It’s kind of funny to me to recount those early days with her. She’s 11 now, pubertal and as sassy as they come! But in the beginning, everything was a juggling act to make sure that she had all that she needed to start her life off well.
My daughter was born at 36 weeks and 6 days and was literally 3 hours and 57 minutes shy of being a “term” infant. When she was first born the hospital staff kept referring to her as a “preemie” and I kept railing against this term knowing its implications. But as the days went by, she exhibited more and more of the signs of a preterm infant and I had to admit that she was in fact a preemie-no matter how close in hours and minutes she had been born to term.
When my daughter was born, she didn’t immediately cry. After the neonatal staff worked on her for a few moments, she did let out a wail that sent the biggest wave of relief through my body. But we weren’t out of the woods. On examination she had some fluid in her lungs and was in a bit of respiratory distress. So they wrapped her up, whisked her by my face and hurried her off to the nursery for a closer look.
In the days that followed, my daughter continued to have difficulty breathing. When I would nurse her, her oxygen saturation would drop into the low 80’s. She would also get quite tired while nursing and we had to supplement her feedings with bottle feedings. Although she never required supplemental oxygen nor slept in an incubator, she did initially have some problems with temperature regulation and slept on a little warming bed. The first time I saw her on this thing, with little eye covers over her face, it reminded me of a tanning bed and I asked “Why was my little brown baby was being tanned?” I was informed that the warming bed would help her regulate her temperature and help with bilirubin metabolism (although she never did have an increased bilirubin level which is common in late phase preemies.) Overall, my daughter did really well and continued to progress during her 10 days in the NICU. By the time she was discharged, her father and I were providing the bulk of her care; holding her skin to skin, feeding her and changing her. I was increasingly frustrated that they would not allow her to go home and actually “had it out” with the neonatologist one day when he proposed yet another day of “watching”. But if I were to have my daughter today, knowing what I know, I would be (and I am now) ever thankful for the care of the NICU staff provided for my daughter.
In 2009, 71% of all preterm infants were late preterm infants, born between 34 and 36 weeks 6/7 days. The most common reasons for these early deliveries were:
- Spontaneous Labor
- Premature Rupture of Membranes
- Pregnancy Induced Hypertension
- Placental Disorders
- Fetal Disorders
- Intrauterine Growth Restriction
- Multiple Gestation (Twins or higher order multiples)
- Maternal Medical Disorders
Because many late phase preterm infants look like term infants, signs and symptoms of complications can be missed. But these can be a crucial errors. Late preterm infants born to mothers with antepartum hemorrhage ae 12 times more likely to develop problems in the early post partum compared to term infants. Infants born to mothers who had pregnancy induced hypertension are 11 times more likely to have post partum complications. The earlier the infant (i.e. the closer to the 34 weeks) the more likely they are to experience complications. And when an infant is an “early late phase preemie” and born to a mother with medical problems such as pregnancy induced hypertension, the more likely the infant is to have complications. The most common complication seen in late phase preterm infants are:
- Elevated Bilirubin levels (hyperbilirubinemia)
- Respiratory Issuesn (rapid, labored breathing and/or Pneumonia)
- Poor feeding (fatigue and poor weight gain)
- Temperature instability (inability to regulate temprature due to lower amounts of brown and white fat on their bodies)
Any one or a combination of these issues may land the infant in the Neonatal Intensive Care Unit (NICU). However, not all infants who exhibit these complications need the expert skill rendered in the NICU. Well trained hospital staff and well educated parents can manage many of these infants. So what do parents and care providers need to know?
Mamas, if at all possible, avoid having a cesarean section-especially if it is your first child. First time Cesarean section delivery of the 32-36 week infant increases the infant’s risk of developing the aforementioned complications as well as their risk of not surviving. Almost all of these infants end up in the NICU. While a cesarean section may be indicated if mama, baby or both are in distress, elective cesarean sections should be avoided.
Watch your child’s feeding patterns. Because these infants often tire easily with nursing, infants who fall asleep while nursing my be mistaken for being full when they are actually fatigued. These infants may have long periods between feedings and fail to gain weight. Parents of such infants must adopt an every 2-3 hour feeding schedule and keep a close watch on weight gain to ensure adequate nourishment and development.
These infants should not be discharged early. Late preterm infants have a high rate of “bounce back admissions”. Many of the complications that arise do so within the first 48 hours to 2 weeks post partum. Careful monitoring in the hospital for 48 hours can allow medical staff to detect arising complications and treat them early to avoid major problems as well as readmission. While these infants should be assessed often, they don’t necessarily need to be in the NICU. They should be evaluated by a pediatrician 48-72 hours after discharge and at 2 weeks then 8 weeks. This may seem like a lot, but complications, if they are going to arise, will occur within the first 28 days of life.
Looking at my daughter today I can hardly believe she was the tiny little baby I held so close. Just 3 inches shorter than me (Okay, I’m only 5 ft, but she’s only 11!) and already developing the curves of a young woman, she has grown and developed really well. She has asthma that is well managed and does anything she wants to do. But those early days of keeping her bundled up (she was an October baby) and watching her feedings were hard-but well worth it. And the expert care of the NICU staff are much credited with her health success. I was a stressed out mama then, just wanting to take my baby home. But I am forever grateful that the staff-the neonatologist in particular-stood firm, monitored her carefully and only sent her home when they were absolutely sure that she wouldn’t come back. And she never has!!!
Erica Saleski Forsythe, MSN, RN, Patricia Jackson Allen, MS, RN, PNP-BC, FAAN “Health risks associated with late-preterm infants: implications for newborn primary care.” Pediatric Nursing. 2013 Jul-Aug;39(4):197-201.
Human Papilloma Virus (HPV) is in the news once again. Korean researchers have reported that high risk HPV increases the risk of premature rupture of membranes (PRM) and preterm labor in Korean women. While more studies are needed to determine exactly how HPV causes PROM and preterm labor, the researchers conclude the HPV is a serious risk to pregnant women and their babies.
These researchers knew that Human papillomavirus (HPV) is known to be more prevalent in spontaneous abortions than in elective terminations of pregnancy. Additionally, placental infection with HPV was shown to be associated with spontaneous preterm delivery. Yet to date, no one had looked at HPV prevalence and preterm births, so the researchers studied this question in Korean women.
311 women who gave birth at Korea University Medical Center were the study sample and included 45 preterm deliveries, 50 cases of premature rupture of the membranes (PROM), 21 preeclampsia cases, and 8 gestational diabetes mellitus (GDM) patients. The women were tested for HPV at 6 weeks post partum using the Hybrid Capture II system to detect high-risk (HR)-HPV infection.
The prevalence of HR-HPV infection was 14.1%. Women with HR-HPV infection had a higher incidence of PROM than those without HR-HPV and HR-HPV infection was associated with an increased risk of PROM. The prevalence of preterm delivery, preeclampsia, or GDM was not different between the women with HR-HPV and without HR-HPV.
This is an interesting and important study. While it was not clearly stated when these women became positive for HPV (seroconversion during pregnancy or “newly infected”), the implication that I read is that they were not positive prior to the study. (Would be an interesting fact to know!) In any event, by delivery, 14.1% of these women were infected with the HPV virus and were at increased risk of having PROM. It seems that this data may be translated to women of other cultures (but again, further studies are needed to confirm the results), but the most important fact to note is that HPV infection causes an increased rate of spontaneous abortion and in pregnancies that progress, an increased rate of PROM and preterm labor.
I was not tested for HPV when I was having my kids and I am not sure if it is routinely done today as part of the first prenatal visit screening laboratories. But given this information, I think its important that clinicians screen for HPV at the first prenatal visit and at the post partum visit and that women ask about being screened if they feel that they may be at risk (and even if they are not at risk!!!).
GeumJoon Cho, Kyung-Jin Min, Hye-Ri Hong, SuhngWook Kim, Jin-Hwa Hong, Jae-Kwan Lee, Min-Jeong Oh, HaiJoong Kim Risk “Human Papilloma Virus Infection is Associated With Premature Rupture of Membranes” BMC Pregnancy and Childbirth 2013, 13:173 doi:10.1186/1471-2393-13-173
November is Prematurity Awareness month.
In this video blog, Bedrest Coach Darline Turner highlights the importance of this campaign initiated by the March of Dimes to raise awareness of and to reduce preterm labor and premature births. The March of Dimes does an excellent job of presenting the statistics regarding prematurity and offering some solutions to slow and reverse the occurence of preterm births. Darline highlights these statistics but also emphasizes the need for increased support and compassion towards women who have high risk pregnancies. As any Mama on Bedrest can tell you, there is not any sort of regular support for high risk pregnant women and when a mama is put on bed rest, life comes to a grinding halt and there are few if any resources available to help a mama and her family keep life on track. This is where Mamas on Bedrest & Beyond is striving to make a difference; to alleviate the logistical as well as the emotional fall out that occurs when a mama is placed on bed rest with a supportive community and educational tools and resources. So while it is crucial that we all are aware of and understand the largeness of the prematurity issue, its also important not to forget that in the midst of the numbers and research going towards alleviating the causes of preterm labor and prematurity, we cannot forget the human side-the necessary care and compassion that must be bestowed upon mamas and their families.