preterm baby and PPROM

Preterm birth

Delivery at less than 37 completed weeks of gestation.

Extreme preterm

Extremely Preterm: Less than 28 weeks gestation (0.5% of all births)

Very preterm

28-32 week gestation. May require intensive care and may face respiratory issues and developmental delays.

Moderate preterm

32-37 weeks gestation

How has survival for preterm changed

neonatal intensive care practices

surfactant therapy for lung development

improved infection control measures.

Survival Factors for Preterm Babies

• A singleton (not a multiple)

• Not small for gestational age

• Born via cephalic vaginal delivery
  Gender Factor: Girls generally have a higher survival rate than boys due to physiological factors.

Possible causes of prematurity

Medical Conditions:

• Overdistension of the uterus (e.g., multiple pregnancies)

• Chorioamnionitis

• Pre-eclampsia

• Placental abnormalities (e.g., APH, placenta previa)

• Premature rupture of membranes in this or previous pregnancy

• Cervical insufficiency

• Congenital abnormalities

• Previous caesarean section at full dilation

• Alcohol and substance abuse

• Low socioeconomic status

• Trauma or surgical history (e.g., appendicitis)

• Unexplained cases

Intrauterine Growth Restriction (IUGR)-Definition

A fetus that has not met its growth potential due to genetic or environmental factors.

Causes of IUGR

• Chronic hypoxia

• Placental insufficiency (including PET)

• Severe anemia

• Sickle cell disease

• Multiple pregnancies

• Maternal substance abuse

• Viral infections (e.g., rubella, CMV)

Complications of IUGR

Hypothermia

hypoglycemia

HIE

poor feeding.

Characteristics of Preterm Babies

• Large head proportionate to body.

• Small triangular face.

• Widely spaced cranial sutures and soft skull bones (poor ossification).

• Pinkish/red skin (absence of fat).

• Thin limbs with underdeveloped muscle tone.

• Small, narrow chest; large abdomen.

• Uncoordinated suck and swallow reflex, which impacts feeding.

Potential complications of prematurity

• Respiratory distress syndrome (RDS)

• Chronic lung disease

• Apneas

• Anemia

• Patent ductus arteriosus (PDA)

• Hypothermia

• Necrotizing enterocolitis (NEC)

• Intraventricular hemorrhage

• Retinopathy of prematurity

Initial management on admission for mom (with suspected preterm)

• Full blood count (FBC)

• C-reactive protein (CRP) if infection suspected

• Blood group and G&S

• Urine dipstick including nitrates to screen for infection and if nitrates are positive or symptomatic for urine infection, consider appropriate treatment

• Abdominal palpations and CTG

Initial Management on Admission for mom (with suspected preterm birth) cont

• High vaginal/rectal swab for Group B Streptococci and bacterial vaginosis to exclude the possibility of infection.

• Consider the possibility of Chorioamnionitis as a cause of preterm birth, particularly at less than 28 weeks.

• Diagnosis should be suspected if there are signs of infection or sepsis and signs that source is intrauterine (e.g uterine tenderness, fetal tachycardia and prolonged rupture of membranes.)

• If possibility of chorioamnionitis, broad spectrum antibiotics should be commenced and birth expedited.

Diagnosing Preterm Labour (PTL) if intact membranes

• Assess Cervical Dilatation normally (done by obstetrician) by:

• Speculum examination to visualise the cervix, if inconclusive

• Digital VE, or

• TV USS - cut off around 1.5 cm to diagnose labour

Fetal Fibronectin/ Patosure Test: For predictive negative value in assessing risk.

Management for Baby (suspected preterm) - corticosteroids

Steroids have decreased preterm births' mortality by over 30%.

• They stimulate the lungs to mature, reducing respiratory distress, systemic infections and intracranial bleeding.

Gestational age between 23+0 and 34+6 (may vary between different hospitals)

• Dose: 2 doses of Betamethasone 12 mg 12-24 hours apart

• Best given 24 hours to 7 days before birth

***Please use caution with Diabetic mothers (especially if Insulin dependent)

Management for suspected Preterm- MgSO4

• Route 4g IV MgSO4 slow bolus- can repeat after 12 hours

• If birth is imminent, MgSO4 should be administered prior to Steroids as immediately effective with neuroprotective properties

• Women must consent to administration of drugs.

***Please note that in other trusts there might be a MgSo4 maintenance dose for another 24 hours

Management for suspercted Preterm- Tocolysis

• Many factor need to be taken into consideration when making decision about stations tocolysis (e.g bleeding, infection and gestation.)

• Consider Nifedipine (not MR as per hypertension) for tocolysis for women between 24+0 and 33+6 weeks of pregnancy who have intact membranes and are in suspected preterm labour.

• If nifedipine is contraindicated, offer oxytocin receptor antagonists (e.g. Atosiban) for tocolysis.

The primary causes of death following PPROM

Sepsis and pulmonary hypoplasia

Diagnosis for a woman with sysptoms of PPROM

• Offer speculum examination to look for pooling of amniotic fluid and:

• if pooling of amniotic fluid is observed, do not perform any diagnostic test but offer care consistent with the woman having P-PROM

• if pooling of amniotic fluid is not observed, perform Amnisure test (at
  OUHFT) of vaginal fluid.

P-PROM management

• Corticosteroids

• Antibiotics (erythromycin for 10 days) - might delay delivery to enable

steroid administration and improve short-term neonatal morbidity, although not mortality.

• Observe for signs of clinical chorioamnionitis

• Clinical tests can help diagnose intrauterine infection (WCC & CRP)

Midwifery intrastate Care During Labour in PPROM for 1st stage

1st Stage:

• Transfer to appropriate unit/hospital and inform NICU

• IA/CEFM depending on gestation

• Supportive 1:1 care, including discussion on what might happen and staffing required

• MDT approach: Neonatologist to counsel parents

• Minimise digital VE's

• Observe for signs of infection and give IV antibiotics (for GBS or broad-spectrum)

• Support mobilization and E&D

• Consider avoiding opiates to reduce the risk of respiratory depression; otherwise, other pain relief is available as usual

• Avoid ARM as it could cause cord prolapse or compression

• Avoid FBS and FSE < 34 weeks

• Prepare resuscitaire and newborn trolley

Midwifery Care During Labour in PPROM for 2nd stage

• Resuscitation equipment ready

• Resuscitaire ready (correct size masks, etc.) and the neonatal team in attendance

• Warm up the room and switch the radiant heater on

• Babies over 32 weeks should be dried and wrapped in warm towels/space blanket. Put a hat on.

• Babies under 32 weeks should NOT be dried and immediately placed in a plastic bag/neo HELP with the radiant heater directly above the baby. Put a hat on.

• Vaginal delivery is generally preferable (no ventouse <34 weeks) for singleton cephalic babies (new evidence on microbiota to support this)

Midwifery intrapatum Care During Labour in PPROM for 3rd and 4th stage

• Delayed cord clamping (1-2 min) and leave the baby's end long in case of UVC. Gentle cord milking after 28 weeks if unable to DCC

• High-flow oxygen support to stabilize the baby while DCC

• Support MDT with resuscitation (consider starting with a higher 02 percentage than 21%)

• Birthday cuddle

• Cord gases and other bloods (sterile equipment)

• Placenta to histology and swabs from the placenta

• Emotional support postnatally and support