Health Care Guideline:
Preterm Birth Prevention
Copyright © 1998 by Institute for Clinical Systems Integration
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Work Group Leaders
Peter Mark, MD, HealthPartners
Family Practice
Leif Solberg, MD, HealthPartners
Carol Stark, MD, Family HealthServices Minnesota
Health Education
Dianne Eggen, RN, MPH, HealthPartners
OB/Gyn
Jerald Barnard, MD, HealthPartners
John Jefferies, MD, Mayo Clinic
Peter Mark, MD, HealthPartners
OB/Gyn Nurse Practitioner
Julie Rice, RN, Women's Health NP, HealthSystem Minnesota
Business Health Care Action Group
Teri Kent, RN, MS, Honeywell, Inc.
Measurement Advisor
Rick Carlson, HealthPartners
Facilitator
Chris Schroeder, ICSI
All pregnant women at first pregnancy visit.
Priority Aims for Medical Groups When Using This Guideline
1. Increase the routine identification of Preterm Birth (PTB) risk factors in all pregnant women.
Possible measures of accomplishing this aim:
a. Percentage of modifiable PTB risk factors screened for all pregnant women.
b. Percentage of both modifiable and non-modifiable PTB risk factors screened for all pregnant women.
2. Increase the rate of interventions for identified PTB risk factors.
Possible measures of accomplishing this aim:
a. Percentage of all identified PTB modifiable risk factors assessed which receive an intervention.
b. Percentage of all identified modifiable and non-modifiable PTB risk factors which receive appropriate follow-up.
3. Increase patient education for preterm birth prevention and preterm labor signs and symptoms for at-risk patients.
Possible measure of accomplishing this aim:
a. Percentage of at-risk women educated for PTB at recommended intervals.
4. Increase the rate of appropriate interventions for identified change in status.
Possible measures of accomplishing this aim:
a. Percentage of women with identified PTB risk factors whose preterm labor signs and symptoms are reviewed at each prenatal visit.
b. Percentage of women with change in status who receive medical intervention.
1. Preterm labor occurring after 20 and before 37 completed weeks;
plus
2. Clinically documented uterine contractions;
(4/20 minutes or 8/60 minutes)
plus
3. (a) Ruptured membranes;
or
(b) Intact membranes and cervical dilation > 2 cm;
or
(c) Intact membranes and cervical effacement > 80%;
or
(d) Intact membranes and cervical change during observation. These can be measured by changes in dilation or effacement, or by changes in cervical length measured clinically or by ultrasound.
Clinical
Algorithms & Annotations
Assessment Algorithm
1. Preconception Visit Including Risk Assessment
3. Provide Education for Each Risk Factor Identified
7. Reinforce Low Risk Behavior; Provide Education
8. Possible Pregnancy
9. Pregnancy Confirmation Evaluation
10. Pregnant?
11. Routine Prenatal Care Per ICSI Routine Prenatal Care
Guideline
12. At Risk for Preterm Birth?
14. Educate 20-24 Weeks per ICSI Routine Prenatal Care
Guideline
15. Reassess at 28 Weeks and PRN Until Term Pregnancy
Assessment Algorithm-Algorithm Annotations
1. Preconception Visit Including Risk Assessment
See the ICSI Routine Prenatal Care Guideline.
See Appendix A: Preconception/Early Pregancy Risk Assessment and Appendix B: Environmental/Workplace Hazards Screening Instrument.
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3. Provide Education for Each Risk Factor Identified
This should occur with every identified risk factor.
Advise of the importance of an early communication with health care provider as soon as pregnancy is suspected. Provide risk-specific interventions and education:
Education:
· Consider available resources and education methods related to risk.
Intervention:
· Review individual risk factors.
· Identify modifiable behaviors:
- Family stress - Other chemical use
- Domestic abuse - Nutritional concern
- Tobacco use - Sexually transmitted diseases
- Alcohol use
· Offer support/interventions/referrals as referred to in the
ICSI Domestic Violence and Preventive
Counseling and Education guidelines.
As appropriate:
- Ask to set a quit or change date, provide educational aids, offer counseling or classes, arrange for follow-up, at least a phone call soon after the quit/change date
- Provide with information about the problems that behavior causes in pregnancy and offer help when ready to change
Strength of the evidence in support of these recommendations: B.
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7. Reinforce Low Risk Behavior; Provide Education
Congratulate and urge early screening if patient becomes pregnant.
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Any woman with amenorrhea, pregnancy symptoms, or positive home pregnancy test who communicates her condition to a health care provider.
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9. Pregnancy Confirmation Evaluation
This would occur as soon as possible within the first two weeks of provider awareness and would confirm pregnancy.
This can be a patient phone call or clinic visit and can be done by a Nurse, Nurse Practitioner, M.D. or Midwife. This may include a pregnancy test, examination, or ultrasound for ectopic or miscarriage. This may be incorporated into the reinforcement of low risk behavior.
Strength of the evidence in support of these recommendations: C
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Confirmation may be by pregnancy test or by a combination of history and exam. If the confirmation test is negative, the patient should be treated as a pre-pregnancy visit (see annotation #1 above).
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11. Routine Prenatal Care Per ICSI Routine Prenatal Care Guideline
The Minnesota Pregnancy Assessment Form, an implementation tool developed by the Minnesota Council of Health Plans, is recommended by the Preterm Birth Prevention guideline work group.
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12. At Risk for Preterm Birth?
Refer to the ICSI Routine Prenatal Care guideline, Visit #1.
The Minnesota Pregnancy Assessment Form, an implementation tool developed by the Minnesota Council of Health Plans, is recommended by the Routine Prenatal Care and Preterm Birth Prevention guideline work groups.
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14. Educate 20-24 Weeks per ICSI Routine Prenatal Care Guideline
All pregnant women should receive information on how to identify and manage signs of possible preterm labor. If the patient is at risk she will be managed as a high risk for preterm birth (See management flow diagram).
See Appendix C: Modified Patient Education Outline.
Strength of the evidence in support of this recommendation: B.
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15. Reassess at 28 Weeks and PRN Until Term Pregnancy
This reassessment should include cervical examination.
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1. Patient at Risk
2. Address Each Risk Factor Identified and Provide
Education for Preterm Labor
4. Intervention
7. Monitor Pregnancy and Risk Status
8. Change in Status?
11. Medical Intervention
12. Continuation of Pregnancy?
13. Delivery
14. 4-8 Week Postpartum Visit
Management Algorithm-Algorithm Annotations
Risk factors for preterm birth may include, but are not limited to:
(Presence of any one of the risk factors listed below constitutes being at risk):
Domestic abuse
Tobacco use
Alcohol use (drank any beer, wine, wine coolers, or liquor since last menstrual period)
Cocaine, marijuana, benzodiazepines, or street drug use this pregnancy
Sexually transmitted diseases
Bacterial vaginosis
Pyelonephritis this pregnancy
UTI this pregnancy
DES exposure
Previous preterm deliveries or low birth weight baby
Previous preterm labor with term delivery
Three or more 1st trimester pregnancy losses
Two or more second trimester losses
Uterine irritability requiring medication, bed rest, hydration
History of cone biopsy
Multiple gestation this pregnancy
Polyhydramnios this pregnancy
Cervical shortening < 1 cm < 34 weeks this pregnancy
Abdominal surgery this pregnancy
Febrile illness this pregnancy
Patient age < 18 or > 35
Currently unmarried
Less than 12th grade education
Cervix dilated > 1 cm < 34 weeks this pregnancy
Cervical cerclage or myomectomy
Three of more first trimester abortions
Bleeding > 12 weeks this pregnancy
The Minnesota Pregnancy Assessment Form, an implementation tool developed by the Minnesota Council of Health Plans, is recommended by the Preterm Birth Prevention guideline work group.
Strength of the evidence in support of this recommendations: A.
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2. Address Each Risk Factor Identified and Provide Education for Preterm Labor
Addressing each risk factor may include treatment, education, or discussion. At risk patients should be identified by 16-20 weeks or any time thereafter when a risk factor is identified.
Educate Patient about:
· Individual risk factors for preterm birth.
· Available resources and education related to risk.
· Steps to minimize risk of preterm labor.
· Warning signs of preterm labor and action.
· Other resources available.
· Treatments of premature labor:
- Schedule hospital tour earlier.
- Community support resources.
- Reading list.
See Appendix C: Modified Patient Education Outline.
Strength of the evidence in support of these recommendations: A.
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· Review individual risk factors.
· Identify modifiable behaviors:
- Family stress - Other chemical use
- Domestic abuse - Nutritional concern
- Tobacco use - Sexually transmitted diseases
- Alcohol use
· Offer support/interventions/referrals as referred to in the ICSI Domestic Violence and ICSI Preventive Counseling and Education guidelines.
As appropriate:
- Ask to set a quit or change date, provide educational aids, offer counseling or classes, arrange for follow-up (at least a phone call soon after the quit/change date).
- Provide with information about the problems that behavior causes in pregnancy and offer help when ready to change.
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7. Monitor Pregnancy and Risk Status
Review signs and symptoms of preterm labor at each prenatal visit.
· See the ICSI Routine Prenatal Care guideline regarding assessment of risk factors.
· Establish accurate gestational age (consider ultrasound prior to 20 weeks to confirm gestational age.)
· Monitor for risk factors:
- drug and alcohol use - urine testing where indicated
- For physicians' legal obligations in testing for chemical use during pregnancy see 1989 Minnesota Legislative Update "What Can I Do To Prevent Harm to Children?" and Minnesota Statutes 626.5561 (Reporting of Prenatal Exposure to Controlled Substances) and 626.5562 (Toxicology Tests Required).
- contractions
- menstrual cramps
- intestinal cramps
- constant backache
- constant pelvic pressure
- vaginal discharge amount and color
- urinary frequency
- periodic review of:
- psychosocial situation - referrals as appropriate, include their "support system" in visits and education
- stress/anxiety - educate about and assist with sources of stress such as medical limitations for work, day care, home help
- dietary inadequacy - educate, assist with referral for food supplement program
· Other strategies of monitoring:
- consider home uterine activity monitoring in selected cases
- consider home health visit
- consider case management
- consider ultrasound evaluation of cervix
Strength of the evidence in support of these recommendations:
Home health visit: A.
Ultrasound evaluation of cervix: B.
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A change in status can be identified by either the patient or the provider. Patients who note warning signs should contact their health care provider for assessment as soon as possible. Patient should be seen by provider within two hours of provider contact unless PROM or bleeding is present in which case patients should be seen as soon as is feasible.
A change in status would include:
· Documented uterine activity (contractions or "irritability")
· Documented cervical changes
· Diagnosis of:
- multiple gestation
- 3rd trimester bleeding
- infections (STDs, B Strep, UTI, etc.)
- any other preterm risk condition
· Documented preterm labor (see Annotation #13 for definitions of term, preterm, and very preterm delivery)
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Intervention based on change in status including education, diagnostic tests and therapeutic modalities. Consultation for management of high risk patients should be considered as indicated.
· Be certain intervention is appropriate:
- Certainty of gestational age (if no ultrasound, consider doing one).
- If well-documented gestational age, may consider nonintervention at 36 weeks.
- Monitor fetal well being/uterine activity (may include NST +/or biophysical profile).
- Do not inhibit labor where there is fetal or maternal jeopardy, fetal malformation or death.
· Obtain urine culture, group B strep and drug screen, even if previously screened and treated.
· Obtain wet prep for bacterial vaginosis and trichomoniasis and consider treatment after first trimester, even if previously screened and treated.
· Consider cultures for GC, chlamydia, group B strep (depending on the patient population).
· Take steps to reduce uterine irritability, such as:
- Reduced physical activity: no exercise, lifting, household or yard activity.
- No orgasm or intercourse.
- # hours of bed rest (day vs. complete BR with BRP).
· Bed rest and careful IV or PO hydration may be sufficient to stop some episodes of preterm labor.
· Avoid vaginal/digital examination for preterm rupture of membranes if there are no contractions or if tocolytic therapy is to be considered.
- Tocolytic therapy. Agents to be considered could include:
- Ritodrine
- Terbutaline (including pump)*
- Magnesium sulfate
- Indomethacin
- Nifedipine
See Reference: "The Treatment of Preterm Labor" by Paul L. Ogburn, Jr, M.D.
· When delivery seems likely, consider use of corticosteroids.
· Consider home monitoring for follow-up.
· Support/resources reading list.
Strength of the evidence in support of these recommendations: A.
*In February 1997, the FDA alerted practitioners to use caution in the continuous subcutaneous administration of terbutaline sulfate. Refer to discussion and references section.
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12. Continuation of Pregnancy?
This pertains to women who have completed 37 weeks of pregnancy, failure of tocolytic therapy or deteriorating maternal/fetal health.
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Term, Preterm and Very Preterm Definitions:
· Term: 37 or more completed weeks of gestation.
· Preterm: > 32 and < 37 completed weeks of gestation.
· Very preterm: < 32 completed weeks of gestation.
For deliveries which occur prior to 37 completed weeks of gestation, review of the prenatal course should be done at the time of delivery. This should include review of any identifiable risk factors or other contributing events which might have led to the preterm birth. Any potentially preventable events should be reviewed with the involved parties.
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The first postpartum visit should be used as an opportunity to review the prenatal course and delivery events with the patient. For patients who deliver full term, this should be a time to reinforce good health practices. For patients who experienced preterm labor yet were able to deliver at term, review of successful therapy (for preterm labor) and the patient's role in successfully complying with prescribed therapy should be emphasized.
For patients who deliver prior to term, the postpartum visit is a time to review risk factors, identify risk factors which are modifiable, and help the patient understand how she might modify or eliminate these risk factors prior to any subsequent pregnancy. This is also an opportunity to discuss other possible management plans in subsequent pregnancies.
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Appendix A - Preconception/Early Pregnancy Risk Assessment
Because your visit today suggested the possibility that you might become pregnant, we believe it is very important to identify any conditions which might cause trouble for such a pregnancy and which are changeable before that happens. Please answer the following brief questions so we may help you:
1. Do you eat less than three meals per day or have fewer than four vegetables or fruit courses per day? Y N
2. Are you on a special diet? Y N
3. Do you use caffeinated supplements or beverages? Y N
4. Do you use tobacco? Y N
5. Do you use alcohol? Y N
6. Do you use street or recreational drugs (i.e. cocaine, speed, marijuana etc.)? Y N
7. Do you use any medications regularly prescribed or over the counter? Y N
8. Are you using a folate supplement? Y N
9. Have you had a urine/bladder/kidney infection in the last three years? Y N
10. Do you know if you are immune to rubella (the German measles)? Y N
11. Have you had chicken pox? Y N
12. Are you aware of Toxoplasmosis and how this organism is transmitted (i.e. cat litter or food preparation)? Y N
13. Are you exposed to chemicals or infections in your work? Y N
14. Have you ever been physically, emotionally or sexually abused? Y N
Appendix B - Environmental/Workplace Hazards Screening Instrument Environmental/Workplace Hazards Screening Instrument
Occupation
What is your occupation? ________________________________________________
Does your employer accommodate flexible work hours? _________________________
Is there a health professional available at work? _______________________________
(If so, can BP monitoring be performed?) _______________________________
(If so, is there a place you may rest or be observed?) ______________________
Workplace Exposure
Are you exposed to lead or chemicals? _____________________________________
Are you exposed to radiation? ___________________________________________
Are you exposed to infections (hospital, lab work, day care, etc.?) ________________
Is there a high level of stress at work? ______________________________________
Is overtime required? __________________________________________________
Physical Requirements of Occupation
Do you:
Stand for prolonged periods of time? __________________________________
(If so, # of hours per day) _________________________________________hr
Sit for prolonged periods of time? ____________________________________
(If so, # of hours per day) __________________________________________hr
Lift heavy objects repeatedly? _______________________________________
(If so, # of lbs at a time) ___________________________________________lb
Kind of special diet, if applicable
Environmental
Do you have home remodeling plans? ______________________________________
List your hobbies _____________________________________________________
______________________________________________________
Exercise Habits
Describe your usual form of exercise _______________________________________
How many times a week do you exercise? ___________________________________
How long do your exercise sessions usually last? ______________________________
Appendix C - Modified Patient Education Outline
Warning Signs
If any of the following warning signs are felt, the pregnant mother should empty her bladder, drink 3-4 8-oz. glasses of non-caffeinated fluids, and lie on her side while she palpates for uterine activity if there is no change in vaginal discharge.
A. Low, dull backache
B. Menstrual-like cramps
C. Increased pelvic pressure (with or without thigh cramps)
D. Abdominal cramping (with or without diarrhea)
E. Increased uterine activity - more contractions than usual pattern
F. Change in vaginal discharge - colored mucus, fluid leaking, spotting or bleeding (contact provider immediately)
G. "Something feels different", e.g., feeling of agitation, flu-like symptoms
Criteria for Health Care Provider Notification
Notify health care provider if:
A. Any change in vaginal discharge
B. Any of the following warning signs continue after resting for one hour:
1. Low backache
2. Menstrual-like cramps
3. Abdominal cramping
4. Increased pelvic pressure
5. "Something feels different"
6. Five contractions are felt within an hour
Grade A: Conclusion based on a randomized, controlled trial that has been published in a peer-reviewed journal.
Grade B: Conclusion based on one of the following study types published in a peer-reviewed journal (but not on a randomized, controlled trial):
· a trial using historical or other non-randomized controls;
· a prospective cohort study;
· a case-control study; or
· a meta-analytic study.
Grade C: Conclusion based on one of the following (but not on any studies of the types mentioned above):
· an uncontrolled case series; or
· medical opinion.
Guidelines obtained from the Agency for Health Care Policy and Research
(AHCPR) or other sources, position statements, panel consensus statements
from the National Institutes of Health (NIH) or elsewhere, review articles,
and textbook chapters that cite primary evidence are not assigned a grade
because they are not primary evidence. The individual studies cited in
such secondary sources can be graded according to the categories presented
above.
Released in June 1998 for General Implementation.
Other Guidelines Referenced Within This Guideline
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