Why have I been referred?
The Preterm Birth Surveillance Clinic aims to provide extra care for women who may be at an increased chance of having a baby born prematurely (early). There are a number of reasons that can make pre-term birth more likely, such as;
- previous birth before 34 weeks
- previous late miscarriage
- the ‘waters’ (amniotic sac) have broken before 34 weeks in a previous pregnancy
- previous surgery or punch biopsy to the cervix after an abnormal smear test
- previous cervical suture to your cervix in a previous pregnancy
- an unusually shaped womb (uterus)
- previous caesarean section when your cervix was fully dilated (10cm)
At your booking appointment, your community midwife will ask you about your history and whether you have experienced any of the above events. This will help to guide your advised pathway of care. If there is an indication that you may be more likely to have your baby prematurely or there are any other factors in your history that require review from a doctor during pregnancy, you will be referred for Consultant Led Care.
What will happen when I visit the clinic?
Following your dating ultrasound scan at 12 weeks, you will see a doctor who will again discuss your medical history and any previous pregnancies with you. This assessment will then help to shape your personalised plan of care. This can vary person to person depending on your individual circumstances but will often involve the following;
From 16 weeks onwards
You may be offered a transvaginal ultrasound scan of your cervix. This is a scan where an ultrasound probe is placed into the vagina. This will allow the sonographer to measure your cervix, to assess for any shortening. Evidence suggests that when a cervix is less than 25mm in length, the higher the chance of going into early labour. Your bladder should be empty for this scan.
From 18 weeks pregnant
You may also be offered a vaginal swab test to measure the levels of a protein known as fetal fibronectin. This is an examination, completed by a doctor or midwife, where they insert an instrument called a speculum into your vagina to help them to see your cervix. They will then place a swab (like a cotton bud) into the vagina for 10 seconds. A speculum examination does not harm you or your baby, but may be a little uncomfortable. Your swab is then put through a machine which takes 10 minutes to provide a result.
The results of your cervical length scan, fetal fibronectin vaginal swab and risk factors for preterm birth are used to calculate your risk of going into labour early using an assessment tool known as the QUIPP app.
Depending on your care pathway, you may have an appointment to see the doctor after your cervical length scan. If so, the results will be passed onto the doctor and they will discuss the results with you and amend your personalised plan of care, if required. If you do not have an appointment to see a doctor after your scan and swab, the midwife performing the test will discuss your result with you. If your results show you are unlikely to go into labour early you will be informed of this result and discharged home. If the results show that there is an increased risk of you going into early labour, you will be asked to wait to see a doctor after your scan to discuss the results and a personalised plan of care.
Depending on your results, your personalised plan of care may include;
- Repeat fetal fibronectin and cervical length scan at 22-24 weeks
- Repeat fetal fibronectin and QUIPP assessment scan at 30 weeks
There are some things which can make the swab test less reliable. We recommend that you avoid the following for two days before you attend the clinic:
- sexual intercourse
- vaginal douching (this involves flushing the vagina with water for the purpose of cleaning)
Where does the clinic take place?
The Preterm Birth Surveillance Clinic is held on Tuesday mornings in the Pregnancy Assessment Unit and Women’s Health Clinic. If you are having a cervical length scan and fetal fibronectin test, this will take place in pregnancy assessment unit. Then you will be directed to Women’s Health Clinic for your appointment with a doctor.
Sometimes emergencies and unexpected events can increase waiting times in the clinic or Pregnancy Assessment Unit. We appreciate your patience and will keep you informed if delays occur.
What is a Quantitative Fetal Fibronectin (gfFn) test?
Fetal fibronectin is a protein which is produced during pregnancy. It works as ‘glue’ between the amniotic sac (where your baby is in its ‘bag of waters’) and the uterus (your womb). As fetal fibronectin is the ‘glue’ around your uterus, it cannot normally be found in the vagina until near term (your due date). If it is found in your vagina earlier it could indicate that you are going into preterm labour. When undertaking a speculum examination, doctors and midwives use a swab to detect any fetal fibronectin present. We normally get the result back within 10-20 minutes. The quantitative fetal fibronectin result can range from 0 to over 500 ng/ml. We then enter the result into the QUiPP app along with your symptoms and history.
What is the QUIPP App?
QUiPP is a mobile phone app which accurately predicts how likely you are to go into preterm labour. The app is based on research from over 1,000 women, can be used in singleton and twin pregnancies, and has been validated (which means we know the results it gives are accurate).
To use the app, the doctor or midwife inputs your medical history and the results from some of the tests explained above (your fetal fibronectin results and/or cervical length measurement). The QUiPP app can then give a percentage chance of giving birth within the next week (for example, a 5% chance of having your baby within the next week vs 95% chance of not having your baby within the next week).
The doctor or midwife caring for you can show you your personalised results on the app and explain to you what your result means. If your chance of giving birth within the next week is 5% or more, the doctors and midwives may advise that you are admitted to hospital so that we can observe for any signs of labour beginning.
If your chance of giving birth within the next week is less than 5% then it will be suitable for you to go home, providing there are no other concerns with you or baby.
You can download the QUiPP app for free (search QUiPP in android or App store, or go to www.quipp.org), however remember you will need to input one of the above test results that the doctor or midwife has completed to get a final result.
When to seek advice
Sometimes there are signs that you may be going into labour. Often the signs may not lead to preterm labour but it is important to let a midwife know if you are experiencing any so you can get advice and be assessed if required.
These signs may include:
- period-like pains, cramps or ‘tightenings’ across your abdomen which come and go
- signs of your waters breaking/fluid leaking from the vagina
- bleeding from the vagina
If you think you may be in labour, do not wait for your next appointment in the preterm birth surveillance clinic. Call the Pregnancy Assessment Unit (PAU) immediately.
Should I still attend my antenatal appointments with my midwife?
Yes. You should attend all other antenatal appointments in addition to visiting us.
The Preterm Birth Surveillance Clinic is extra care for women more likely to have a preterm birth. It does not replace any other care you have.
Research in the clinic
There is much that is still unknown about the causes, best management and prevention of preterm birth. The clinic is dedicated to enhancing knowledge in the hope to establish an evidence based approach to care.
You may be eligible for one, or more, research projects going on in the clinic. You may be approached and asked to consider taking part. Taking part is voluntary, and will not affect your maternity care, but may help care for women in the future.
Useful sources of information
At the Queen Elizabeth Hospital Maternity Unit, we advocate a shared decision making approach to all decisions made by our patients. This leaflet aims to give you additional information and to act as a point of reference following a discussion with your obstetrician or midwife. If you are asked to make a decision about your own care please make sure you have asked all the questions you need to ask and are given the appropriate time to do so. Some questions you might want to ask could be;
- What are my options?
- What are the pros and cons of each option?
- Who will support me making the decision that is the right one for me
If you have any additional queries please contact:
Any personal information is kept confidential. There may be occasions where your information needs to be shared with other care professionals to ensure you receive the best care possible.
In order to assist us to improve the services available, your information may be used for clinical audit, research, teaching and anonymised for National NHS Reviews and Statistics.