Premature infant

Contrary to popular belief, human pregnancy does not last "9 months". It normally varies somewhere from 38 to 42 weeks post conception. Any birth less than 37 weeks post conception is considered to be "premature" but that really doesn't say much. Anything less than 23 weeks is considered to be a non viable fetus almost everywhere but they are always pushing that window. 23 and 24 weekers are very dicey and if the baby lives s/he may have multiple and major life long impairments but some survive intact. 25 and 26 weekers are considered in many areas to have a fair chance of a normal life but still; many die or live but are impaired. 27 to 30 weekers can still have major problems but we are getting into a comfort zone with these babies. 32 - 33 weekers are almost easy. 34 - 37 weekers may not even go to the Neonatal Intensive Care Unit but need close follow up and have more frequent hospital readmissions.

Size is not the only issue. Babies can be AGA (appropriately sized for their gestational age) or LGA (large for their gestational age) and SGA (small for their gestational age). A SGA full term baby may superficially look like an AGA preemie but developmentally they are quite different. A LGA preemie may be bigger than a SGA full termer but have trouble breathing on his own.

Another classification system uses standard weights. Average BW (birth weight) is 3400g. LBW (low birth weight) means less than 2500g. Very low birth weight (VLBW) means babies with a BW less than 1500g. and extremely low birth weight (ELBW) means babies with a BW less than 1000g. Babies under 500g. do occur and survive (with frequent impairments).

LBW, VLBW and ELBW are not a diagnosis. They are just a convenient label to identify a group of babies with similar types of risks (premature and/or SGA).

Feedings of their own mother's milk is essential for premature babies. It should not be considered optional. Mother's milk is different if the baby is born prematurely than full term in a positive way. It has more of the components that premature babies need. It is also a life saving intervention that only the mother can provide. Already fragile, premature babies are more susceptable to infections when fed on formula.

Even if a mother did not plan to breastfeed she should pump her milk for her infant while in the NICU.

Paula Meier, a well known researcher in the field of breastfeeding premature infants speaks and writes about near term infants as well. She presents evidence that babies of 38 weeks gestation and below have developemental behaviors that mark them as premature. They look full term but they don't sustain their temperature nor feed as well as babies of 39 weeks or more. They are more often readmitted to hospitals because of this. Take home message, those near term 34 to 37 week gestation babies sent home after 2 days in hospital merit closer supervision than the average full term infant.

I was going to have a baby. Must have been kismet since I had gotten knocked up on Mother's Day.

At 30 years of age and in good health, I was ecstatic but a little scared. My husband and I had only been married about a year, but we were confident and blissfully unaware of what lay ahead.

As pregnancies go, mine was pretty routine, at first. Saltine crackers became my best friend in the battle of nausea. It's amazing how well sandwiches can sustain you when aromatic cooking odors stimulate the gag reflex.

I followed the "rules " to the letter. I quit all caffeine and began drinking water (goodbye Diet Coke) of all things. Took my vitamins and didn't smoke. I even modified my die hard aerobic exercise program and began walking and swimming instead. In fact, I was the poster child for a healthy pregnancy.

The first sign of trouble came at about 28 weeks GA gestational age. It was a normal Sunday afternoon but I kept having this nagging back pain. Reminded me of the cursed cramps. Finally I called my midwife (that's another story for another day). "We better check it out" she said. Off to the hospital I went. They prodded and checked this and that and said my cervix was a "little soft." So I was just to take it a little easy for a day or so.

Being the fearless (i.e. stupid) woman that I am, I went right back to work the next day. Hey, I wasn't sick so what was I going to do at home all day? Sometime in the middle of the morning I noticed a red discharge and felt real fear for the first time. Tears threatened to surface as horrible thoughts flashed through my mind of miscarriage, pain and loss. I went home and spent the rest of the day in bed.

A week later at a checkup I was told that my cervix was undergoing some definite changes. I was going to have to quit work and go on bed rest for the remainder of my pregnancy.

Visions of rest and relaxation flashed through my mind. And then it hit me like a furnace blasting in the middle of a blizzard: anger, guilt and pain, all at once. What had I done to bring this on? Thoughts of some past transgressions came to mind, a sort of karmic justice. However; as I later learned, the reasons for premature labor aren't always known. In fact in half of all cases of preterm labor there is no identifiable cause. Around 11% of all births are premature, meaning less than 37 weeks gestational age.

Causes of preterm labor

Multiple factors may increase the chances of preterm delivery. Lifestyle choices which may increase a woman's risk include:

• Late or no prenatal care
• Smoking
• Drinking alcohol
• Using illegal drugs
• Domestic violence, including physical, sexual or emotional abuse
• Lack of social support
• High levels of stress
• Long working hours with long periods of standing
• Low income

Other risk factors may be due to medical conditions including:

• Multiple pregnancies – twins, triplets etc
• History of preterm birth
• Uterine or cervical abnormalities
• Premature rupture of the membranes (the sac inside the uterus that holds the baby breaks too soon)
• Urinary tract infections, vaginal infections, sexually transmitted infections and possibly other infections
• High blood pressure
• Diabetes
• Clotting disorders (thrombophilia)
• Being underweight before pregnancy
• Obesity
• Short time period between pregnancies (less than 6-9 months between birth and the beginning of the next pregnancy)
• Certain birth defects in the baby
• Bleeding from the vagina

The truth of the matter is the experts don't know exactly what triggers labor, so they don't know why it starts too early.

Some of the symptoms of preterm labor (experienced before 37 weeks) include:

• Frequent uterine contractions, every every 10 minutes or more often
• Clear, pink or brownish fluid (water) leaking from your vagina
• Pelvic pressure (may feel like the baby is pushing down)
• Low, dull backache
• Menstrual-like cramps (which may come and go)
• Abdominal cramps (with or without diarrhea)

Treating preterm labor with drugs and bed rest will sometimes prevent an early delivery. Such was not to be my fate or that of my daughter, Sarah. After being at home for about a week I started having those nagging back pains again. My husband, at a new job in a new city, was unable to be there with me. A friend drove me to the hospital and I was admitted to the labor and delivery floor.

Hooked up to a baby monitor I could see my contractions spike on the machine in a very regular wave pattern. By this time I was about 30 ½ weeks along, still too early to even think of having that baby pop out. A drug called magnesium sulfate was administered to me IV in the hopes of stopping the contractions. No pleasant drug this. Dreams of desert heat and burning sands flood my memories of this experience. Imagine a red hot poker slicing through your veins and you will have a good idea of the effects of this drug.

Insurance companies were much more lenient 20 years ago so I continued to stay in bed, eat and watch TV. One day ran into the next. With only 4 local channels I was getting pretty sick of As the world turns, He-Man and She-Ra. The doctors were worried about the side effects of the drug and it wasn't doing a damn thing anyway. Those little squiggles on the chart continued to peak in spite of everything the medical professionals did.

Finally, after about a week and a half, I had had enough. I wanted to go home. I had already made arrangements for friends and family to come by and bring food or whatever I needed. The doctors gave me an injection of Beta Methasone, a corticosteroid that would help mature my baby's lungs if she decided to come early, and sent me home.

I went home on a Sunday. My husband had been home for the weekend but he had to leave for his job later that day. My mother-in-law had graciously agreed to stay and help out. She was really wonderful, preparing my food and getting everything I needed. For the first time in my life I came to appreciate what life must be like for the disabled and elderly. I was only allowed to get up for the basic necessities.

Early Monday morning I got up to relieve myself when I felt this trickle down my leg. My water had broken and ready or not Sarah was coming. After calling my midwife, my mother-in-law drove me to the hospital. She is usually a pretty cautious driver but I believe she broke some records that day. The contractions had begun and they were coming fairly frequently. There was a direct correlation between my screams and her use of the accelerator. We must have been doing 90 by the time we reached the hospital.

For a normal pregnancy the cervix needs to dilate to approx 10 cm for birth. In premature deliveries the smaller baby requires less room. On admission I was already dilated to 6 cm. Sarah was born an hour later. At 32 weeks GA, she weighed 1735 gms (3.5 lbs).

I was able to hold her for a couple of minutes before she was whisked off to the Neonatal Intensive Care Unit (NICU) where she stayed for 3 weeks. I went every day touching her leg or arm and speaking to her until I was finally able to hold her, tubes and all. Babies, especially preemies, need touch in order to survive.

She developed jaundice and apnea of prematurity but not the dreaded hyaline membrane disease. She was kept on oxygen for several days but eventually was able to breathe on her own. Preemies may develop a host of medical problems depending on their size and gestational age at birth. Temperature instability due to decreased body fat often requires the baby be kept in an temperature controlled bed. Breathing problems or chronic lung disease may develop from long term (greater than 4 weeks) use of oxygen or a ventilator. Increased risk of infections and brain bleeds (intraventricular hemorrhage), intestinal inflammation (necrotizing enterocolitis), blindness (retinopathy of prematurity) and anemia are among some of the other complications that can occur.

Breastfeeding was my answer to the helplessness most parents feel when they have a baby in the hospital. I rented an electric breast pump and dutifully expressed milk every 4 hours night and day until Sarah was old enough to begin nursing.

The milk of a mother with a premature infant is different, formulated by nature to provide just what a preemie baby needs. Depending on the size and age of the baby, the sucking/swallowing reflex is not developed until 32 to 35 weeks. In addition, the energy required to nurse may be too much for a low birth weight baby. Initially a preemie may be fed mother's milk by a nasogastric tube (NG), extending from her nose directly into the stomach. The baby can then gain all the benefits of breast milk, especially antibodies to help fight infection.

Finally the day arrived. We were going to take our baby home. Weighing in at a little over 4 lbs (2030gm), Sarah was a very tiny bundle of joy. We still have a picture of her daddy holding her in the palm of his hand. Developmentally she was right on target. Up until the 1st birthday premature babies are measured by their "adjusted age," the gestational age plus the number of weeks they were born early.

Even after discharge home preemies will be at risk for future problems. Some infants may be sent home with monitors or breathing devices and special medicines. Follow-up care in addition to regular checkups may include specialized neurological, visual and auditory examinations. Speech, occupational or physical therapy may be needed to overcome developmental delays. The younger the child at birth (26 weeks or less) the greater the risk for more severe complications. Happily, 80% of children born at 30 weeks or older suffer no long term effects.

Other than being a colicky baby, Sarah had no further problems and has grown into a beautiful, intelligent young woman. It's hard to remember how tiny that little girl was, wearing those doll's clothes we had to dress her in during her first few days at home.