Premature birth

What is it?

A pregnancy normally lasts about 40 weeks. Preterm means before 37 weeks. Within that, the earlier the birth, the greater the risk.

• Late preterm, 34 to 36 weeks. Often looks like a term baby and still carries higher rates of feeding difficulty, jaundice and low blood sugar. ⁶
• Moderate preterm, 32 to 33 weeks.
• Very preterm, 28 to 31 weeks.
• Extremely preterm, before 28 weeks.

Why being born early causes injury

Organs finish developing late in pregnancy, and the brain is the clearest example.

The lungs do not make enough surfactant until late, which causes respiratory distress syndrome. ¹

The brain contains a fragile layer of blood vessels called the germinal matrix until about 34 weeks, which is where intraventricular hemorrhage starts. ⁷

The white matter beside the ventricles has a blood supply at the end of the line, which is why periventricular leukomalacia is a preterm injury. ⁸

The bowel is immature, which is why necrotizing enterocolitis is a preterm illness. ⁹

None of this is caused by anything the parents did. The most common causes of preterm birth are not identified at all. ¹

What does standard care look like?

Antenatal corticosteroids. A course given to the mother before an expected preterm birth reduces newborn death, respiratory distress syndrome and bleeding in the brain. Guidance sets out the gestational age window and the situations in which a course is recommended. ^{2 10}

Magnesium sulphate for fetal neuroprotection before 32 weeks, which reduces cerebral palsy in the child. ³

Delivery at a hospital with the right level of newborn care, or transfer of the mother before the birth. Levels of neonatal care are formally defined, and moving a mother is safer than moving a very small baby. ⁴

Antibiotics where indicated, including for Group B strep prevention. ¹¹

Delayed cord clamping where the baby's condition allows, which improves blood volume and reduces the need for transfusion. ¹²

Resuscitation following the newborn algorithm, with attention to temperature, which matters greatly in very small babies. ¹²

Head ultrasounds on a schedule in very preterm babies, since most bleeding happens in the first 72 hours. ⁸

Developmental follow-up arranged before discharge. ¹³

What can go wrong?

Steroids not given when preterm birth was expected and there was time. ^{2 10}

Magnesium not given before 32 weeks. ³

The mother not transferred before delivery to a hospital with the right level of care, when there was time. ⁴

Preterm labor not recognized, so neither treatment was given.

Infection not treated, where it caused or accompanied the preterm birth. ¹¹

Resuscitation not following the algorithm, or the baby allowed to become cold. ¹²

Head ultrasounds not done on schedule, so bleeding or enlarging ventricles were not tracked. ⁸

No term-equivalent MRI, so white matter injury was not identified. ⁸

No developmental follow-up arranged. ¹³

Whether any of this amounts to a departure from the standard takes a physician expert reading the whole record.

Which injuries can follow?

• Respiratory distress syndrome and chronic lung disease. ¹
• Intraventricular hemorrhage. ⁷
• Periventricular leukomalacia. ⁸
• Hydrocephalus after significant bleeding. ¹⁴
• Cerebral palsy, most often spastic diplegia. ¹
• Necrotizing enterocolitis. ⁹
• Neonatal sepsis. ¹¹
• Cortical visual impairment and retinopathy of prematurity. ¹⁵
• Hearing loss. ¹⁶
• Developmental delay and later learning differences. ¹⁷

What does this look like in the records?

From the prenatal and labor record

• The reason for the preterm birth, if one was identified.
• Whether antenatal corticosteroids were given, how many doses, and the time of each relative to delivery. ¹⁰
• Whether magnesium sulphate was given, and for which indication. ³
• Whether transfer to another hospital was considered or arranged. ⁴
• Antibiotics given, and Group B strep status. ¹¹
• The fetal monitoring strip. ¹⁸

From the newborn record

• The resuscitation record, including temperature on admission. ¹²
• Every head ultrasound report, with dates. ⁸
• Whether a term-equivalent MRI was done.
• Blood pressure and blood gas records from the first days.
• Eye screening results.
• Hearing screening results. ¹⁶
• The discharge summary and the follow-up plan. ¹³

What can you do this week?

1. Request the complete labor and delivery record for you and your baby. The records request builder writes the letters for you.
2. Write down what you remember while it is fresh, using the delivery timeline builder.
3. Read how to read your labor and delivery records before the records arrive.
4. Check the deadline to file in your state with the statute of limitations lookup.