5. TREATMENT: Tocolysis
A. Indication: Preterm Labor; Confirm the indication by (1) and (2), and either (3) or (4):
(1) Gestational age between 20 and 37 weeks confirmed by dates or ultrasound;
(2) Frequent, regular uterine contractions preferably documented by a tocodynamonmeter;
(3) Documented progressive change in the cervix;
(4) Cervical dilation greater than 2 cm and effacement greater than 80%.
B. Actions Prior to Treatment:
(1) Between 34 and 37 weeks gestation an individual treatment plan is required.
(2) For patient less than 34 weeks:
(a) Document historical risk factors which may include:
(1) Previous preterm labor or delivery;
(2) Pyelonephritis;
(3) Heavy smoking;
(4) Hypertension;
(5) Uterine anomaly;
(6) Age less than 16 or greater than 40 years;
(7) Overdistension of the uterus;
(b) Bed rest;
(c) Adequate hydration;
(d) Documented fetal heart rate and uterine activity monitoring;
(e) Ultrasound to confirm date and rule out anomalies;
(f) Pelvic exam to confirm cervical status;
(g) Laboratory studies including:
(1) CBC;
(2) Urine for culture and sensitivity; and
(3) Group B beta hemolytic strep culture or rapid identification test;
(h) Consider amniocentesis in afebrile patient.
C. Management:
(1) Use of specific drugs should be by individual preference and/or by institutional policies and protocols.
(2) Tocolysis should be instituted if contractions persist for greater than 1 hour or there is documented cervical change.
(3) Appropriate monitoring during tocolysis may include any or all of the following:
(a) Pulmonary status;
(b) Cardiovascular status;
(c) Glucose;
(d) Clotting factors;
(4) Discharge instructions should include:
(a) Instructions regarding early signs of labor;
(b) Early follow-up appointment.
D. Contraindications:
Absolute Relative
1. Severe hypertension 1. Advanced labor
2. Fetal compromise 2. Cardiac disease
3. Chorioamnionitis 3. Mild hypertension
4. Severe abruption 4. Hyperthyroidism
5. Severe IUGR 5. Diabetes mellitus
6. Lethal fetal anomaly 6. Mild abruption
7. Severe uterine bleeding 7. Mild IUGR
8. Fetal anomaly
9. Stable placenta previa
(References: Precis IV; An Update in Obstetrics and Gynecology; Quality Assurance in Obstetrics and Gynecology; The American College of Obstetricians and Gynecologists UNICORN; Guidelines for Obstetrical Care, University of Connecticut Regional Network.)
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