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Prematurity is defined as birth occurring before the end of the 37th gestational week, regardless of birth weight. Most preterm babies are appropriately grown; some are small for gestational age (SGA), while a small number are large for gestational age (LGA), mostly where the mother has diabetes.
Causes of preterm labour
Appearance of the preterm baby
Management at birth
Current cot availability in the NICU, transitional care unit (as applicable) and postnatal ward should be known. The ambient temperature of the birthing room should ideally be between 23°C and 25°C. The neonatal resuscitaire should be checked and ready for use. A second person skilled in resuscitation skills should be present. On cutting the cord, leave an extra length, in case access to the umbilical vessels is necessary later. The Apgar score is traditionally scored at 1 and 5 minutes. Labelling of the preterm/LBW baby is particularly important because separation of mother and baby could happen at any time if the baby's condition becomes unstable. A detailed but expedient examination of the baby should be carried out. Once it is established that the baby is healthy, the midwife may attempt to normalise care by emphasising to the parents the importance of preventing cold stress and promoting skin-to-skin contact for a period of up to 50 minutes. Ensure that the baby is thoroughly dried before skin-to-skin contact is attempted. The baby's body temperature should be maintained between 36.5°C and 37.3°C.
Thermoregulation Thermoregulation is the balance between heat production and heat loss. The prevention of cold stress, which may lead to hypothermia (body temperature < 36°C), is critical. Newborn babies are unable to shiver, move very much or ask for an extra blanket, and therefore rely upon physical adaptations that generate heat by raising their basal metabolic rate and utilising brown fat deposits. As body temperature falls, tissue oxygen consumption rises as the baby attempts to raise its metabolic rate by burning glucose to generate energy and heat. Care measures should aim to provide an environment that supports thermoneutrality.
Hypoglycaemia Low blood glucose concentration is more likely to occur in conditions where babies become cold or where the initiation of early feeding (within the first hour) is delayed.
Both preterm and SGA babies benefit from human milk because it contains long-chain polyunsaturated omega 3 fatty acids, which are thought to be essential for the myelination of neural membranes and retinal development. Preterm breast milk has:
The baby is normally able to co-ordinate breathing with sucking and swallowing reflexes between 32 and 36 weeks. Preterm babies are limited in their ability to suck by their weak musculature and flexor control, which is important for firm lip and jaw closure. Before 32 weeks, most healthy preterm babies will need to be tube-fed on a regular basis, usually on a 3-hourly regime with breast milk or formula milk.
The care environment
The ideal environment should provide a cycle of day and night, regular nourishment, rest, stimulation and loving attention. The mother's desire to be involved is seen as an essential element in the success of caring for LBW babies on postnatal wards. Handling and touchKangaroo care (KC) is used to promote closeness between a baby and mother and involves placing the nappy-clad baby upright between the maternal breasts for skin-to-skin contact, for varying periods of time that suit the mother.
Noise and light hazards
Sleeping positionPreterm babies have reduced muscle power and bulk, with flaccid muscle tone; therefore their movements are erratic, weak or flailing. Without support they may, to differing degrees, develop head, shoulder and hip flattening, which in turn can lead to poor mobility. Nesting the more immature preterm babies into soft bedding, in addition to the use of close flexible boundaries, helps to keep their limbs in midline flexion. However, it is vital that they are nursed in a supine position to prevent asphyxia.
Sudden infant death syndrome (SIDS)
There is a need to remind parents constantly of the risk factors and safety procedures (feet-to-foot sleeping position, smoke-free room) associated with SIDS, alongside teaching them to keep their babies warm. The midwife needs to explain that families should take into consideration time of year, gestational age and postnatal age. Parental training on 'what to do if my baby stops breathing' should be offered to parents but the decision to receive training should be their choice.
The prevention of infection
LBW babies, particularly preterm ones, are especially vulnerable to infections caused by immaturity of their host defence systems.
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World Health Organization (2015) Preterm birth. http://www.who.int/mediacentre/factsheets/fs363/en/
NHS Choices (2015). Pregnancy and baby: Premature labour and birth. http://www.nhs.uk/conditions/pregnancy-and-baby/pages/premature-early-labour.aspx
Institute of Medicine (US) (2007). Preterm birth: Causes, consequences, and prevention. http://www.ncbi.nlm.nih.gov/pubmed/20669423