Premature Labor

Symptoms Of Premature Labor 

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

• Pressure in the pelvis or lower belly, like the baby is pushing down

• Menstrual type cramps 

• Constant or low back pain

• Contractions that occur more than 6 times an hour continuously at a gap of ten minutes apart

• Painful or hard uterus

• Increasing pressure in the vagina

• Vaginal secretion, spotting or light bleeding 

• Blurred or troubled vision 

• Swelling on the hands, feet, and face 

• Preterm rupture of water membranes surrounding the baby breaks or tears 

• Decreased fetal movements 

• Nausea, vomiting, and diarrhea

What are Braxton Hicks contractions? 

Braxton hicks contractions are mild, irregular, and infrequent contractions, also referred to as 'false' or 'practice' contractions. They feel like tightness in the abdomen and are relatively less painful. They 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 with time, and are much more painful.

Watch this video to understand what happens during labor pain and how to identify labor pain.
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Types Of Premature Labor 

Premature labor is defined as babies born alive before 37 weeks of pregnancy are completed. There are sub-categories of premature labor, based on gestational age:

• Extremely premature birth (less than 28 weeks)

• Very preterm (28 to less than 32 weeks)

• Moderate to late premature birth (32 to 37 weeks)

Babies are born early because of spontaneous preterm labor or because there is a medical indication to plan an induction of labor or cesarean birth early.

Causes Of Premature Labor 

In cases where labor starts spontaneously before 37 weeks, it’s often hard to tell the exact cause. However, there are several factors discussed in the next section that increase the risk of premature birth.

Risk Factors of Premature Labor 

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

• Age 

Mothers younger than 18 years of age and older than age 35 years of age are at a high risk of having preterm infants.

• History of Preterm Labor

Women who have a history of delivering preterm, or who have experienced preterm labor during their previous pregnancies, are considered to be at high risk for preterm labor and birth.

• Multiple Pregnancy 

A multiple pregnancy is a pregnancy in which you're carrying more than one baby at a time. Being pregnant with twins, triplets, or more, is associated with a higher risk of preterm labor and birth. One of the research studies has shown that more than 50% of twin births occurred preterm, compared with only 10% of deliveries of single infants. 

• Short Interpregnancy interval 

Interpregnancy interval refers to the time between the end of one pregnancy and the conception of another. An interpregnancy interval of less than 6 months increases the risk of preterm birth. The longer the interval between pregnancies, the lesser the risk.

• Anomalies of the reproductive organs 

Women with certain anomalies like a shorter cervix (the lower part of the uterus) or weak or incompetent cervix that doesn't stay closed the way it's supposed to during pregnancy, increases the risk of preterm labor.

• Certain medical conditions 

Certain medical conditions that occur during pregnancy and place a woman at higher risk for preterm labor and delivery include:

1. Sexually Transmitted Diseases (STDs)

2. Urinary Tract Infections (UTIs)

3. Bacterial Vaginosis (infection of vagina)

4. Hypertension (High Blood Pressure)

5. Being underweight or obese before pregnancy

6. Diabetes (high blood sugar)

7. Gestational diabetes (diabetes that occurs during pregnancy)

8. Blood clotting problems 

9. Certain developmental anomalies in the fetus

10. Placenta previa (the placenta grows in the lowest part of the uterus and covers all or part of the opening to the cervix)

11. Polyhydramnios (excessive amniotic fluid surrounding the baby in the womb) 

12. Premature rupture of the fetal membranes (PROM) (The water bag breaks early and there is not enough amniotic fluid surrounding the baby)

13. Intrahepatic cholestasis of pregnancy (ICP) (a liver disorder during pregnancy)

14. Placental abruption (the placenta starts to separate from the inside of the womb wall)

15. Antiphospholipid syndrome (APS) (an immune system blood disorder)

• Smoking  

Many studies have shown that maternal exposure to smoke during pregnancy is a key modifiable risk factor for premature birth (birth before 37 weeks gestation), stillbirth, as well as miscarriage. 

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• Drinking alcohol 

For women who consumed seven or more drinks per week, the relative risk of very premature delivery is increased by many folds as compared to non-drinking women. 

Studies have shown that younger mothers may be “At A Higher Risk Of Consuming Alcohol”.
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• Disruption of the internal clock

Research has found that disruption in the 24-hour circadian rhythm (internal clock in the brain that regulates the cycles of alertness and sleepiness) increases the risk of miscarriages, preterm birth, and low birth weights.

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• Air pollution

Research has found a significant relationship between exposure to air pollution and preterm birth, particularly if the pollutants are sulfur dioxide.

• Stress 

Stress seems to increase the risk of preterm birth as it leads to high blood pressure during pregnancy. The high blood pressure further puts at risk of preeclampsia, and premature birth. 

Is stress affecting your overall well-being? Try some relaxation techniques to manage stress.
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• Lack of social support

Lack of social support aggravates mental stress, anxiety, and depression in a female sometimes leading to premature labor. 

• Domestic violence 

Many studies have shown that women facing issues of physical, sexual, or emotional abuse are at a doubled risk of preterm labor and low birth weight infants. This risk was increased further for women who experienced two or more types of domestic violence during their pregnancy.

Diagnosis Of Premature Labor 

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

Physical Examination 

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

2. A pelvic examination might be done to evaluate the firmness and tenderness of the uterus, the baby's size and position, to determine whether the cervix has begun to open, and to check for any uterine bleeding. 

Lab and Imaging tests 

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

2. Transvaginal ultrasound: This imaging scan is performed to check the Cervical-length measurement and is an essential part of assessing the risk of preterm labor and delivery. This test is considered to be the gold standard in women who are considered to be at a high risk of preterm birth. 

3. Monitor contractions: If a woman is facing contractions, the doctor uses an instrument called a tocodynamometer for monitoring and recording uterine contractions before and during labor.

4. Fetal Fibronectin Screening: This is a protein that helps the amniotic sac (the membrane that cushions the baby during pregnancy) stay attached to the lining of the uterus. This protein begins to break down as the body prepares for birth, and detecting the presence of fetal fibronectin in vaginal discharge in the second and third trimesters of pregnancy signals a high risk of labor. The doctor may swab the cervix and test the secretions for fetal fibronectin protein. 

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

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Prevention Of Premature Labor 

A full-term pregnancy is 40 weeks. The babies' 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 points:

Lead a healthy lifestyle 

• Eat a well-balanced, nutritious diet 

• Keep yourself hydrated

• Take all the prescribed supplements on time.

• Gain a healthy amount of weight.

• Try to stay active every day. Walking is always a good idea.

• Don’t do strenuous activities that put pressure on the abdomen and cause you significant fatigue.

• Make sure you take adequate rest and allow the 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

• Don’t drink alcohol while trying to get pregnant and during the full phase of pregnancy

• Quit tobacco, smoking, e-cigarettes, and vaping.

• Don’t consume any recreational drugs or nonprescribed medications

Seek prenatal care

• Seek prenatal care early in the pregnancy, particularly if someone has any risk factors for preterm birth such as having a history of a premature baby in the past, or having issues related to your uterus or cervix

• Consult with your doctor immediately if you think you are facing any signs of premature labor

• If both the mother and the baby are healthy and fine, it is best to wait until at least 39 weeks and let labor begin on its own.

Know the signs of preterm labor before it becomes too late 

Consult your pregnancy care physician immediately if you are facing any issues like 

• Contractions, cramping, or tightening of your 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 important risk factors for premature labor.

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

• Probiotics containing these strains have the potential to reduce vaginal infections and therefore 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.

Specialist To Visit

Doctors that can help in the prevention and management of preterm labor are: 

• Obstetrician & Gynecologist

• Perinatologist

An obstetrician & gynecologist specializes in diagnosing and treating diseases of the female reproductive system along with delivering babies, and providing medical care during pregnancy and after birth. A Perinatologist is an obstetrician who specializes in high-risk pregnancies. They work with mothers and infants to ensure safety before and after birth. 

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Treatment Of Premature Labor 

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 

1. 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. A few examples include: 

• Azithromycin 

• Erythromycin

• Ceftriaxone

• Clarithromycin

• Metronidazole

2. Tocolytic Agents: These are the drugs 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 into the vein (intravenously). A few 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 the placental abruption (placenta detaching from the wall of the uterus.

3. Corticosteroids: If a woman is less than 34 weeks pregnant and experiencing the symptoms of labor, corticosteroid is injected to help promote the baby's lung maturity. A few examples include: 

• Betamethasone

• Dexamethasone

Note: These corticosteroids also benefit patients with PPROM (Preterm premature rupture of the membranes and those with hypertensive syndromes. But the repeated course of corticosteroids is not recommended.

Progesterone Therapy 

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

Note: Progesterone is not beneficial in multiple gestation pregnancies

Surgical procedure 

Cervical Cerclage 

• This is a surgical procedure that might be recommended in 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

• It 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.

Complications Of Premature Labor 

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 amongst 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 the delivery.

• Women delivering preterm babies can have a great emotional impact leading to anxiety, postpartum depression, and Post-traumatic stress disorder.

Alternative Therapies For Premature Labor 

Some of the alternative therapy that has shown some promising results in preventing preterm labor and delivery: 

Prenatal yoga 

Prenatal yoga focuses on positions that are specifically designed for pregnant women's bodies. These yoga postures should be performed under the guidance of a trainer. This can help improve flexibility and it is great for blood circulation too. This helps in keeping the baby and mother healthy in proper coordination and hence reduces the chances of preterm labor. 

Learn about yoga that is safe to practice during pregnancy.
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Massage therapy 

Massage therapy during pregnancy has been shown to provide many benefits, including a sense of wellness, improved relaxation, and better sleep. This massage helps in reducing stress, anxiety, and emotional disturbance faced by a pregnant woman and hence reduces the risk of preterm labor. 

Warm baths 

Warm baths help in calming the body and relaxing the muscles. This is a really great way to calm and de-stress. 

Living With Premature Labor 

1. If a woman is at risk of premature labor, she may always feel scared or anxious about the pregnancy. This adds on if the woman is having a history of preterm labor. In the above cases, it is advisable to consult your doctor at each step to stay relaxed and calm. 

2. If a woman is feeling anxious or depressed, it is important she is accompanied by a loved one or caretaker while visiting your doctor. This would give her moral support and a sense of protection.

3. Ask multiple questions from the doctor. Do not hesitate or be fearful about asking anything about your condition. 

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