All About Preterm Labor and Preemie Babies

All parents have questions about caring for their newborn, but when your baby arrives early and requires an extended hospital stay before going home, it’s natural to have even more concerns. Here are some of the most common questions about babies born prematurely:

When Is a Baby Considered Premature?

A full-term pregnancy lasts for about 40 weeks from the first day of a woman's last menstrual period. If born between weeks 38 or 39 to 42, the baby is considered full-term.

So, what is considered a premature baby? Definitions differ slightly among medical experts and organizations, but in general, when a baby is born at 37 or 38 weeks or earlier, he is considered premature, and the birth is called preterm.

The calculation is based on the date of the mother's last period and an evaluation of the physical and neurological maturity of the baby, using ultrasound measurements while he is still in the uterus and a direct examination after birth.

What Is Extremely Premature?

Not all premature babies fall into the same category. That’s because the number of weeks the baby is premature affects his health and the type and amount of medical assistance required to ensure he develops, and is kept comfortable. Many experts group preemies into three broad categories: extremely premature, very premature, and moderate to late preterm.

Babies born before 25 to 28 weeks of pregnancy are considered extremely premature. The major organs of a baby born this early are not fully formed. Specialist NICU staff will be able to help you make decisions about treatment and other measures to make the baby more comfortable.

What Is Very Premature?

If a baby is born before week 32 of pregnancy, he is considered very premature. The survival rate at this point is much higher than those babies born extremely prematurely, but they will still face health challenges, which NICU staff will be able to explain. These highly trained staff members will also be able to walk you through the best treatment and care options, and in many cases, there may be few long-term adverse health consequences.

What Is Moderate to Late Preterm?

Moderate to late preterm is when a baby is born between week 32 and 37 of pregnancy. Babies born moderate to late preterm can look pretty much like full-term babies, only smaller. They can still face health challenges, such as respiratory, feeding, and thermoregulation difficulties. Your baby’s medical team will be able to give you advice on ways to reduce any risk of complications, so that you can take your newborn home as soon as possible.

What’s the Difference Between Small, Medium, and Large Preemie Babies?

In addition to noting birth weight, relative size for a given gestational age is another way to characterize a newborn. A baby’s weight relative to his gestational age is compared to well-established norms for growth in the uterus, and the classifications are:

• Appropriate for gestational age (AGA): A baby who is in the average range for his gestational age.

• Small for gestational age (SGA): A baby who is low weight for his gestational age.

• Large for gestational age (LGA): A baby whose weight falls above the average range.

• Intrauterine growth retardation (IUGR): This is when the fetus or baby does not receive the necessary nutrients and oxygen needed for proper growth and development of organs and tissues.

Additional concerns come up with SGA and LGA infants, requiring further testing and monitoring. It's good for the baby to be AGA, even if he is very early and very small.

This means that there are three possible ways to describe newborns of the same birth weight. For example, a 5-pound infant may be an SGA baby at 42 weeks, an LGA baby of 30 weeks, or an AGA baby at 36 weeks. Depending on his weight and gestational age, he will need different kinds of diagnostic testing, monitoring and support, and follow-up recommendations.

How Common Is Premature Birth?

After decades of increases, the rate of premature births has declined over the last several years in the United States. Today, about 1 in 10 infants — around 380,000 babies — are born at or before week 37 of pregnancy.

The percentage of babies born with low birth weight — considered to be less than 2,500 grams, or 5 pounds, 8 ounces — is now just over 8 percent.

What Do We Know About a Premature Baby’s Survival Rate?

Each day, science and medicine add more to what is known about prematurity. Because of this, today's fragile babies have a greater chance of survival than those of 10 years ago. It is difficult to assign an exact limit of viability — the minimum amount of time a baby has to spend in the womb in order to survive outside — given that each baby is different. Your baby's medical team and the NICU staff are the best resources to consult.

What Are the Causes of Preterm Births?

There are many causes of prematurity; some are known and some are not. Known risk factors account for about half of the cases of preterm delivery. These known risk factors include:

Infections: Urinary tract infections, respiratory illnesses, and vaginal infections are known to be associated with preterm birth. Recently, gum disease and undetected viral illnesses have been associated with increased rates of prematurity. Even if there is no known infection at the time of a preterm birth, the placenta may show signs of infection.

Group B streptococcus bacteria, in particular, are linked to preterm birth even without causing any disease in the mother. That's why there's a test for this infection, using cultures or rapid screening on swabs of the mom's genital and rectal areas. If identified, this infection can be treated with antibiotics before or during labor to prevent the spread of infection to the infant. With the onset of preterm labor, infection is presumed to be a factor, so after birth, mom and baby are treated with antibiotics.

The membranes surrounding the baby in the womb are a major barrier to infection. If these break or rupture early, the baby is at risk for infection. This is called premature rupture of membranes. If any sign of infection occurs in the mom or is suggested in the monitoring of the fetus, an early delivery will be needed. It could be that the premature rupture of membranes may be caused by infection.

Multiple births: Twins, triplets, and other multiples are not often carried to full term. Twins have a 25 to 50 percent chance of an early arrival, and the odds rise from there as the number of babies carried in the uterus increases. The uterus may get tight and begin contracting, the placental blood flow may decrease, or the placenta(s) may wear out. For any of these reasons, multiples often come early, or a decision is made to deliver them early.

Congenital abnormalities: Infants with irregularities in development may start knocking at the door early. Ultrasound testing often helps to identify them. If the baby needs an intervention before the due date, a premature delivery may be planned.

A condition of the mother: Moms with uterine or cervical abnormalities; chronic illnesses such as kidney disease, preeclampsia/eclampsia (a pregnancy-related illness with high blood pressure), or diabetes; or a poorly functioning, bleeding, or damaged placenta usually require early delivery of the baby. Delivery may be by cesarean section (c-section) or a vaginal birth may be induced for the well-being of the mother and/or the baby.

Other health factors of the mother have been linked to a higher rate of preterm birth. These include:

• A previous preterm delivery

• Fertility problems, a second trimester abortion, or miscarriage

• Becoming pregnant six weeks or less after a previous birth

• Being underweight at conception or gaining less than 20 pounds during pregnancy

• Being younger than 17 or older than 35

• Working late into pregnancy, performing heavy labor, or being subject to a lot of physical or emotional stress

• Smoking, or using drugs such as cocaine or amphetamines

What Are Some Common Myths About the Causes of Preterm Birth?

Moms and dads of preterm infants may wonder what they did to cause an early delivery, and feel guilty. In the vast majority of cases, there is nothing that could have been done to prevent an early birth. But myths about the causes of premature births include:

• Worrying

• Bad thoughts

• Arguments between mom and dad

• Air travel

• Bad food

• Swimming

• Tight clothes, particularly pants

• Getting chilled

• A relative's or friend's jealousy

How Can I Decrease the Chances of My Baby Being Born Prematurely?

Preventing preterm births is not possible, but there are some things you can do to help reduce the risk. Getting good prenatal care and having good medical care between pregnancies might help. The right medical attention will also help you catch and treat any infections early. If yours is a high-risk pregnancy, or if you have a chronic or acute health condition, then see your healthcare provider early and often. Good nutrition, appropriate weight gain, and not smoking or using drugs can also decrease the chances of a preterm birth.

How Is a Preemie’s Age Calculated?

There are three “ages” to consider with a preemie baby.

• Gestational age: A premature infant's gestational age is the number of weeks completed in the womb at birth, as calculated from mom's menstrual dates and the infant's maturational features at birth.

• Chronological age: This is the actual time since birth.

• Adjusted age: This is the chronological age corrected for the amount of prematurity.

For example, if your child was born three weeks ago (meaning his chronological age is 3 weeks) after spending 30 weeks in the womb (in other words, at birth his gestational age was 30 weeks), his adjusted age is considered 33 weeks old, until he reaches term (at 40 weeks). At 6 months of chronological age, he would have an adjusted age of 3 1/2 months: 6 months minus the 2 1/2 months (10 weeks) he was early.

Adjusted age is commonly used when the subject is your baby's development, but chronological age is best for calculating the timing of healthcare visits and immunizations.

Your preterm infant’s development will more closely follow his adjusted age than his calendar age, but because he did arrive on a specific calendar date, that will be his legal birthday. Each year, remember how far you've come. When he turns 2, start telling him his birth story. All kids like to hear all about themselves, and prematurity is part of his story.

What Is the Delivery of a Preterm Infant Like?

About 20 percent of preterm babies are delivered electively (a planned delivery) because of the mother's or infant's condition. Many of these are delivered by C-section to avoid the stress of labor, while some births have labor induced. Another 30 percent have a preterm delivery after the membranes rupture, and about half of all preterm births are delivered after the start of preterm labor.

Your labor may be induced or an operative delivery proposed if your baby is in distress — this is called fetal distress. Signs of distress and reasons to consider an early delivery include less movement, poor response to induced contractions of the womb (a stress test), slowing growth, or bleeding of the placenta.

The chance of needing a C-section increases as the number of baby’s you are carrying increases. This is due in large part to the different positions these womb-mates take besides the usual head-down position. Read more about expecting twins, triplets and multiples for more information about delivering more than one baby.

If you have a high-risk condition and/or a preterm delivery is imminent, you may be transferred to a high-risk center for delivery, so that both you and your baby can get the specialized care you might need. Expect a large team at the delivery so your and your baby’s needs are met completely and rapidly. It's better to be overly prepared than to need, but not have, essential equipment and specialist doctors.

Find out more about the signs of preterm labor, so that you can tell the difference between early labor and “practice” contractions called Braxton Hicks contractions during your pregnancy.

What’s the Difference Between Small, Medium, and Large Preemie Babies?

In addition to noting birth weight, relative size for a given gestational age is another way to characterize a newborn. A baby’s weight relative to his gestational age is compared to well-established norms for growth in the uterus, and the classifications are:

• Appropriate for gestational age (AGA): A baby who is in the average range for his gestational age.

• Small for gestational age (SGA): A baby who is low weight for his gestational age.

• Large for gestational age (LGA): A baby whose weight falls above the average range.

• Intrauterine growth retardation (IUGR): This is when the fetus or baby does not receive the necessary nutrients and oxygen needed for proper growth and development of organs and tissues.

Additional concerns come up with SGA and LGA infants, requiring further testing and monitoring. It's good for the baby to be AGA, even if he is very early and very small.

This means that there are three possible ways to describe newborns of the same birth weight. For example, a 5-pound infant may be an SGA baby at 42 weeks, an LGA baby of 30 weeks, or an AGA baby at 36 weeks. Depending on his weight and gestational age, he will need different kinds of diagnostic testing, monitoring and support, and follow-up recommendations.

What Can I Expect at the Hospital?

If your baby is found to be unexpectedly premature and/or develops complications, he may be taken by plane, helicopter, or ambulance to a regional perinatal center where his needs can be met. When his medical condition stabilizes, he is often transferred back to the neonatal intensive care unit (NICU) of a hospital nearer to your home to continue to grow and mature until he's ready to go home.

You might be a little confused about some of the terms that hospital staff are using, so here is a short glossary of some of the most common problems and treatments that you might hear mentioned at the NICU. Depending on the situation, your baby may need a variety of specialized tests, and you might encounter a range of equipment that’s specially designed for preemie babies. It can help to familiarize yourself with these tests and equipment types to help you feel a little less overwhelmed. Of course, NICU staff will always be able to walk you through your baby’s specific situation. Ask them to use “plain English” if you feel that you do not fully understand something.

Every mom worries about starting to breastfeed her baby, but with a preemie, the questions about breastfeeding can be a little different. NICU staff are highly trained experts who can provide you with the best, personalized guidance about pumping breast milk and more.

You might be surprised about the little things that become bigger questions if you are a parent of a preemie. For example, what clothes and diapers does a preemie wear? Remember, for NICU staff, no question is silly, so take the time to get all the answers you need — no matter how big or small it might seem.

How Do I Deal With the Costs of Special Medical Care for My Preemie Baby?

When a baby is born prematurely, there's no doubt that medical expenses can be very high, due to the high-tech treatments and long hospital stays that may be necessary. Contact your insurance company as soon as possible after your baby's birth to set up coverage. The hospital business office will assist you, as well. If you don't have insurance, the hospital social worker and business office staff, as well as local social service agencies, are your go-to resources to help identify programs that could offer financial help, such as Medicaid.

When Will My Preterm Baby Be Discharged From Hospital?

Premature babies generally go home two to four weeks before their original due date, but there are a number of exceptions. Many factors contribute to the decision to discharge a preemie. For example, the baby's breathing, heart rate, and temperature must be steady and stable in a regular bassinet. If your baby is being monitored for apnea (breathing stoppage) or bradycardia (slow heart rate), you must know how to use the monitor and respond to alarms. A hearing screening, an eye exam, and other tests need to be completed before your baby leaves the hospital.

Your baby needs to be gaining weight steadily, so you must be able to feed him by breast, bottle, gavage (feeding by a tube in the stomach), or a combination of these methods. If your baby needs medication, a regular regimen needs to be set up, and you need to be able to give the medicine accurately. Most preterm clinics require that you learn infant CPR, which is a good skill, in any case. To ease the transition from hospital to home, your hospital might offer you the opportunity to stay one or more nights to take full care of your baby while nurses are nearby.

Your little one will need a car seat test to judge whether his breathing is okay for the ride home, and if not, modifications need to be made. Your home may also require some modifications or special equipment to be installed. Finally, your child's primary healthcare provider will need to know the medical history so she is ready to take over.

Before you leave the hospital, your medical team will run all the right tests, and give you all the information you need about how to continue to care for and aid the development of your preemie. If you happen to have any remaining questions, feel free to ask your doctors, so you feel more confident about taking care of him at home. Once you’re home, there’s a lot you can do to help support the development of your preemie: everything from kangaroo care, to having the right-sized preemie clothes, and even ensuring you have preemie diapers that fit your baby well and keep him dry.

Caring for your preemie might put extra pressure on your household finances, but there are plenty of ways you can save money.

Once You’re at Home With Your Preemie

The next sections answer some common questions about home life and follow-up care once you’ve taken your preemie home.

Can My Premature Infant Have Visitors at Home?

It's exciting to share the joy of bringing home a baby! However, depending on how little or fragile your baby is, you may need to limit or restrict visitors for a while. A preemie who's been in the hospital for weeks may need a period with no visitors, for example.

Basically, limiting visitors limits the germs to which the infant is exposed. Someone with a cough or cold, for instance, could present a risk to a baby born prematurely who’s recovering from lung disease, a common condition for preemies. Contact with mildly ill household members and regular care providers is not a big problem, since they share the same environment as the infant and aren't bringing in new germs. However, a household member with a juicy cold should limit contact if possible and practice very serious hand-washing and sneeze control.

Limiting visitors also reduces the risk of overstimulation, not only for your baby but for the whole family. Too much handling, talking, and bouncing can be stressful for young infants. You will know best how much your little one can handle. Be sure you reserve time to bond together as a family, to get to know your child, and to gently help him take on the world.

For How Long Will My Preemie Need Follow-Up Appointments?

Follow-up clinics are special clinics for children born early or with conditions that place them at risk for physical or developmental problems. Periodic appointments are often made for infants beginning at hospital discharge. These clinic appointments supplement the regular visits to the child's primary care physician. The clinic's developmental evaluations go beyond what a healthcare provider can normally do in a regular office visit.

At each visit, the clinic staff will spend time with you and your baby to evaluate progress, address new situations that may have arisen, and make referrals to medical and community-based services and programs. Although the appointments can be time-consuming, that's generally not the reason some families resist going. The hard part is facing the possibility of finding a new problem when you'd rather forget all the troubles you went through when your baby was born. But do get around those worries and show up for every appointment. Most of the time, you'll receive lots of reassurance and support, plus valuable education and suggestions for programs and activities. Because some subtle learning problems or perceptual concerns don't appear until school age, it's best to keep going to the clinic until you are packing a lunch box. In fact, one of the most important visits can be the one prior to the child entering kindergarten.

How Will My Family Be Impacted and What Can We Do to Handle This Situation?

A fragile baby does demand extraordinary care and vigilance, and it's a challenge to meet the needs of other family members — parents as well as older children. Include older children from the beginning by providing them with simple descriptions of what's happening, clear explanations of why your emotions may be up and down, and suggestions for what they can do to help.

When your baby is in the hospital, older children can get involved by sending drawings or pictures to put on the incubator, and picking out small toys or clothes. As soon as the technical equipment supporting your newborn has lessened enough so as not to be overwhelming, bring siblings to visit, provided they are healthy. Touching the baby, even a little, helps.

At home, be sure to involve big sisters and brothers in your care of the baby. A toddler, for example, can help by bringing you a diaper or fastening it once it's on. Spend one-on-one time with your older children every day, no matter how brief. Have someone else watch the baby while you provide exclusive attention to your older kids, rather than just handing them off to a sitter. When feeding the baby, get a basket of quiet toys for your older children so they can sit with you and occupy themselves with these special items.

Expect regressions in behavior, such as wet pants, sleep issues, and tantrums — your older child is adjusting to changed circumstances, just as you are. Don't expect her to like the baby very much; from her point of view, the baby's not much fun and causes a lot of trouble. Remember to use others to fill in for you for a while so you can exercise and rest. You can't parent well if you are tired and crabby. Let the house get a little messy (or hire someone to clean it), make meals simple, and limit social and work demands as much as possible to save your energy. All of these measures will help life go more smoothly for everyone in the household.

It’s natural to feel overwhelmed and fearful. Read more about coping with the worries of having a preemie.

Will My Next Baby Be Premature?

That depends on why your first baby came early. If you have no known risk factors for prematurity other than the history of a previous preemie, the chances are good that your next child’s birth date will be close to the due date. However, if you have irregularities of the uterus or a chronic health condition such as diabetes or kidney disease, it's very likely that you will experience another premature birth. Also, women older than 35 have an increased risk of an early birth.