Premature labour and birth

What does premature birth mean?

Once you reach 37 completed weeks of pregnancy, you baby is what’s called term, or full-term. He’ll be premature, or pre-term, if he arrives before you’re 37 weeks pregnant.

Most premature babies arrive after 32 weeks (AIHW 2016a, b) and have a good chance of surviving and growing up to be healthy.

Intensive care for extremely early babies has improved dramatically, and survival rates are much better than they used to be (Kyser et al 2012, RCOG 2014). But there can sometimes be long-lasting effects for babies arriving very early, including cerebral palsy and learning difficulties (RCOG 2014).

Most babies who are relatively early, at around 34 weeks to 36 weeks, thrive and do well. They can, however, be at greater risk of long-term developmental problems when compared with babies born at term (Boyle 2012, Engle and Kominariak 2008).

Generally, the further on in your pregnancy you are, the more likely it is that your baby will do well. His organs will be more mature, his lungs will be better prepared for breathing, and he'll have more strength for sucking and feeding.

How common is premature birth?

In Australia, nearly nine per cent of births are premature (AIWH 2016a). Most of these are only somewhat premature, rather than very early. Only eight births in 1,000 happen between 28 and 31 weeks, and eight in 1,000 happen between 20 and 27 weeks (AIWH 2016b).

If you're healthy and your pregnancy is going well, you're likely to give birth when your baby is term (37 weeks to 42 weeks). Only about two per cent of women who are carrying one baby and have a healthy pregnancy go into labour early (Haas 2011).

Why does premature birth happen?

Less than a third of premature births happen when labour starts by itself, without the waters breaking (AIHW 2016b). The rest are planned early inductions or caesareans, performed because of complications affecting either the mum or her baby.

Premature birth is much more common among pregnancies with more than one baby, where the risk is as high as 63 per cent, compared to seven per cent in pregnancies with only one baby (AIHW 2016b).

In single pregnancies though, it's very common for there to be no explanation as to why a baby has arrived early (Haas 2011). But going into premature labour can be linked with:

• Having a very full and stretched womb (uterus). This can happen if you're carrying twins or more, or if you have a condition such as too much amniotic fluid (polyhydramnios).
• Cervical weakness, or a short cervical length. Your sonographer will be able to pick this up at your mid-pregnancy ultrasound scan.
• A history of spontaneous premature birth.
• A bacterial infection in the bag containing the waters or in the amniotic fluid itself.
• Your waters breaking early.
• Heavy bleeding.
• Some abnormalities of the womb.
  (Haas 2011, Romero et al 2014)

The timing of your pregnancy and other lifestyle factors have also been linked with an increased risk of premature birth. You're at increased risk if you:

• have a short gap between pregnancies (Shacher and Lyell 2012)
• have a lack of emotional and financial support during your pregnancy (Haas 2011)
• smoke (Been et al 2014, Flood and Malone 2012) or take drugs, particularly cocaine (Gouin et al 2011)
• are underweight (Dekker et al 2012, Han et al 2011) or very overweight (Jeyabalan 2013, Torloni et al 2009a, b)
• are pregnant as a result of IVF (RCOG 2012a)

Why might my baby need to be born early?

Your baby may need to be born early for medical reasons. If this is the case, your labour may need to be induced, or you may need an early caesarean section. Nearly three quarters of premature births happen this way (AIHW 2016b).

Doctors may advise that your baby needs to be born early if he:

• isn't growing as well as he should be
• has an abnormality

Or if you have:

• a complication, such as pre-eclampsia or diabetes
• a medical condition that means it's safer for your baby to be born early (Haas 2011, Romero et al 2014)
• suffered a trauma to your abdomen

Remember that having one or more of these factors doesn't mean your baby will definitely be born prematurely. It just increases the chances of it happening.

What should I do if I go into premature labour?

If you're not sure whether you're in labour, it's always better to be cautious. Call your midwife, doctor or the maternity ward of your hospital straight away if:

• your waters break
• you start having contractions before you’re 37 weeks pregnant

You’ll probably be asked to go into hospital. Ask someone to drive you there, or, if that isn’t possible, call the hospital and ask for an ambulance.

What will happen at the hospital?

When you arrive at the hospital, a midwife or doctor should tell you what's happening throughout. Although you're likely to feel anxious, try to ask plenty of questions. This will help you to make informed decisions about your care.

Your doctor or midwife will ask you to describe what’s happened, and whether anything like this happened to you in a previous pregnancy. He’ll offer you a check-up, which may include a vaginal examination using a speculum, and an ultrasound scan (RCOG 2012b). These checks will reveal whether your cervix is shortening and opening ready for labour.

You may also be offered a fetal fibronectin test. A fetal fibronectin test checks for a particular protein secreted by your baby when your body is ready to give birth. This, combined with a check of your cervical length, is a good way to tell if your early contractions or tummy pains are a false alarm, or if you're in premature labour (DeFranco et al 2013, van Baaren et al 2014). But fetal fibronectin tests aren’t available in all hospitals and aren't so useful in multiple pregnancies (NCCWCH 2011a).

If your waters haven't broken, and there aren’t any signs that labour is about to start, you'll probably be able to go home again. The symptoms of early labour often stop, in which case your pregnancy can continue for a while longer (van Baaren et al 2014, RCOG 2013). But if you’re really in labour, it may not be possible to stop it.

What if my labour really has started?

If you're between 23 weeks and 34 weeks pregnant, your doctors can give you steroid injections to help your baby's lungs mature (RCOG 2012b, c, RHWS 2016). This reduces the risk of some early problems for your baby, especially breathing difficulties (RCOG 2012b). Steroids are most effective if your baby is born at least 24 hours after you’re injected with a dose. You’ll be given another dose 24 hours after the first one. Then, if you haven’t yet given birth, you may be given another dose of steroids every seven days if you’re still at risk of giving birth preterm (Crowther et al 2015, RHWS 2016).

Drugs called tocolytics may delay labour for a few days (NCCWCH 2015, RHWS 2014). They can suppress your contractions long enough for you to complete the course of steroids or be transferred to a hospital that offers more specialist care (NCCWCH 2015, RHWS 2014).

Your doctor won't usually offer you tocolytics if you're more than 34 weeks pregnant, or if he thinks that it's safer for your baby to be born early. This may be if:

• your baby isn’t growing well
• you're more than 4cm dilated
• you're seriously unwell
• you have an infection in your womb
  (NSWH 2011, RHWS 2012)

If your waters have broken, your midwife will take a swab from your vagina to test for bacterial infection, such as group B streptococcus (GBS) (RCOG 2012b).

Even if you don't have an infection, doctors recommend that you have antibiotics anyway. Antibiotics can help to prolong your pregnancy and improve outcomes for your baby (RCOG 2013). If GBS is detected, you'll also be offered intravenous antibiotics during labour to reduce the risk of passing it on to your baby (RCOG 2012d).

Your doctor or midwife will monitor your baby's heartbeat. You may ask for pain relief, though you’ll be advised against pethidine and other opiate drugs if you’re in advanced labour. Opiate drugs could affect your baby's breathing when he's born. An epidural is your most likely option.

Your doctor is likely to recommend that you try for a vaginal birth. But he’ll advise you to have a caesarean section if there are complications such as heavy bleeding, or if your baby is in distress (NCCWCH 2011b). You'll probably also be offered a caesarean section if your baby is in breech position (bottom first).

What will happen when my baby is born?

If your baby is born:

• Extremely early (27 weeks or earlier): He’ll need to be cared for in a neonatal intensive care unit (NICU), which may mean he'll be moved to another hospital. He'll need to be kept very warm as he'll have a high risk of hypothermia, and will need dextrose to prevent low blood sugar. He’ll also be at risk of low blood pressure and infection, and will need help with his breathing (Tommy's 2016).
• Very early (28 weeks to 31 weeks): He’s likely to be cared for in a special care baby unit (SCBU). He’ll be stronger than younger babies, but still at risk of hypothermia, low blood sugar and infection. He may need more specialised care at a NICU.
• Moderately early (32 weeks to 33 weeks): He may have problems with breathing, feeding and infection that require specialised care. He may be taken straight to the SCBU.
• Early (34 weeks to 36 weeks): He may not need any treatment. He may look small, but still be able to go straight to the postnatal ward with you. Or he may be admitted with you to a transitional care ward. It will depend on how well he's feeding, and whether he has problems with blood sugar levels, blood pressure or infection.

If your baby needs immediate care, you may only have a brief glimpse of him before he’s whisked away. This can be frightening, and you’ll need lots of support.

Once your baby is stable, you can see him as often as you like. There's lots that you can still do for him, such as change his nappy, stroke him and talk to him. You may also be able to hold him, give him a massage and feed him.

Sadly, babies born before 22 completed weeks of gestation are unlikely to survive. Babies born at 23 weeks or 24 weeks may survive, but it depends on their birth weight and their health at birth (RCOG 2014). The further your pregnancy progresses, the better the chance your baby has.

Doctors will do their best to make sure that your baby is as comfortable as possible. They'll discuss with you whether actively trying to keep your baby alive, such as by using resuscitation, is the best course of action for your baby in the short term and in the long term (RCOG 2014). Decisions like these are very hard for parents and doctors to make, which is why clear guidelines have been created.

Whatever the situation, your baby needs the special comfort that his parents can give him just as much as he needs medical help.

Breastfeeding is important for all babies but perhaps even more so for premature babies, who are at greater risk of infection. Breastfeeding provides additional protection against infection as well as all the nutrients your baby needs.

It may be that your baby is too small to latch on to your nipple but your midwife will be able to support and teach you how to express your milk. Sometimes premature babies need a small feeding tube going from their nose into their tummy. Milk can then be passed down the tube.

Where can I get more information on premature labour and birth?

For further advice, information and support, contact:

• Miracle Babies is a national organisation supporting premature and sick newborns, their families and the hospitals that care for them (Tel: 1300 622 243).
• Austprem provides friendship, information and support to parents and carers of prematurely born babies and children.
• National Premmie Foundation is a national organisation representing parent groups around Australia (Tel: 1300 773 622).
• Preterm Infants’ Parents’ Association is a support network for families experiencing premature birth in Queensland and northern New South Wales (Tel: 1300 773 672).
• Yasminah’s Gift of Hope provides A Gift of Hope, support and guidance for families experiencing premature birth and neonatal and infant loss (Tel: 1300 779 242).
• L’il Aussie Prems Foundation offers support and services to families of premature and sick newborns online and in the community (Tel: 1300 887 875).
• Tiny Sparks WA provides support, information and care packages for families in Western Australia with high-risk pregnancies and babies born sick or premature (Tel: 1800 846 977).
• Walk With Wings provides support and services for families in South Australia with premature babies (Tel: 08 8244 4979).

You can also find support from other parents in our community.