In a 28-year-old gravida 1, para 0 woman at 30 weeks gestation with active preterm labor (regular contractions, cervical dilation 2 cm, 80% effacement, no rupture of membranes), what is the most appropriate management?

Management of Active Preterm Labor at 30 Weeks Gestation

The most appropriate management is dexamethasone (or betamethasone), nifedipine for tocolysis, and GBS prophylaxis (Option C). This patient has active preterm labor with documented cervical change, requiring a comprehensive intervention strategy to optimize neonatal outcomes while prolonging pregnancy for corticosteroid administration.

Rationale for Combined Intervention

Antenatal Corticosteroids (Essential)

• A single course of corticosteroids is mandatory for pregnant women between 24 0/7 and 33 6/7 weeks gestation at risk of preterm delivery within 7 days 1
• At 30 weeks gestation, corticosteroid administration significantly reduces death and neurodevelopmental impairment, decreases intraventricular hemorrhage, periventricular leukomalacia, and necrotizing enterocolitis 2
• Corticosteroids are the only antenatal intervention proven to improve postdelivery neonatal outcomes, including reduction in neonatal mortality, intracranial hemorrhage, necrotizing enterocolitis, and neonatal infection 3
• The standard regimen is 2 doses of 12 mg betamethasone administered intramuscularly 24 hours apart (or equivalent dexamethasone dosing) 4

Tocolytic Therapy (Indicated for Steroid Administration Window)

• Tocolytics, especially calcium channel blockers like nifedipine, may allow time for administration of antenatal corticosteroids and are effective in delaying delivery for 48-72 hours 3
• Nifedipine tocolysis may delay delivery between 48-72 hours after 26 weeks gestation, providing the critical window needed for corticosteroid efficacy 2
• While tocolytics have not been shown to decrease overall preterm delivery rates, their role in providing a 48-hour window for steroid administration is clinically valuable 5, 6
• The goal is temporary pregnancy prolongation—tocolytics should be used for the shortest time possible and are not recommended for long-term maintenance therapy 5

GBS Prophylaxis (Mandatory in Preterm Labor)

• GBS prophylaxis is mandatory for all women with preterm delivery (<37 weeks) and labor or rupture of membranes, regardless of known GBS colonization status 2
• At 30 weeks gestation, GBS screening results are not yet available (typically performed at 35-37 weeks), so empiric prophylaxis is required 2
• Intrapartum antibiotic prophylaxis reduces vertical transmission of GBS and provides 86-89% effectiveness in preventing early-onset neonatal sepsis 7
• Initiate IV penicillin G (5 million units loading dose, then 2.5-3 million units every 4 hours) or ampicillin (2 g loading dose, then 1 g every 4 hours) immediately 2, 7

Why Other Options Are Inadequate

Option A (NICU notification only) - Insufficient

• While NICU notification is appropriate, simply anticipating delivery without intervention abandons proven therapies that reduce neonatal morbidity and mortality 1
• This approach fails to utilize the 48-72 hour window that tocolytics can provide for corticosteroid administration 2

Option B (Corticosteroids alone) - Incomplete

• This omits tocolysis, which is needed to prolong pregnancy long enough for corticosteroids to take effect (optimal benefit requires 24-48 hours) 6, 3
• Critically, this option fails to provide GBS prophylaxis, which is mandatory in preterm labor regardless of colonization status 2

Option D (Observation only) - Dangerous

• This patient has active preterm labor with documented cervical change (2 cm dilated, 80% effaced, regular contractions), not threatened preterm labor 2
• Observation alone denies the patient all three evidence-based interventions that improve outcomes 2, 1, 3

Clinical Implementation Algorithm

1. Immediate actions (within first hour):

   • Obtain vaginal-rectal GBS culture (though treatment should not be delayed pending results) 2
   • Initiate IV GBS prophylaxis with penicillin G or ampicillin 2
   • Administer first dose of betamethasone 12 mg IM 1
   • Begin nifedipine tocolysis (loading dose 20 mg orally, then 10-20 mg every 4-6 hours as needed) 2

2. Within 24 hours:

   • Administer second dose of betamethasone 12 mg IM 4, 1
   • Continue GBS prophylaxis every 4 hours until delivery 2
   • Continue tocolysis for 48 hours to allow steroid efficacy 6

3. Ongoing management:

   • Notify NICU of potential preterm delivery 2
   • Continuous fetal heart rate monitoring 7
   • Monitor for signs of chorioamnionitis (fever, maternal/fetal tachycardia, uterine tenderness) 8

Critical Pitfalls to Avoid

• Do not use amoxicillin-clavulanic acid in the setting of preterm labor with intact membranes—it increases necrotizing enterocolitis risk and does not prolong pregnancy 2, 8
• Do not delay GBS prophylaxis waiting for culture results in preterm labor 2
• Do not continue tocolytics beyond 48-72 hours—prolonged maintenance tocolysis has not been shown to prevent preterm delivery and increases maternal/fetal risks 5
• Do not administer antibiotics for pregnancy prolongation in preterm labor with intact membranes (only indicated for PPROM) 2