KKH and the COGS launch guidelines to address Singapore’s preterm birth rates

17 Apr 2026

Shifts focus from ‘crisis management’ to prevention
Cervical length screening for pregnant women
Standard treatments to minimise early labour while protecting the baby’s brain

17 April 2026, Friday, Singapore – KK Women's and Children's Hospital (KKH) and the College of Obstetricians and Gynaecologists (COGS) today launched the first comprehensive update to Singapore's Guidelines on the Management of Preterm Birth.

Unveiled by Mdm Rahayu Mahzam, Minister of State, Ministry of Digital Development and Information & Ministry of Health, the Guidelines standardise preterm birth¹ screening, prevention and management to improve outcomes for mothers, babies and families.

Singapore’s preterm birth rate has remained consistently elevated at 8.5 per cent² – higher than other developed Asian neighbours like Hong Kong and China³ - for reasons that are not well understood.

Professor Teoh Tiong Ghee, Senior Consultant, Department of Maternal Fetal Medicine, KKH, said, “Preterm births affect close to 3,000 babies in Singapore every year. Premature infants often face a ‘marathon’ of health hurdles, including lifelong respiratory, neurological and developmental challenges that require intensive care and long-term specialist support. Beyond this, it also imposes substantial emotional and economic toil on the families.

“We are moving the needle from reactive treatment to proactive prevention. Preterm birth has always been managed only from the final months of pregnancy. The Guidelines ensure that risk assessment starts from the very first visit pregnancy visit. By identifying vulnerable pregnancies in advance, we can intervene early, reduce the need for neonatal intensive care, and give every baby the best start in life.”

Every pregnancy matters: prevention from day one

Main highlights of the recommendations designed to identify and manage risks early include:

Structured risk assessment at key pregnancy milestones

Healthcare professionals are recommended to conduct formal risk screening at the first pregnancy visit and reassess at key milestones throughout the pregnancy - at 11 to 13 weeks, 18 to 22 weeks, and 24 weeks.

A history of previous preterm birth is the most obvious risk factor. However, this structured approach ensures that first-time mothers and women with previous full-term births are not overlooked. Other important risk factors also considered include cervical surgery, multiple pregnancies, or infections that could lead to preterm birth in any pregnancy.

Cervical length screening for pregnant women

Cervical length screening is recommended for pregnant women during second trimester checkups (18 to 22 weeks). This simple procedure uses an ultrasound to identify a “short” cervix – a primary indicator of preterm birth.

Women with a short cervix (≤25mm) may benefit from early interventions like progesterone therapy or cerclage (surgical stitches around the cervix) for high-risk cases, that can help to prolong the pregnancy.

The Guidelines recommend for cervical length screening to be implemented gradually over the coming years, to allow sufficient time for adoption into clinical practice.

Standard treatments to minimise early labour while protecting the baby’s brain

Oral medication replaces intravenous (IV) treatment as first-line intervention
Nifedipine in oral tablet form has replaced the IV beta-agonists given through intravenous drips, offering a safer and more convenient way to stop or slow down preterm labour contractions. This change removes the need for monitoring and complex infusion protocols, whilst remaining equally effective at suppressing contractions.
Fetal brain protection
Magnesium sulphate is recommended as standard treatment for pregnant women at risk of delivering babies between 24 and 32 weeks. This treatment administered to mothers before delivery can significantly reduce the risk of brain damage in their babies during the most vulnerable period of premature birth. This represents a shift from the earlier previous guidelines where the treatment was used sparingly due to safety concerns.

(Refer to Annex A for the Guidelines)

From evidence to action

A KKH study⁴ conducted earlier this year revealed a gap in patient knowledge of preterm births. The study, involving 115 pregnant women aged 21 to 45 years, revealed:

45 per cent of the women were unaware of risk factors even though 87 per cent have heard of preterm birth.
67 per cent were unaware/unsure of preterm labour symptoms.
63 per cent were unaware/unsure of the long-term implications.

Professor Tan Kok Hian, Head and Senior Consultant, Perinatal Audit and Epidemiology Unit, KKH, said, "The KKH findings show that pregnant women require more comprehensive guidance and support from healthcare professionals regarding preterm birth risks, symptoms, and consequences. The 2026 Guidelines provide healthcare professionals with internationally validated, evidence-based tools for enhanced preterm birth care. These proven interventions enable early identification of at-risk women and offer treatments that can significantly reduce the likelihood of preterm birth.”

The Guidelines were developed by a workgroup under COGS, comprising obstetricians and gynaecologists from Singapore's leading maternity hospitals – KKH, Singapore General Hospital, National University Hospital, Thomson Medical Centre, Mount Alvernia Hospital. The Guidelines were endorsed by the COGS and the Academy of Medicine, Singapore.

The Guidelines join other evidence-based resources tailored by the KKH Maternal and Child Health Research Institute specifically for the region's multi-ethnic Asian population. These resources cover gestational diabetes, perinatal nutrition and mental health, sexual health for women of reproductive age, menopause management, child health and development.

¹Preterm birth is when a baby is born before 37 weeks of pregnancy.

²Preterm birth incidence in Singapore

³Preterm birth incidence in Hong Kong; Preterm births in China

⁴Phaik Ling QUAH, Angela HO, Tiong Ghee TEOH, Kok Hian TAN (2026). Knowledge, Awareness, Practices, and Perceptions of Preterm Birth Risk Among Women and Clinicians in Singapore: Implications for Guideline Development. Singapore Journal of Obstetrics & Gynaecology, 57 (2).

Annex A - Overview of the Singapore Guidelines on the Management of Preterm Birth

1. Preterm birth screening strategies	The Guidelines help healthcare professionals identify pregnant women who might deliver their babies too early (before 37 weeks), so they can take steps to prevent it or be better prepared. Who this applies to: Women expecting single or multiple babies Women with past history or no past history of preterm birth Women who have no signs and symptoms of preterm birth All levels of care (primary, acute hospitals) in public and private sectors.
Clinical risk assessment
1.1 Timing of screening	At the first pregnancy appointment At important pregnancy milestones (around 11-13 weeks, 18-22 weeks, and 24 weeks) If new problems arise during pregnancy
1.2 Documentation of risk factors	Clinicians should specifically enquire about and record the following high-risk factors to look for. Women are at higher risk if they have had: Previous early birth or pregnancy loss (16-34 weeks) Previous preterm prelabour rupture of membranes (PPROM) which is early water breaking (before 34 weeks) Previous cervical stitches (cerclage) Certain types of cervical surgery Major cervical procedures
1.3 Screening recommendations
1.3.1 Infection-related screening	Don’t routinely test for bacterial vaginosis in low-risk women Do test urine for bacteria in women who have had preterm birth before Don’t routinely screen for gum disease
1.3.2 Biomarker screening:	Don’t use fetal fibronectin (a protein that acts like "glue" holding the baby's membranes to the womb in pregnancy) as a main screening test
1.3.3 Universal cervical length screening in asymptomatic low-risk singleton pregnancies	Do measure cervix length with internal ultrasound at 18-22 weeks for all single pregnancies
1.3.4 Cervical length screening in twin pregnancies	Consider measuring cervix length for twin pregnancies
1.4 Definition of a short cervix	A "short cervix" is 25mm or less Use internal (transvaginal) ultrasound, the most accurate method

2. Antenatal management of asymptomatic women at risk of preterm birth	Once clinicians identify women at risk for preterm birth, here are the treatment options available:
2.1 Recommendations for the asymptomatic low-risk singleton pregnancy (no prior spontaneous preterm birth or mid-trimester loss)
2.1.1 Vaginal progesterone for low risk women with short cervix	If cervix is short (≤25mm), prescribe vaginal progesterone. What: Progesterone suppository/capsule inserted vaginally every night Dose: 200mg nightly When: Start between 16-24 weeks, continue until at least 34 weeks Why it works: Reduces risk of preterm birth by about 36-45 per cent Monitoring: Check cervix length every one to two weeks until 24 weeks Don’t use 17-OHPC (a synthetic form of the hormone progesterone), including compounded formulations) for the treatment of a short cervix)
2.1.2 Role of cervical cerclage (cervical stitch) for low-risk women with short cervix	For very short cervix (≤15.9mm): Can be considered For moderately short cervix (16-20.9mm): May be offered as alternative to progesterone What it is: A surgical stitch around the cervix to keep it closed Benefit: Reduces early birth risk by about 25 per cent Decision: Requires discussion with specialist about risks vs benefits
2.1.3 Role of cervical pessary for low risk women with short cervix	Don’t prescribe cervical pessary
2.2 Recommendations for the asymptomatic high risk singleton pregnancy
2.2.1 Vaginal progesterone for the high risk women	Consider giving vaginal progesterone to prevent preterm birth in high-risk women For women with short cervix and high risk for preterm birth, choice of vaginal progesterone or cervical cerclage depends on patient preference after discussing risks/benefits Progesterone: Regular nightly use throughout pregnancy Cerclage: One-time surgical procedure If cervix gets shorter despite progesterone: May need to add cerclage
2.3 Role of cervical cerclage in pregnancies	Types: History-based cerclage: For women with 3+ previous early births or classic cervical weakness Placed early in pregnancy based on history alone Ultrasound-indicated cerclage: For women with a single pregnancy and undergoing transvaginal cervical length measurement with a shortened cervix (see above) Emergency cerclage: For women whose cervix opens unexpectedly in mid-pregnancy Can extend pregnancy by four to five weeks on average
2.4 Transabdominal cerclage	For women where regular cerclage failed before Placed through abdomen, requires C-section delivery More effective than regular cerclage in select cases Can be done before getting pregnant or early in pregnancy. Doing it before conception may work better and doesn't affect fertility
2.5 Antenatal management of twin pregnancies	Twins are naturally at much higher risk (>50 per cent deliver early) Regular progesterone for all twins: Not recommended (may actually be harmful) Progesterone for twins with short cervix: May be considered (limited evidence) History-based cerclage for twins: Not recommended Emergency cerclage for twins with opening cervix: May be considered
2.6 Antenatal management of patient with congenital uterine anomalies	Surgery before pregnancy: Not proven helpful Progesterone: Not recommended Cervical monitoring and cerclage: Uncertain benefit

3. Management of symptomatic women at risk of preterm birth	When women are already showing signs of preterm birth, here's how clinicians manage the situation.
3.1 Antenatal corticosteroid	Give steroid injections before preterm birth to help baby's lungs mature and prevent death.
3.2 Aim of the inhibition of preterm birth	Delay preterm delivery for at least 48 hours after starting treatment to allow sufficient time for antenatal corticosteroids to promote fetal lung maturation. Do not attempt to stop preterm labour when immediate delivery is in the best interest of the mother and/or baby. Discontinue therapy if labour continues to progress despite treatment. When not to delay delivery: Baby has died or has fatal problems Baby is in distress Mother has severe pre-eclampsia or eclampsia Mother is bleeding heavily Signs of serious infection
3.3 Tocolytic agents (medications used to suppress or stop contractions during preterm birth)	For women 24-33 weeks with intact membranes and suspected or diagnosed with preterm birth Benefit: Prolong pregnancy, enabling the giving of corticosteroids, starting of antibiotics or transferring a pregnant woman to a different hospital or medical facility while the baby is still in the womb, before delivery occurs. First Choice: Nifedipine How well it works: Delays birth by 48 hours in most cases, extends pregnancy by ~five days Side effects: Headaches (most common), some may need to stop due to side effects Duration: Usually until labour stops or after 48 hours Second choice: Oxytocin blockers How well it works: This medication works similarly to nifedipine and can be substituted if patients experience side effects from nifedipine.
3.4 Role of magnesium sulphate (MgSO4)	Always give babies 24-32 weeks of pregnancy if in preterm labour Benefit: Reduces cerebral palsy risk by 29 per cent Dose: 4g injection over 15 minutes, then 1g per hour for up to 24 hours Monitoring: Check pulse, blood pressure, breathing, reflexes every four hours Side effects: Nausea, flushing, dizziness Repeat doses: Not recommended
3.5 Antibiotic use	Don’t give routinely if membranes are intact and no signs of infection Do give if: Group B streptococcus (a type of bacteria that commonly lives in the human body, particularly in the intestinal and genital tracts) carrier Previous baby had Group B streptococcus infection Signs of infection in womb If membranes are ruptured (water leaking)
3.6 Diagnostic tests for preterm labour	Consider biomarker tests - PAMG-1 or phIGFBP-1 to help predict whether a pregnant woman with symptoms of preterm labour will actually deliver within the next seven days Fetal fibronectin: No longer available (withdrawn in November 2025) Important: These tests help with decisions but don't diagnose labour by themselves
3.7 Management of preterm prelabour rupture of membranes (PPROM)	Give steroids to decrease risks of death and severe breathing condition Give antibiotics Don't give labour-stopping drugs - increases infection risk without benefit If PPROM happens before 34 weeks: Wait and monitor if mother and baby are well Deliver immediately if signs of infection or baby distress After 34 weeks: Either approach acceptable: immediate delivery OR wait and monitor Consider immediate delivery if Group B streptococcus carrier Must deliver by 37 weeks if labour hasn't started naturally Benefits of waiting: Reduces infection risk for mother Benefits of immediate delivery: Reduces lung problems for baby
3.7.5 Cerclage in-situ	If women has PPROM: If > 34 weeks, consider removal in most cases (reduces infection risk) May wait 48 hours only if 24-34 weeks and no infection (to complete steroid course) Never leave cerclage in during labour

To access the full Guidelines, please visit here