Let’s Talk Prematurity!

November is Prematurity Awareness Month. This time of the year is dedicated to premature babies who through no fault of their own came into this world earlier than expected. The goal is to focus on what can be done to reduce the rate of premature deliveries. It is also important to focus on the ongoing challenges and concerns faced by our precious little ones and how we can use this opportunity to support mothers during this period of adjustment.  

What is prematurity? 

A premature baby is born before the beginning of the 37^th week of pregnancy. The earlier the gestational age, the greater the complications. According to the American College of Obstetricians and Gynecologists(ACOG), babies born before 28 weeks are considered extremely premature. Late preterm babies are born between 34 and 36 weeks of completed gestation.

What are the signs and symptoms of premature delivery?

Signs of preterm delivery is like that of regular labor:

• Abdominal pain.
• Change or increase in vaginal discharge which indicates leakage of fluid.
• Vaginal bleeding.
• Pelvic pressure.
• Contractions.
• Lower backache.

What causes premature birth?

The exact cause is not known. The following are some of the known risk factors of premature delivery:

• Previous delivery of a premature baby.
• Pregnancy with multiple gestations like twins, triplets, quadruplets, or other multiples.
• Chronic medical conditions such as uncontrolled Diabetes and Hypertension.

• Infections- Amniotic fluid and genitourinary infections.
• Short interval pregnancy of 6 months or less.
• Trauma to the abdomen.
• Maternal intrinsic stress or exposure to a stressful environment.
• Cervical Problems- cervical incompetence
• Uterine Problems-Fibroids or other abnormality of uterus.
• Smoking, maternal use of alcohol or illicit drugs.
• Certain abnormalities of the fetus.

How can we prevent premature births?

The Obstetrics team plays an important role in caring for mothers experiencing preterm labor. The treatment regimen for mothers includes the use of Progesterone, Betamethasone, Magnesium Sulfate and placement of a Cervical Cerclage. Management depends on the stage of prematurity and the clinical findings of the patient. Mothers are usually admitted or closely monitored. Strict bed rest is also a recommendation.

Providing access to prenatal care is vital for the maintenance of pregnancy and delivery outcome. Educating mothers during their prenatal visits and determining their risks of having a preterm delivery can make a big difference with delivery preparations. Measures to help mothers to be proactive can also be discussed such as having a bag packed way ahead of time and having a designated contact person in the event that there is an emergency.  During pregnancy, mothers can be referred to local community programs, offered lactation education and referred to reputable resources that can help with gaining access to information as they prepare for the birth of their newborns.

How do we manage a premature baby?

Management is based on the clinical presentation and gestational age of the baby and predelivery care. Neonatologists are also a part of this team. You may meet the Neonatologist before delivery and will continue to interact with these newborn specialists and neonatal nurses in the Neonatal Intensive Care Unit (NICU). 01
The team will treat your baby in anticipation of the expected findings and prevent or reduce the effects of possible complications. The treatment is based on the body system or systems that are affected. In terms of the respiratory system, if breathing problems develop and based on severity, management includes administration of oxygen via nasal cannula, Continuous Positive Airway Pressure (CPAP), and ventilator use. Chest X-ray is an imaging modality that is commonly performed to look closely at the lungs, line placement, or tube placements. The use of antibiotics will be necessary if the infection is suspected. IV fluids are given if the baby is unable to feed by mouth right away. Once stable, Expressed Breast Milk is the preferred type of feeding for a premature baby because this will put them at a lower risk of developing an intestinal disease called Necrotizing Enterocolitis (NEC). Babies will also require monitoring of blood glucose levels and placement in an isolette (incubator) for thermoregulation. For suspected Neurological symptoms, seizure precautions will be taken and head ultrasound may be indicated especially if Intraventricular Hemorrhage (IVH) is suspected. Pediatric ophthalmologists are consulted to examine the eyes to look for signs of Retinopathy of Prematurity. Blood transfusion(s) may be required if Anemia of Prematurity is suspected. Blood work is necessary in order to guide the management of your newborn baby. The Social Work team will also be a part of the team. They want to ensure that mothers have solid social support and help them to connect with necessary social programs for the baby when it’s time for discharge planning. Kangaroo care also known as skin-to-skin care is also recommended during the NICU course. This is beneficial to solidify mother-baby bonding and help your baby to thrive. Other routine management like that of a full-term baby such as hearing screen, metabolic screening and screening for critical congenital heart disease are also done before discharge.

What are the complications of a premature baby?

Short term complications usually occur immediately and during the first weeks of life and long-term complications are usually expected after the newborn period and or later in life. Babies are either admitted to the Neonatal Intensive Care Unit (NICU) or Transitional nursery status and treatment is based on the findings at birth. Some of the complications are listed below, according to body systems.

Short term:

Respiratory-Respiratory Distress Syndrome (RDS) and Apnea of Prematurity.

Cardiovascular- Heart Murmur due to Patent Ductus Arteriosus (PDA), Ventricular Septal Defect (VSD) or other cardiac abnormalities. 

Infectious Disease– Neonatal Sepsis.

Gastrointestinal- Necrotizing Enterocolitis (NEC), poor suck and swallow coordination concerns leading to feeding problems.

Hematology- Anemia of Prematurity and Jaundice.

Metabolic-Hypoglycemia and Hypothermia.

Neurology- Hypotonia, Hypertonia, Seizures andIntraventricular Hemorrhage (IVH).

Ophthalmology- Retinopathy of Prematurity (ROP) also known as retrolental fibroplasia.

Long Term:

Neurological: Seizures, Hypertonia.

Developmental and Behavioral- Vision, learning, hearing, speech and intellectual disability.

Other Chronic Medical Problems- Chronic infections and Asthma.

Post-delivery, what’s next for mothers and babies?

This depends on the classification of preterm babies because they may require prolonged hospitalization and the duration may vary from patient to patient. Discharge criteria is met when there is resolution of acute problems and if baby is stable enough to leave the hospital. Before discharge, baby has to pass a car seat challenge test and mother will require CPR Training. Babies will require close follow-up with their Pediatricians and Pediatric Subspecialists, based on the clinical findings during the hospital course and upon discharge. It is also important to assist mothers to prevent them from being overwhelmed. Social Workers are usually involved to determine if they also have a support person and assist with getting Home Visit Nurses, especially if the baby has complex medical problems.  Spousal or other family support is also encouraged.

March of Dimes, American College of Obstetricians and Gynecologists and the American Academy of Pediatrics are reputable national organizations with a wealth of educational information available for mothers to read before and after delivery. The Once Upon A Premie Academy is another professional organization that focuses on the care of premature babies. This organization was formed to raise awareness and help with providing training for perinatal and neonatal health care professionals.