and so delay labour and birth. This could be either progesterone (a natural female sex hormone) inserted into the vagina or a stitch in the cervix, with the choice of treatment depending on the woman’s preferences and circumstances.

Source guidance

Preterm labour and birth (2015, updated 2019) NICE guideline NG25, recommendation 1.2.1

Definitions of terms used in this quality statement

Prophylactic vaginal progesterone
Progesterone by vaginal suppository to reduce the incidence of spontaneous preterm birth .
[NICE’s full guideline on preterm labour and birth, glossary]
Prophylactic cervical cerclage
A treatment for cervical weakness (also termed cervical incompetence or insufficiency) to prevent preterm birth and miscarriage.
[Adapted from NICE’s full guideline on preterm labour and birth]

Information for women having a planned preterm birth

This quality statement is taken from the preterm labour and birth quality standard. The quality standard defines clinical best practice in preterm labour and birth and should be read in full.

Quality statement

Women having a planned preterm birth are given information about the risks and potential outcomes.

Rationale

Women who are having a planned preterm birth need information about the level and nature of the risks, including how likely it is that their baby will survive. This should be given as early as possible in the antenatal period. It can help the woman and her family to understand what neonatal care their baby might need and inform their discussions with their neonatologist or paediatrician. The woman and her family should also be offered a tour of the neonatal unit.

Quality measures

Structure
Evidence of local arrangements and clinical protocols to ensure that women having a planned preterm birth are given information about the risks and potential outcomes.
Data source: Local data collection.
Process
Proportion of women having a planned preterm birth who are given information about the risks and potential outcomes.
Numerator – the number in the denominator who are given information about the risks and potential outcomes.
Denominator – the number of women having a planned preterm birth.
Data source: Local data collection.
Outcome
Women’s awareness of the risks and potential outcomes of having a planned preterm birth.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that women having a planned preterm birth are given information about the risks and potential outcomes and the care available.
Healthcare professionals (such as obstetricians, neonatologists and paediatricians) give information to women having a planned preterm birth about the risks and potential outcomes and the care available.
Commissioners (clinical commissioning groups) commission services that ensure that women having a planned preterm birth are given information about the risks and potential outcomes and the care available.
Women who are having a planned preterm birth (before the 37th week of pregnancy) for medical reasons are told about what may happen. This should include:
  • information about the care that the woman and her baby might need, and whether this might include being transferred to another hospital for specialist care
  • information about the types of problems that a preterm baby might have, both at birth and as they grow up, including how likely these are
  • offering to show the woman round the neonatal unit, and an opportunity for her to talk with a neonatologist or paediatrician.

Source guidance

Preterm labour and birth (2015, updated 2019) NICE guideline NG25, recommendation 1.1.2

Definitions of terms used in this quality statement

Planned preterm birth
A planned birth before 37+0 weeks of pregnancy because of medical complications.
[NICE’s full guideline on preterm labour and birth, glossary]
Information
Women should be given oral and written information, and directed to organisations that can provide further support.
[Adapted from NICE’s full guideline on preterm labour and birth]
Potential outcomes
These include the likelihood of the baby surviving and long-term neurodevelopmental outcomes.
[Adapted from NICE’s full guideline on preterm labour and birth]

Equality and diversity considerations

Women having a planned preterm labour should have access to information that is understandable if they:
  • have additional needs, such as physical, sensory or learning disabilities
  • do not speak or read English
  • have religious, ethnic or cultural needs.
Interpreters and advocates should be provided if needed.

Tocolysis for women between 26+0 and 33+6 weeks of pregnancy

This quality statement is taken from the preterm labour and birth quality standard. The quality standard defines clinical best practice in preterm labour and birth and should be read in full.

Quality statement

Women between 26+0 and 33+6 weeks of pregnancy who have intact membranes and are in suspected or diagnosed preterm labour are offered tocolysis.

Rationale

For women in suspected preterm labour, tocolysis may delay the birth and reduce the risk of problems such as cerebral palsy and of neonatal death. Not all women between 26+0 and 33+6 weeks of pregnancy who have intact membranes and are in suspected or diagnosed preterm labour are currently offered this treatment. It is important that the potential benefits and risks of this treatment are discussed with the woman and her family members. Tocolysis is appropriate only under particular circumstances, and a range of factors need to be taken into account.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that women between 26+0 and 33+6 weeks of pregnancy who have intact membranes and are in suspected or diagnosed preterm labour are offered tocolysis.
Data source: Local data collection.
Process
a) Proportion of women between 26+0 and 33+6 weeks of pregnancy who have intact membranes and are in suspected or diagnosed preterm labour who receive tocolysis.
Numerator – the number in the denominator who receive tocolysis.
Denominator – the number of women between 26+0 and 33+6 weeks of pregnancy who have intact membranes and are in suspected or diagnosed preterm labour.
Data source: Local data collection.
Outcome
a) Neonatal death.
Data source: Local data collection.
b) Intraventricular haemorrhage.
Data source: Local data collection.
c) Incidence of neonatal sepsis.
Data source: Local data collection.
d) Use of antibiotics.
Data source: Local data collection.
e) Ventilation.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as secondary or tertiary care services) ensure that women between 26+0 and 33+6 weeks of pregnancy who have intact membranes and are in suspected or diagnosed preterm labour are offered tocolysis as appropriate.
Healthcare professionals (such as midwives and obstetricians) offer tocolysis as appropriate to women between 26+0 and 33+6 weeks of pregnancy who have intact membranes and are in suspected or diagnosed preterm labour.
Commissioners (clinical commissioning groups) commission services that ensure that women between 26+0 and 33+6 weeks of pregnancy who have intact membranes and are in suspected or diagnosed preterm labour are offered tocolysis as appropriate.
Women who are more than 26 weeks but less than 34 weeks pregnant and in suspected or diagnosed preterm labour are offered tocolytics (medicines that slow down or stop labour) if these medicines are likely to help their baby. The benefits and risks of this treatment are explained to them.

Source guidance

Preterm labour and birth (2015, updated 2019) NICE guideline NG25, recommendation 1.8.3

Definitions of terms used in this quality statement

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.
[NICE’s guideline on preterm labour and birth, terms used in this guideline]
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.
[NICE’s guideline on preterm labour and birth, terms used in this guideline]
Tocolysis
Drugs used to stop or delay the progress of labour. The NICE guideline recommends nifedipineAlthough this is common in UK clinical practice, at the time of publication (August 2019), nifedipine did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Prescribing Guidance: prescribing unlicensed medicines for further information. The suggested dose of nifedipine is a loading dose of 20 mg nifedipine orally, followed by 10 mg to 20 mg 3 to 4 times daily, adjusted according to uterine activity. At the time of publication, some brands of nifedipine were specifically contraindicated in pregnancy by the manufacturer in their summary of product characteristics. Refer to individual summaries of product characteristics for each preparation of nifedipine for further details. as the first choice, or oxytocin receptor antagonists if nifedipine is contraindicated.
[Adapted from NICE’s full guideline on preterm labour and birth]

Corticosteroids for women between 24+0 and 33+6 weeks of pregnancy

This quality statement is taken from the preterm labour and birth quality standard. The quality standard defines clinical best practice in preterm labour and birth and should be read in full.

Quality statement

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 preterm prelabour rupture of membranes (P-PROM) are offered maternal corticosteroids.

Rationale

Giving corticosteroids to a woman before a preterm birth reduces the severity of lung disease of prematurity and of other associated complications for her baby. Maternal corticosteroids also have the potential to reduce the number of days that the baby needs to be on a ventilator.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that 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 are offered maternal corticosteroids.
Data source: Local data collection.
Process
a) Proportion of women between 24+0 and 33+6 weeks of pregnancy in suspected, diagnosed or established preterm labour who receive maternal corticosteroids.
Numerator – the number in the denominator who receive maternal corticosteroids.
Denominator – the number of women between 24+0 and 33+6 weeks of pregnancy in suspected, diagnosed or established preterm labour.
Data source: Local data collection.
b) Proportion of women between 24+0 and 33+6 weeks of pregnancy having a planned preterm birth who receive maternal corticosteroids.
Numerator – the number in the denominator who receive maternal corticosteroids.
Denominator – the number of women between 24+0 and 33+6 weeks of pregnancy who are having a planned preterm birth.
Data source: Local data collection.
c) Proportion of women between 24+0 and 33+6 weeks of pregnancy with P-PROM who receive maternal corticosteroids.
Numerator – the number in the denominator who receive maternal corticosteroids.
Denominator – the number of women between 24+0 and 33+6 weeks of pregnancy with P-PROM.
Data source: Local data collection.
Outcome
a) Ventilation.
Data source: Local data collection.
b) Incidence of neonatal sepsis.
Data source: Local data collection.
c) Use of antibiotics.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that 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 are offered maternal corticosteroids by healthcare professionals.
Healthcare professionals (such as obstetricians and midwives) 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.
Commissioners (clinical commissioning groups) commission services that ensure that 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 are offered maternal corticosteroids.
Women over 24 weeks and under 34 weeks of pregnancy are offered corticosteroid injections to help their baby’s lungs develop if:
  • they are in suspected preterm labour or
  • they are in diagnosed preterm labour (they have had a test that shows they are in labour) or
  • they are in established preterm labour or
  • they are having a planned preterm birth or
  • they have preterm prelabour rupture of membranes (also called P-PROM) – this is when a woman’s waters break early but labour hasn’t started.

Source guidance

Preterm labour and birth (2015, updated 2019) NICE guideline NG25, recommendation 1.9.2

Definitions of terms used in this quality statement

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.
[NICE’s guideline on preterm labour and birth, terms used in this guideline]
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.
[NICE’s guideline on preterm labour and birth, terms used in this guideline]
Established preterm labour
A woman is in established preterm labour if she has progressive cervical dilation from 4 cm with regular contractions.
[NICE’s guideline on preterm labour and birth, terms used in this guideline]
Planned preterm birth
A planned birth before 37+0 weeks of pregnancy because of medical complications.
[NICE’s full guideline on preterm labour and birth, glossary]
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.
[NICE’s full guideline on preterm labour and birth, terms used in this guideline]
Maternal corticosteroids
Corticosteroids (glucocorticosteroids) are anti-inflammatory medicines given to the woman (usually by intramuscular injection) which cross the placenta and accelerate fetal lung maturation.
[Adapted from NICE’s full guideline on preterm labour and birth]

Magnesium sulfate for women between 24+0 and 29+6 weeks of pregnancy

This quality statement is taken from the preterm labour and birth quality standard. The quality standard defines clinical best practice in preterm labour and birth and should be read in full.

Quality statement

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 are offered magnesium sulfateAlthough this use is common in UK clinical practice, at the time of publication (August 2019), magnesium sulfate did not have a UK marketing authorisation for this indication. The prescriber should see the summary of product characteristics for the manufacturer’s advice on use in pregnancy. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information..

Rationale

With advances in neonatal care in recent years, more babies born preterm are surviving. These children frequently have long-term complications associated with preterm birth. Neurological effects are common and may cause severe disability. Magnesium sulfate can protect the developing fetal brain and so has significant potential to reduce disability.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that 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 are offered magnesium sulfate.
Data source: Local data collection.
Process
a) Proportion of women between 24+0 and 29+6 weeks of pregnancy in established preterm labour who receive magnesium sulfate.
Numerator – the number in the denominator who receive magnesium sulfate.
Denominator – the number of women between 24+0 and 29+6 weeks of pregnancy in established preterm labour.
Data source: Local data collection.
b) Proportion of women between 24+0 and 29+6 weeks of pregnancy who are having a planned preterm birth within 24 hours who receive magnesium sulfate.
Numerator – the number in the denominator who receive magnesium sulfate in the 24 hours before the birth.
Denominator – the number of women between 24+0 and 29+6 weeks of pregnancy who have a planned preterm birth.
Data source: Local data collection.
Outcome
Incidence of cerebral palsy.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as secondary or tertiary care services) ensure that 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 are offered magnesium sulfate.
Healthcare professionals (such as midwives, obstetricians and neonatologists) offer magnesium sulfate 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.
Commissioners (clinical commissioning groups) commission services that ensure that 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 are offered magnesium sulfate.
Women who are more than 24 weeks but less than 30 weeks pregnant and in established preterm labour, or having a planned preterm birth within 24 hours, are offered magnesium sulfate, as this medicine is likely to help their baby. The benefits and risks of this treatment are explained to them.

Source guidance

Preterm labour and birth (2015, updated 2019) NICE guideline NG25, recommendation 1.10.2

Definitions of terms used in this quality statement

Established preterm labour
A woman is in established preterm labour if she has progressive cervical dilatation from 4 cm with regular contractions.
[NICE’s guideline on preterm labour and birth, terms used in this guideline]
Planned preterm birth
A planned birth before 37+0 weeks of pregnancy because of medical complications.
[NICE’s full guideline on preterm labour and birth, glossary]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in 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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Discuss the general benefits and risks of caesarean section and vaginal birth with women in suspected preterm labour, diagnosed preterm labour or established preterm labour and women with P-PROM (and their family members or carers as appropriate) – see deciding whether to offer caesarean section.
Explain to women in suspected, diagnosed or established preterm labour and women with P-PROM about the benefits and risks of caesarean section that are specific to gestational age. In particular, highlight the difficulties associated with performing a caesarean section for a preterm birth, especially the increased likelihood of a vertical uterine incision and the implications of this for future pregnancies.

Glossary

(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)
(a woman is in diagnosed preterm labour if she is in suspected preterm labour and has had a positive diagnostic test for 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 care in latent first stage of labour))
Medicines and Healthcare products Regulatory Agency
(preterm prelabour rupture of membranes; 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)
(cervical cerclage performed as an emergency procedure in a woman with premature cervical dilatation and often with exposed fetal membranes)
summary of product characteristics
(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)
(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)

Paths in this pathway

Pathway created: November 2015 Last updated: August 2019

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