Now we've all heard the term 'Premmie" and we've seen the little babies in the Special Care Nurseries with their naso-gastric tubes, little caps on their heads and surrounded by monitors. It's a frightening image but sometimes it always seems to happen to someone else - until it doesn't.
Brigid: This podcast is all about defining what prematurity is. What are the known reasons for why a baby comes early. What are the signs that your baby might be coming early. The treatment your baby would need if they are born early and the current medical thinking about preventing prematurity.
And we end the podcast with what we can all do to support mums of preterm babies. So Dr. Pat I know you wanted to include this podcast for something that happened this week. Can you tell our listeners about that?
Patrick [00:01:23] Yes sure. This was amazing.
Patrick [00:01:25] I saw a patient in her mid 40s for a gynaecological problem and I vaguely recognized her name but it wasn't until I saw her face that that I remembered who she was. 15 years earlier I'd seen the same woman when I was her registrar at the Royal Women's Hospital in Melbourne when she came in from a country area and and had two twins prematurely at 25 weeks.
Patrick [00:01:53] So that's the most extreme prematurity one of those babies survived, one sadly did not but she's an amazing woman who who had lived through that experience and then our paths met again 15 years later.
Brigid [00:02:08] Wow. That's that's an incredible story. And so how common is prematurity.
Patrick [00:02:13] Well thankfully that type of prematurity is pretty uncommon to that degree in Australia about 9 per cent of babies are born preterm and most of those are between 32 and 36 weeks so early but not so early that we see major problems. About one per cent of those very tiny babies born before 28 weeks.
Brigid [00:02:33] Yeah I would imagine that having a premmie baby, that's what we all talk about and we may know one of our friends has had a premmie baby but we don't really know the difference between the different times that a premature baby might be born and the complications that come at the different times of a prematurity. It's just really an overarching term isn't it?
Patrick [00:02:52] Absolutely, so it just means preterm which is less than 37 weeks but the degree of prematurity is what it's all about. So technically there's preterm which is 34 to 37 early preterm which is 32 to 34 very preterm which is 28 to 32 and extremely preterm which is less than 28.
Brigid [00:03:14] Yeah because 28 weeks, I remember in all of my pregnancies, the pregnancies before I met you and got a lot wiser, so my first two pregnancies and I had 28 weeks as the date marker in my head where you know I felt that if I went into labour and the baby was born then it had a good chance of survival but that was a bit simplistic wasn't it.
Brigid [00:03:36] So a 28 weeker is very different from a 37 weeker
Patrick [00:03:39] Well yeah massively different.
Patrick [00:03:41] So I find it useful to break it down a little bit for people and say that basically in Australia in 2019 you need to have 24 weeks under your belt for the baby to survive, that you need to get about twenty eight weeks for the baby to survive and grow up with a good chance of not having disability related to the prematurity. And then here in Ballarat which is a regional centre we need to be more than 32 weeks to two for the baby to stay here in Ballarat.
Brigid [00:04:13] Okay so for the regional centres, there so many in Australia. So these are the community hospitals.
Patrick [00:04:18] That's usually it. Yeah. Your local community hospital you.
Brigid [00:04:21] And so what happens to those babies that are born in community hospitals before 32 weeks.
Patrick [00:04:24] Well if the baby is sick or is of a prematurity that that can't be managed at that hospital then the baby needs to be transferred to a city hospital for a high level of care and ideally we try and do that before the baby's born. So if I've got a patient who's at high risk of preterm labour or who is coming into labour but the baby is not out yet, it's usually best to stabilise that woman, start some of the preliminary treatment and transfer her to a city hospital so that if she does go on and have that baby in the next 24 hours the baby's born in the high acuity unit.
Brigid [00:05:04] Right. Which is called the NICU.
Patrick [00:05:07] Yeah. So NICU is neonatal intensive care unit and they have those had big city hospitals and ideally if your baby is going to need the NICU, then the mother will actually have that baby in the hospital where a NICU is located.
Brigid [00:05:22] So these are known reasons for prematurity, what are some of the other known reasons.
Patrick [00:05:28] Yeah. What people don't always realise is that a lot of this prematurity are things that we've sort of made to happen on purpose. Put simply it's where we're in a situation where despite the prematurity, the baby is better out than in. So we're talking about conditions like severe preeclampsia, so severe complicated high blood pressure of pregnancy, severe growth restriction so that a baby's clearly not growing properly and the placenta isn't working well which is often as a result of pre-eclampsia. And we've been doing some very, very careful monitoring but it's clear after the after careful consideration that a baby is better out than in despite only being 27, 28, 29, weeks.
Patrick [00:06:12] And that actually accounts for a lot of the premature birth and ultimately that baby despite the risks of being born that early, if they weren't born that early and the woman had been left undelivered. That may have gone on to be a stillbirth situation which is obviously much worse.
Brigid [00:06:28] Yeah incredibly sad. I know from our experience at the practice that there's some women that their waters either start leaking or their waters break and they go into early labour that way.
Patrick [00:06:43] Sure. So that's the other group. These are women who we haven't intervened to end the pregnancy early but something happens to bring about premature labour.
Patrick [00:06:52] And sometimes that might happen in a setting like the waters breaking too early followed by a labour, or the labour starting or bleeding occurring which can trigger labour.
Brigid [00:07:06] And do we know why someone might go into early labour in those circumstances?
Patrick [00:07:11] We don't know enough about it. So this is an area of very important research. Some people are prone to premature labour and one of the major risk factors of having an extremely premature baby is is having had one before in in a previous pregnancy. And we know some people are for various complex medical reasons are kind of going to be prone to having a pregnancy that ends early. But it's an important field of research. What we'd like to do is to do something to intervene in a preventative way, to do something for everybody for the whole cohort of pregnant women. That would help the small number of women who are going to deliver prematurely.
Brigid [00:07:57] In our obstetrics and gynaecology journals that we get, there's been some research done around omega 3 long chain fatty acids.
Patrick [00:08:06] Yeah. So that's one of the things that I'm talking about. There's been a lot of really interesting research about that. It looks like a subset of those omega 3 fatty acids are probably active within the cervix and they stop the cervix softening prematurely. The Cervix is a surprisingly dynamic organ. We think of it being open or closed but it actually will soften and shorten before it dilates and there's a subset of those omega 3 fatty acids that probably work against that process in favour of the cervix staying long and closed. Yeah. And these fatty acids are also easy to make cheap to make and potentially could be given to everybody to help prevent the very small number of people who are going to get into extremely premature labour in the same way that we did with folate for neural tube defects.
Brigid [00:09:00] Yeah. And you know there are tablets in there tablets on they. So people have to be very aware of what sort of Omega 3 tablets to take.
Patrick [00:09:10] Yeah that's right. It's a specific subgroup of them but you know it's a watch this space thing. I think that that could easily become very very widespread advice pretty soon.
Brigid [00:09:22] Oh well when it comes up we'll make sure that all our listeners know and they know how much to take and when to take it and when to start and when to stop. So yeah keep listening will will tell you as soon as we know more.
Patrick [00:09:33] Yeah. That's an exciting development. You said when to stop. That's relevant too because you want the cervix to soften the point you don't want to be pregnant forever. Yes. So in the studies they got people to stop taking it around about term (37 weeks) so that it wasn't making the pregnancy go too long.
Brigid [00:09:46] Yes. So since we're talking about how you can lower your risks for prematurity what are other things that you could do.
Patrick [00:09:54] I think the best things that an individual woman can do is firstly to have her best health before she's pregnant in the first place. So important things like having a normal body weight is certainly going to reduce the chances for that woman of getting complications like preeclampsia and like diabetes which can lead to interventions which can lead to prematurity.
Brigid [00:10:16] When we're talking about normal body weight we're talking about BMI or how does somebody assess their normal body weight.
Patrick [00:10:23] BMI is one tool. It's it's probably a little flawed but it's one tool that that you can use just to to make sure that you're as close as you can to the healthy range on on BMI and then what. You can Google the World Health Organisation for their weight gain in pregnancy and they've published a table saying if you start off at BMI of x y z then a reasonable amount of weight for you to gain in the pregnancy is is blah blah blah. Good. All right. And that's easy for people to find.
Brigid [00:10:50] All right. Well that's the second thing we'll put in the show notes. We put the link to that World Health Organization.
Patrick [00:10:55] I use that one all the time. It's nice for people to have an idea at the start of what a reasonable weight gain is within the pregnancy and they know that within that projected weight gain there's three and a half kilos of Baby and some placenta and all the water and the big uterus. So a lot of that comes off straight away.
Patrick [00:11:15] And then the rest is what we have to take off to get back to our pre pregnancy weight. Yes.
Patrick [00:11:21] So being in good shape to start with is one of the really powerful things that we can do so that we have less chance of developing a complication that may lead to premature birth.
Patrick [00:11:32] And the other is having any existing health issues optimized.
Patrick [00:11:37] So for example somebody with type 1 diabetes. We want that to be as well managed as possible, as a strictly managed as possible. Someone with a problem of drugs and alcohol ideally it's managed before they get pregnant and so forth. Smoking. Absolutely smoking. So that's a perfect example. Smoking can give you a a small placenta with stiff blood vessels which can lead to growth restriction which means that you have an ultrasound and the baby is way too small and struggling to survive.
Patrick [00:12:09] And we have to get the baby out at 30 weeks because it might not be alive at 31 weeks and of course, if we have given up the smokes before we started we'd have a much less chance of that scenario progressing in that direction.
Brigid [00:12:23] So are there any other things that someone can do to lower the risk of prematurity.
Patrick [00:12:27] I think that being in an appropriate level of antenatal care is really important. So if you've had a 28 weeker before they need to be in an appropriate level of antenatal care and by that I mean seeing obstetricians in a hospital, which not everybody needs, but for this woman, this is what she needs. And being under a very watchful eye, multiple scans to make sure the baby's growing strict attention to two blood pressure things like the administration of antenatal steroids. So if someone's at high risk of having their baby early will give a big dose of cortisone to that woman which kick starts the baby's lung development.
Patrick [00:13:08] So the baby's born at thirty two weeks. But you've given the steroids then the baby will be born with lungs more like a 35 week and will go better in the nursery and be discharged earlier. And we can do that if we have identified that woman as someone at high risk of preterm labour or preterm birth and we can do that if that if that woman's in the right stream of antenatal care. Yes.
[00:13:33] And then there's a few other things about what can be done to prevent preterm labour. There are some cases where progesterone supplementation in pregnancy can help prolong the pregnancy. You know it's not the cure for everything but certainly in women where a short cervix is part of the problem the data on on vaginal supplementation of progesterone is definitely helps.
Brigid [00:13:58] You mentioned short cervix. So in one of my pregnancies I am pretty sure it was my second they thought that I had a short cervix except back then they called it an incompetent cervix. Is that the same thing?
Patrick [00:14:10] Incompetent cervix is one of those terms we've got rid of thankfully so it's insufficient cervix. So incompetent cervix is like geriatric pregnancy it's a dreadful term.
Brigid [00:14:21] I just remember thinking already it's my body is sort of failed because you're incompetent. Yeah I'm incompetent Yeah.
Patrick [00:14:27] So an insufficient cervix just means a cervix that might get short and come opened too early. And these days the scanners are good; they'll routinely measure cervical length on a routine pregnancy ultrasound. Yes.
Brigid [00:14:41] And is that an average. Does everyone have about the same length of cervix.
Patrick [00:14:46] Give or take - it should be about four centimetres long and closed and if it looks like it's short or something called beaking, where it's trying to come open then the sonographer will report that and we can then pay careful attention to that woman and do what we can to prevent the cervix opening too soon.
Brigid [00:15:08] I'm just remembering a patient that you did a procedure on to help with a shortening cervix.
Patrick [00:15:15] Yeah. So in a true case of cervical insufficiency the cervix is probably structurally abnormal and it comes open way too soon and leads to a relatively painless second trimester loss of the pregnancy. So it's not so much a proper Labour as the cervix just opens. Yeah. Way before viability, so way before 24 weeks and if a woman's had a story of that, that sort of a textbook story of that and there is something sort of inherently weak or insufficient about the cervix then it probably happen again. So some women benefit from stitching the cervix closed.
Patrick [00:15:56] So that's an operation that can be done vaginally or more recently techniques being developed to do it laparoscopic. And I think the patient you're thinking of is one of the first ones I did laparoscopy, it was very exciting.
Patrick [00:16:13] And I think the one you were thinking of, that woman went on to have a successful term pregnancy. Yeah the laparoscopic approach has got some pros and cons and its a relatively challenging surgery but it does mean that the stitches up on your insides where there aren't any germs rather than in the vagina which has got bacteria that can affect the quality of the stage.
Brigid [00:16:32] And I'd just like to remind our listeners of all the thousands of patients that Pat has helped birth their babies. That's like one one or two.
Patrick [00:16:41] Oh yeah yeah. We've we've strayed from what is common. So in any discussion about the technical medical aspects of pregnancy care it's going to lean towards discussion of abnormalities. Yeah but of course most people don't develop any abnormalities.
Brigid [00:16:58] All right. So someone has gone into early labour and they've had their little premmie baby. What what are some of the common short term problems that that baby might have.
Patrick [00:17:07] Well again it all depends on the degree of prematurity. That's super important to understand. But you know the overarching sort of problems they have are breathing problems the more premature the baby is. Good functioning lungs are one of the last things to develop during pregnancy and premmie babies will all be a bit short of breath.
Patrick [00:17:29] Most people have seen a baby in a isolette where they can dial up the oxygen to higher levels than are in room air.
Patrick [00:17:38] And so the baby born mildly premature might be in the isolette for a few days breathing air with a higher percentage concentration of oxygen and then the clever pediatricians will just dial that percentage down, and once that's the same as room air, you can open the isolette and let the baby go home.
Patrick [00:17:56] Other problems - They get feeding problems due to sucking issues. Again a term baby comes out hungry especially the big hungry hippo babies, they'll get straight on a breast or bottle and suck but prem babies find that exhausting. So often a naso-gastric tube is put down the nose, down the back of the throat and into the stomach to to give that baby breast milk or formula. They can get bleeding problems. Prem babies are at risk of bleeding into important structures like around the brain. Infections, they are particularly prone to picking up infections so cleanliness is important in the nursery and they're often treated carefully with antibiotics.
Patrick [00:18:38] In that scenario sometimes, it might have been an infection in Mum that triggered the prem labour. The baby comes out through the vagina where there are bacteria and the baby might come out at higher risk of infection from the get go.
Patrick [00:18:51] Hypothermia. They get cold so that they're not very good at regulating their heat. A full term big chubby full term baby get cold very easily in the operating theatre which we like to keep a bit cold. If a baby's born by Caesarean section one of the first things we really want to do is wrap the baby because it's cold in there. Prem babies are particularly prone to getting too cold and their blood sugar getting too low. So lots of babies born early could get hypoglycaemia. They used to use a lot of drips to run some sugar into the baby's vein, now they use a gel that can be rubbed around the baby's gums which is a less invasive way of giving the baby a shot of sugar. And they will get other things that any other baby can get but it's much more common when you're premature, like jaundice when babies are often under those jaundice lights.
Brigid [00:19:43] And is it true that a prem baby stays in the hospital until at least their due date?
Patrick [00:19:49] Well yes and no. A sick premmie might be in the hospital much longer than their expected due date but it's more about their progress, how they improve, how they get stronger, we want them to be bigger, better feeders.
Brigid [00:20:04] There's a lot of short term issues. Do babies go home normally with all of those issues resolved or are there some long term problems for prem births?
Patrick [00:20:16] Yeah again highly dependent on the degree of prematurity so one of the reasons, why it's a research priority, is to try and really work out the true causes of premature labour and ways that we can prevent it. Lots of childhood disability, that becomes adult disability, started with prematurity. So a baby that's born late preterm might have nothing. Nothing wrong at all. The first few days in the nursery and it is fine. But a baby with severe prematurity, a very very early birth runs a risk of permanent disability, deafness, cerebral palsy, intellectual disability - and it can affect that person for life.
Brigid [00:20:59] So again that's very prem. That's less than 1 per cent of all births.
Patrick [00:21:04] The very very prem babies have the highest risk and they less than 1 per cent. Yeah that's right. I think it's really important really for him to say to our listeners don't panic.
Brigid [00:21:12] I mean, I'm panicking just listening to this.
Patrick [00:21:14] Yes these are the things that people worry about and why wouldn't you? It's a worrying thing. That milestone model thing, that I've got to get to 24 then I'll get to 28. Then 32 weeks, normal healthy people worry about this, people who aren't at especially high risk of birth. It's normal to be worried about things.
Brigid [00:21:34] Yeah. And I think one of the reasons why we're talking about this in the podcast is we don't want people to be blindsided. This is about again our premise that when a woman knows better she goes better. Absolutely. So my advice is that you listen to this you take it in but don't take it on board.
Patrick [00:21:52] Yes. Don't don't let it add to your worries. I think that knowing about some of the complexity of obstetrics and some of the possible complications we think is part of a sort of a desirable level of pregnancy literacy. And it probably suits some people to not know anything that could go wrong and just hope for the best. But I think it's clear that if you know a bit about this and that, it is useful and helpful.
Brigid [00:22:20] Yeah I think what also would be useful and helpful is that you know if you did have a premature baby it's often a huge learning curve about the hospital system isn't it. So can you just describe to our listeners what happens in a scenario where born babies born at 33 weeks which is kind of like a common preterm week.
Patrick [00:22:42] Yeah. So if that happened, let's take a common scenario that we would see every year of a twin pregnancy where the waters break at 33 weeks. That's a super common thing to happen when a woman with twins gets to about 33 weeks her belly is bigger than a term singleton pregnancy. And it's like a balloon, it can only blow up so far and the walls will break. So those babies would typically be admitted to our special care nursery. So special care nurseries are for the babies who are born later on. NICU is neonatal intensive care unit for babies that are extremely premature or very sick.
Patrick [00:23:19] So the special care nursery is where they have those isolettes and they help babies by supporting their breathing. It's not that uncommon for a baby to be admitted to a special care nursery for some nights, just even the first night for observation of mild prematurity, maybe a bit of jaundice or a baby that's irritable or at risk of infection and so forth.
Patrick [00:23:40] So when we book our obstetric patients into our local private hospital and they do the tour to familiarise themselves with the environment, they get a tour of the nursery as well. It helps to take some of the mystery out of it, it's a good idea.
Brigid [00:23:55] Yes I highly recommend doing that. You can have a look and see the workings of your hospital. So also, just from a practicality point of view. Once a baby is born premmie and goes off to the special care nursery, they're now an inpatient are they?
Patrick [00:24:17] Yeah that's right that the baby becomes a patient in the hospital and in their own right.
Brigid [00:24:21] Yeah. Because in a full term birth it's only the mother that's the inpatient and the baby's an outpatient.
Patrick [00:24:29] That's right. Yeah. Yeah. For funding reasons, the baby is isn't officially a patient in the hospital if they don't need care from a pediatrician or attention in their own right.
Brigid [00:24:40] Yeah. And the reason why I bring that up is it is a bit of a bill shock for some people.
Brigid [00:24:44] I know this is a side note but when for example they've had a baby at term and they have a pediatrician or someone come to visit them in the hospital they will get a bill from whoever visits the baby. So if there's a pediatrician visiting the baby they will be sent it a bill it's not covered in the inpatient costs.
Patrick [00:25:02] That's true. But to be more accurate if it's just for the pediatrician to give the baby the once over then that would normally be a known event and not an excessive fee. Yes but if the baby needs elaborate care then the baby will be admitted.
Brigid [00:25:18] So as an as an inpatient typically covered under the parents insurance and then that would be funded care from then on. Yeah.
Brigid [00:25:25] So if the baby is admitted to the special care nursery. What happens, can the mother hold the baby?
Patrick [00:25:31] Well it depends on the level of prematurity. I keep saying this, but it's critical. So yeah, depending on the prematurity, you can hold the baby in the special care nursery and the isolette has a little window in the side and you can open that and reach in touch your baby. Yeah. And a baby may not need to be in there the whole time. And then the environment in a neonatal intensive care unit is is like an adult intensive care unit. It's a highly highly regulated environment that some people find very challenging.
Brigid [00:26:04] I want to just go to our journal again and so there's this couple Scott and Joanne and they had premmie twins, they formed the helping Little Hands Foundation to help other parents with the time that they have a premmie baby and they're in the hospital.
Brigid [00:26:22] But I just thought it would be really interesting just to read out their story. How the father was feeling and then the mother. Scott says "people don't seem to understand the need to be with Lewis. (Lewis is the surviving twin) my sister said well it's not like he knows you're there. My mom wants me to take it easier on myself and go play golf with Dad. I know that they're doing their best but they don't understand that time away from Lewis just makes it worse. It adds to the guilt it adds to the fear of what we'll find when we see him next. The support from our friends is dropping away too. I suppose people assume Lewis is fine. They assume we've learned to cope. It feels like we're on this roller coaster alone.
Brigid [00:27:01] So I just wanted to sort of talk about how we can support ourselves and others that perhaps are in the hospital with a premmie baby. And part of it is what the mother said. And she said "the power of someone just caring someone to talk to" is the thing that sort of helps and gets her through.
Patrick [00:27:18] So you know it is a lonely time and so often the baby stays in for far longer. Yes the mother you know, she's given birth and has spent two or three days in the hospital, but then she's able to be discharged.
Patrick [00:27:31] Yeah. So I think that some useful things that people can do really is to you know, is to be present with those people to turn up and to keep turning up. Yes. And to acknowledge the complexity of the problem, it's a big deal and we all keep up when it is in full crisis and sort of say encouraging things but we need to back those up with some actions.
Brigid [00:27:53] Yeah I find that we all do it. I do it too. I'm practicing not doing it. But the "call me if you need anything". Or "sing out If you need some help". Yes. I don't find that a very useful thing to say in these times because the parents are probably overwhelmed. It's better to say I can come in on Tuesday. Would you like me to bring you a change of clothes or whatever it might be.
Patrick [00:28:16] Exactly. Exactly right. Rather than leaving it to the person to ask you for help. And knowing that the baby might be in the hospital for five weeks six weeks - so don't stop caring. You never stop caring but don't stop supporting and expressing your care and acknowledging what the family going through.
Brigid [00:28:34] Yeah. All right. So we've talked a little bit about the program during this podcast. So if you're interested in finding out about the GrowMyBaby program then just jump on to our website www.growmybaby.com.au/program and join our wait list to find out the minute it launches.
Brigid [00:28:54] And if you haven't already subscribed make sure you search for the show and your podcast app of choice or listen at growmybaby.com.au And by subscribing you'll be alerted to when our next episode hits which is all about why the position of your placenta is important.