新生兒死亡中仍以早產者佔大多數，因此應讓胎兒儘量留在子宮內至足月。 

需安胎之情況：

1.    早期宮縮（Preterm labor, PTL）。

2.    早期破水（Premature rupture of membrane, PROM）。

3.    子宮異常。

4.    子宮過度漲大，如羊水過多（Polyhydramnios），多胞妊娠。

5.    產前出血（Antepartum hemorrhage, APH），如胎盤早期剝離，前置胎盤。

6.    母親疾患，如妊娠高血壓（PIH），妊娠糖尿病（GDM）等。

一般住院安胎醫囑：

ò Admitted to the service of Dr.                     

ò Check vital sign as DR/Ward routine

ò On diet

ò Check CBC/DC, U/A, CRP

ò Set IV with D5W run 100 ml/hr

ò Bed rest (with hip elevated when PROM)

ò On fetal monitor & check FHB q30 min.（若週數較小，則適時聽胎心音即可）

ò Ultrasonography

安胎第一線藥物為Ritodrine，但須注意其禁忌症，其用法為：

ò Ritodrine 3 Amp in D5W 500 ml run 20 mgtt/min

ò Ritodrine á30 mgtt/min（必要時每10鐘調整至無宮縮）

ò Ritodrine á40 mgtt/min（必要時每10鐘調整至無宮縮）

ò Ritodrine á50 mgtt/min（必要時每10鐘調整至無宮縮）

ò Ritodrine á60 mgtt/min（必要時每10鐘調整至無宮縮）

ò Ritodrine á70 mgtt/min 

若仍有規則宮縮則考慮加上第二線藥物MgSO4

ò MgSO4 2 amp IV slowly push ( > 15 min) as loading dose

ò MgSO4 10 amp in D5W 300 ml run 1 gm/hr（調整至無宮縮）

ò MgSO4 10 amp in D5W 300 ml run 1.5 gm/hr（調整至無宮縮）

ò MgSO4 10 amp in D5W 300 ml run 2 gm/hr（調整至無宮縮）

ò Check DTR, RR & I/O q4h, if DTR ê, RR< 12/min & urine output < 100 ml/4hr, notify Dr. soon

ò Prepare Ca gluconat 1 amp at bedside.-----------必要時拮抗MgSO4之作用。 

其他安胎常用之方法尚有：

1.  Hydration

2.  Indomethacin (Inteban) 1# supp (大於32週者禁用，以避免ductus arteriosus提早關閉)

3.  Nifedipine 

& 為促進胎兒肺部成熟，於28週以後可給予steroid (Dexan 12.5 mg ´ 3 dose qwk)，必要時可做羊膜穿刺術測胎兒肺部成熟（PG, L/S, Lamellar body）

 & Ritodrine (b-mimetic): 50 mg/5 ml/amp; 10 mg/tab.

MgSO4: 10%, 20 ml/amp.

Inteban: 50 mg/supp.

 Ritodrine由IV form改成口服方法：

ò Ritodrine run 10 mgtt/min combined with Ritodrine 1# P.O. q2h ´ 12 hr

ò DC IV form Ritodrine & keep Ritodrine 1# P.O. q2h ´ 12 hr

ò Ritodrine change to 1# P.O. q4h ´ 1 day

ò Ritodrine change to 1# P.O. q6h

Contraindications of tocolytic agents:

ð Ritodrine: Heart disease, Hyperthyroidism, Hypertension, DM.

ð MgSO4: Heart block, Myasthenia gravis, Myocardial damage, Impairment renal function.

Can not be used with Barbiturate, Narcotics, Hypnotic drugs.

Can not be used when Resp rate < 12/min, Urine output < 30 ml/hr

ð Nifedipine: Hypersensativity

Steroid administration:

  Dexan 12.5 mg iv q12h ´ 3 doses qwk

Contractions for the steroid administration

1.  PROM

2.  Multiple gestation

3. Less than 28 wks GA

Tocolysis Abdominal pain in later pregnancy and after childbirth 　

PROBLEMS

• The woman is experiencing abdominal pain after 22 weeks of pregnancy.

• The woman is experiencing abdominal pain during the first 6 weeks after childbirth.

GENERAL MANAGEMENT

• Make a rapid evaluation of the general condition of the woman including vital signs (pulse, blood pressure, respiration, temperature).

• If shock is suspected, immediately begin treatment. Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly. If shock develops, it is important to begin treatment immediately.

Note: Appendicitis should be suspected in any woman having abdominal pain. Appendicitis can be confused with other more common problems in pregnancy which cause abdominal pain. If appendicitis occurs in late pregnancy, the infection may be walled off by the gravid uterus. The size of the uterus rapidly decreases after delivery, allowing the infection to spill into the peritoneal cavity. In these cases, appendicitis presents as generalized peritonitis.

DIAGNOSIS

TABLE S-16 Diagnosis of abdominal pain in later pregnancy and after childbirth 

PRETERM LABOUR

Preterm delivery is associated with higher perinatal morbidity and mortality. Management of preterm labour consists of tocolysis (trying to stop uterine contractions) or allowing labour to progress. Maternal problems are chiefly related to interventions carried out to stop contractions (see below).

Make every effort to confirm the gestational age of the fetus. 

TOCOLYSIS 

This intervention aims to delay delivery until the effect of corticosteroids has been achieved (see below).

• Attempt tocolysis if:

- gestation is less than 37 weeks;

- the cervix is less than 3 cm dilated;

- there is no amnionitis, pre-eclampsia or active bleeding; 

- there is no fetal distress.

• Confirm the diagnosis of preterm labour by documenting cervical effacement or dilatation over 2 hours. 

• If less than 37 weeks gestation, give corticosteroids to the mother to improve fetal lung maturity and chances of neonatal survival:

- betamethasone 12 mg IM, two doses 12 hours apart;

- OR dexamethasone 6 mg IM, four doses 6 hours apart.

Note: Do not use corticosteroids in the presence of frank infection.

• Give a tocolytic drug (Table S-17) and monitor maternal and fetal condition (pulse, blood pressure, signs of respiratory distress, uterine contractions, loss of amniotic fluid or blood, fetal heart rate, fluid balance, blood glucose, etc.).

Note: Do not give tocolytic drugs for more than 48 hours.

If preterm labour continues despite use of tocolytic drugs, arrange for the baby to receive care at the most appropriate service with neonatal facilities. 

TABLE S-17 Tocolytic drugs^a to stop uterine contractions

^a Alternative drugs include terbutaline, nifedipine and ritodrine.
 

ALLOWING LABOUR TO PROGRESS

• Allow labour to progress if:

- gestation is more than 37 weeks;

- the cervix is more than 3 cm dilated;

- there is active bleeding; 

- the fetus is distressed, dead or has an anomaly incompatible with survival;

- there is amnionitis or pre-eclampsia.

• Monitor progress of labour using the partograph. 

Note: Avoid delivery by vacuum extraction as the risks of intracranial haemorrhage in the preterm baby  are high. 

• Prepare for management of preterm or low birth weight baby and anticipate the need for resuscitation.