The idea of giving birth to a premature baby is daunting for any new parent. For the past 20 years I have been involved in looking after preemies in hospital and then following them up for a couple of years afterwards. It comes with huge ups and downs, not only for the parents but also for the medical personal.
In this article I will try to explain why premature births happen, what to expect while in the Neonatal Unit and what to expect when going home.
Premature (also known as preterm) birth is when a baby is born too early, before 37 weeks of pregnancy has been completed. The earlier a baby is born, the higher the risk of death or serious disability.
- Late preterm, born between 34 and 36 completed weeks of pregnancy
- Moderately preterm, born between 32 and 34 weeks of pregnancy
- Very preterm, born at less than 32 weeks of pregnancy
- Extremely preterm, born at or before 25 weeks of pregnancy
Most premature births occur in the late preterm stage.
What leads to premature birth
There are known risk factors contributing to premature births. These include:
- Previous premature birth
- Pregnancy with twins, triplets or other multiples
- Less than six months between pregnancies
- Conceiving through in vitro fertilization
- Uterine, cervical, or placental problems
- Smoking cigarettes, e-cigarettes or using illicit drugs
- Infections of the amniotic fluid, urinary tract infections, gastroenteritis
- Underlying conditions, such as high blood pressure and diabetes in pregnancy
- Being underweight or overweight before pregnancy
- Stressful events
- Previous miscarriages or abortions
- Physical injury or trauma
- Pre-existing or underlying medical illness
A premature birth can happen to anyone. In fact, many women who have a premature birth have no known risk factors.
In most cases however, premature births are unexpected and not preventable, but by regularly following up with your Obstetrician and leading a healthy lifestyle at least you have a good chance of reaching full term or a healthy preterm baby.
The following table shows the median (average) birth weight of premature babies at different gestational ages:
What to expect during the delivery
Due to the unexpectedness of most preterm deliveries, you might not have had the opportunity to have met your babies paediatrician/neonatologist.
In most cases, due to the urgency of the delivery, it will not be possible to accommodate a birth plan.
Most preterm babies get delivered via caesarean section, but there are the exceptions.
Skin to skin after the delivery will in most cases not be possible.
As mother, you will most likely only see your baby the following day once you are stable and mobile. As the father or partner, you will be able to visit your baby as soon as he/she is stable.
Your baby will be admitted to the neonatal high care unit or neonatal intensive care unit to receive the necessary medical support and you will be updated by the caring doctor and nursing staff.
Neonatal units encourage as parent baby contact; however, they do also have visiting hours which will be communicated to you. This is needed so doctors can do their rounds and necessary medical procedures and nursing staff can do their cares.
Despite delivering a preterm baby, breastmilk gets produced nearly immediately. Until your baby can breastfeed, breastmilk production needs to be encouraged by either manual expression or by using a breast pump.
In the first 24 hours manual expressing has the best results, producing 2-5ml every 3 hours. In most cases the milk disappears for one or two days and then starts flowing. It is a good idea to invest in a good electric or manual breast pump. Your Obstetrician can prescribe medication to encourage breastmilk production if there is a need for it.
Your baby may need extra help feeding and adapting immediately after delivery. Your health care team can help you understand what is needed and what your baby’s care plan will be.
While not all premature babies experience complications, being born too early can cause short-term and long-term health problems. Generally, the earlier a baby is born, the higher the risk of complications.
Some problems may be apparent at birth, while others may not develop until later and will be picked up on your follow up consultations with your paediatrician.
Short-term complications during stay in Neonatal Unit
The more premature your baby is at delivery, the more assistance he/she will be needing. That could mean that the first time you meet your baby it might have some medical devices attached to him/her which could look very intimidating. This is however to make sure that your baby’s vital signs get monitored accurately and that your baby gets the necessary supportive treatment.
These attachments could include intravenous lines, nasogastric feeding tubes, saturation monitors, ECG leads, temperature monitors, breathing devices, etc.
In the first weeks, the complications of premature birth may include:
Immediate breathing problems – When a preterm delivery is anticipated, you will in most cases receive antenatal steroid injections to help mature your baby’s lungs.
Despite this,premature babies often have difficulty in breathing due to an immature respiratory system. Your baby may need breathing support- nasal cannula oxygen, HiFlow oxygen, CPAP or ventilation.
Apnea – is also common in preterm babies. Your baby will stop breathing for a few seconds and then start again.
Bronchopulmonary dysplasia – very premature babies can develop a lung disorder known as bronchopulmonary dysplasia, where they remain oxygen dependent for more than a month. In exceptional cases they might even get discharged home on oxygen support.
Heart problems – the most common heart problem premature babies experience is a patent ductus arteriosus (PDA). PDA is a persistent opening between the aorta and pulmonary artery. While this heart defect often closes on its own, left untreated it can lead to a heart murmur, heart failure as well as other complications.
Brain problems – the more preterm your baby is born, the greater the risk of bleeding in the brain. This is known as an intraventricular haemorrhage. Most haemorrhages are mild and resolve with little short-term implications. Some babies may have larger brain bleeding that causes permanent brain injury. The size of the bleed does not necessarily predict the neurological outcome.
Temperature control problems – premature babies’ skin is still underdeveloped and relative to their weight they have a significantly bigger body surface area. They can lose body heat rapidly. They don’t have the stored body fat of a full-term infant, and they can’t generate enough heat to counteract what is lost.
Hypothermia in a premature baby can lead to breathing problems and low blood sugar levels. In addition, a premature infant may use up all of the energy gained from feedings just to stay warm. That is why smaller premature infants require additional heat from a warmer or an incubator until they’re larger and able to maintain body temperature without assistance.
Gastrointestinal problems – premature infants are more likely to have immature gastrointestinal systems, resulting in complications such as necrotizing enterocolitis (NEC). This potentially serious condition, in which the cell lining of the bowel wall is injured, can occur in premature babies after they start feeding. Premature babies who receive only breast milk have a much lower risk of developing NEC.
Blood problems – premature babies are at risk of blood problems such as anaemia and neonatal jaundice. Anaemia is a common condition in which the body doesn’t have enough red blood cells. While all newborns experience a slow drop in red blood cell count during the first months of life, the decrease may be greater in premature babies. For this reason, they might need a blood transfusion (mostly the very premature infants) or be started on iron supplementation.
Newborn jaundice is a yellow discoloration of your baby’s skin and eyes that occurs because the baby’s blood contains excess bilirubin, a yellow-coloured substance, from the liver or red blood cells. While there are many causes of jaundice, it is more common in preterm babies, and they might need phototherapy for a few days
Metabolic problems – premature babies often have problems with their metabolism. Some premature babies may develop an abnormally low level of blood sugar (hypoglycaemia). This can happen because premature infants typically have less brown fat than full-term babies. Premature babies also have more difficulty converting their stored glucose into more-usable, active forms of glucose.
Immune system problems – an underdeveloped immune system can lead to a higher risk of infection. Infection in a premature baby can quickly spread to the bloodstream, causing sepsis and needing I intravenous antibiotics.
In the long term, premature birth may lead to the following complications:
Cerebral palsy – cerebral palsy is a disorder of movement, muscle tone or posture that can be caused by infection, inadequate blood flow or injury to a newborn’s developing brain either early, during pregnancy or after delivery while the baby is still young and immature.
Impaired learning – premature babies are more likely to lag behind on various developmental milestones. A child who was born prematurely might be more likely to have learning disabilities which can range from mild attention deficit disorder to severe learning disabilities.
Vision problems – premature infants may develop retinopathy of prematurity, a disease that occurs when blood vessels swell and overgrow in the light-sensitive layer of nerves at the back of the eye (retina). If undetected this can impair vision and cause blindness. There are certain criteria the neonatal units follow to determine which babies need a ROP screening test.
Hearing problems – premature babies are at increased risk of some degree of hearing loss. All babies will have their hearing checked before going home.
Dental problems – premature infants who have been critically ill are at increased risk of developing dental problems, such as delayed tooth eruption, tooth discoloration and improperly aligned teeth.
Behavioural and psychological problems – children who experienced premature birth may be more likely than full-term infants to have certain behavioural or psychological problems, as well as developmental delays.
Prevention of premature births
In most cases the reason for the premature birth is unknown but for especially those mothers who have an increased risk for premature labour one can reduce their risk by:
- A healthy lifestyle – diet, exercise, reduced stress, less alcohol, less smoking.
- An early follow up with Obstetrician.
- Progesterone supplements for women who have a history of preterm birth.
- Cervical cerclage; this is a surgical procedure performed during pregnancy in women with a short cervix, or a history of cervical shortening that resulted in a preterm birth.
What to expect when bringing a preemie baby home
Taking your premature baby home may feel intimidating and you no longer have the neonatal staff on hand for support. Preemies’ needs are different to those of full-term babies.
- You might need some extra equipment. Apnea monitoring, saturation monitoring if your baby comes home on oxygen.
- It can be trying at first. Most preemies will be discharged both breast and bottle feeding. They feed more frequently because their endurance is less, and their tummies are smaller. Therefor the rest period between feeds is shorter than for full-term babies. Also, they don’t sleep as deeply or for as long as full-term babies. Sleep-deprivation is a sure cause for heightened parental anxiety and stress.
- Minimize visitors. You need the time to rest/sleep, to reconnect and it keeps unwanted infections away.
- The first month at home will not be perfect. Contact your paediatrician if you have concerns and see them regularly, but also remember that the NICU experts wouldn’t have sent your baby home unless they felt you were both ready.
Tips on bringing your preemie home
Make sure you have a support network in place once you are at home.
- Paediatrician- have your follow up appointments booked.
- Breastfeeding consultant-Preemies usually get discharged breast and bottle feeding. Slowly breastfeeding will replace the bottles. Preemies have difficulty latching and once latched they battle to stay awake long enough to get a full feed. Your milk supply might also diminish the first week after discharge. Once you settle into a routine it usually improves again. It is worth your while to invest in a good breast pump.
- CPR course. Attend a course while your baby is in hospital.
- Grandparents/Aunt/ helper.
- Stay in touch with the preemie parents you met in the NICU. Nights can get long, and t is good to be able to text someone going through the same situation in the middle of the night.
- Be conscious of possible postnatal depression in both you and your partner. Get help sooner rather than later. Fluctuating hormones, anxiety and sleep deprivation are a sure recipe for postnatal depression.
What to expect when caring for a preemie at home
- Your baby might be smaller when you take him home than a full-term newborn. The discharge is not dependent on the size but the ability to feed well and gain weight. Spend as much time as possible with your baby in the neonatal unit and become comfortable with caring for your baby.
- Your baby’s immunity is not the same as that of a newborn. Limit visitors if possible. Limit exposure to toddlers. Avoid overcrowded spaces. It should be safe to take your preemie into public spaces by 3 months of age.
- Your baby needs more rest. It’s exhausting for preemies to simply be awake, much less in an alert state or breastfeeding. Make sure your baby gets good uninterrupted sleep between feeds. They need frequent feeding during the night and still need to be woken up for feeds. Make sure that you get rest between feeds and don’t have too much planned for the initial days at home. Caring for your premature baby may be all-consuming, at least for a while.
- Your baby’s development will initially take time to catch up to the newborn. Your baby will not follow the typical developmental milestones. You won’t be able to follow the typical apps available. Their milestones are determined by their adjusted age. So, if your baby was born at 32 weeks gestation, 8 weeks premature, he or she will only be behaving like a newborn at 8 plus 8 weeks.
- Sleeping positions. The UK follows ‘Back is Best”. Some preemies may have to sleep on their sides because of lung issues, so ask your doctor about sleeping positions. But for most babies, back is best, which is especially important for premature babies because they’re at greater risk of Sudden Infant Death Syndrome (SIDS). Leave blankets, soft bedding, pillows, and stuffed animals out of the crib. Maintain the room temperature between 20-22 degrees Celsius. Keeping the room cool can reduce the risk of SIDS. Additionally, avoid smoking.
It is a tremendous journey with lots of ups and downs. Your healthcare practitioners are there to guide you and walk this path with you.
Dr Hedi van der Watt is a Paediatrician based in Claremont, Cape Town. She has a special interest taking care of preterm infants and newborns, mainly operating from Life Kingsbury Hospital’s Neonatal and Paediatric units. Dr van der Watt’s smallest surviving newborn to date is 390 gram and the youngest surviving gestation of 23 weeks.
Her practice is not limited to neonatology alone, it also includes general paediatrics, ranging from paediatric dermatology, childhood asthma, feeding related difficulties, learning difficulties and adolescent health.
T +27 21 761 3408