1. Adapted by Pam Jordan, PhD, RNC
Premature Infants
Adapted by Pam Jordan, PhD, RNC
from Susan Jones, MN, RNC

2. Case study
After 8 days, Tasheka’s contractions begin to break through the magnesium sulfate and are not stopped by trials of terbutaline and ritodrine.
All of the medications are stopped and Tasheka continues in labor. After 8 hours, Tasheka gives birth to a baby girl at 31 weeks gestation.
The baby is flaccid at birth with weak respiratory efforts. She perks up after being given oxygen. She is taken to the NICU for further assessment and stabilization.

3. Troubling & Persistent Disparities in Rates of Preterm Birth [2010 statistics]
Non-Hispanic Blacks %
Native Americans 13.9%
Hispanics %
Non-Hispanic Whites 10.9%
Asians %
Preterm birth is the leading cause of neonatal mortality and morbidity in the US.

4. Definitions
Preterm birth refers only to gestational age at birth, regardless of birth weight.
Very preterm=<32 weeks
Moderately preterm=32-34 weeks
Late preterm=34-36 weeks

5. Definitions
Low birth weight [LBW] refers only to birth weight regardless of gestational age.
Low birthweight <2500 g [5.5 lbs]
Very low birthweight <1500 g [3.5 lbs]
Extremely low birthweight <1000 g [2.2 lbs]

6. Adverse Outcomes Associated with PTB
Respiratory distress syndrome
Transient tachypnea of the newborn
Pulmonary infection
Unspecified respiratory failure
Recurrent apnea
Temperature instability
Jaundice
Bilirubin-induced brain injury
Rehospitalization for all causes
Rehospitalization for dehydration
Feeding difficulties
Long term neurodevelopmental delay
Periventricular leukomalacia

7. Sequelae for VLBW and ELBW Infants
Respiratory distress syndrome
Patent ductus arteriosus
Severe intraventricular hemorrhage
Necrotizing enterocolitis
Sepsis
Bronchopulmanary dysplasia
Retinopathy
Cerebral palsy
Asthma
Poor vision
Low IQ [<85]
Poor motor skills
Poor academic skills
[Hack et al., 2011; IOM, 2007]

8. Cost of PTB $26.2 billion in US in 2005 [IOM, 2007]
Costs to employers:
$64,713 for mother and baby compared to
$15,047 for uncomplicated birth and healthy newborn [Thomson Reuters, 2008]

9. Clinical Criteria for Dx of Preterm Labor
20 and 0/7 to 36 and 6/7 weeks’ gestation AND
Regular uterine contractions AND
Change in cervical dilation AND/OR
Change in cervical effacement by digital examination or transvaginal ultrasound assessment of cervical length OR
Initial presentation with regular contractions and cervical dilation ≥ 2 cm

10. NOTE
Less than 10% of women with clinical dx of PTL actually give birth within 7 days of dx
~ 30% of PTL resolves spontaneously
~ 50% of women hospitalized for PTL actually give birth at term

11. Pathophysiology of Preterm Labor & Birth
In nearly 40% of PTBs, cause is unknown [March of Dimes, 2011]
Multiple causes, including:
Social factors
Physiologic factors
Medical history factors
Illness factors

12. Determinants of Preterm Labor

13. Four Main Routes Leading to PTL [March of Dimes, 2011]
Infections/inflammation: from genital and urinary tract, fetal membranes, periodontal disease
Maternal or fetal stress
Chronic psychosocial stress in mother or physical stress in fetus
Bleeding [placental abruption]
Uterine stretching [multiple gestation, polyhydramnios, uterine or placental abnormalities]
~25% of PTBs are intentional R/T health problems in mother or fetus
~another 25% of PTBs follow premature preterm rupture of membranes

14. Most Common Risk Factors for PTL/PTB
Current multifetal pregnancy
History of preterm birth
Uterine/cervical abnormalities

15. Other Possible Risk Factors for PTL
Chronic health problems
Hypertension
Diabetes mellitus
Clotting disorders/thrombophilia
Low prepregnancy weight
Obesity [as related to comorbidities, such as HTN, DM, not a risk factor for spontaneous preterm labor

16. Other Possible Risk Factors for PTL
Behavioral and environmental factors
Late or no prenatal care
Smoking
Alcohol abuse
Use of illicit drugs
DES exposure
Intimate partner violence
Lack of social support
High levels of stress
Long working hours
Long periods of standing

17. Other Possible Risk Factors for PTL
Demographic risks
Non-Hispanic black race
Age <17 years
Age >35 years
Low socioeconomic status

18. Other Possible Risk Factors for PTL
Genetics-assisted reproductive technologies
Medical risks in current pregnancy
Infection [esp. genitourinary]
Short interpregnancy interval
Fetal anomalies
Preterm premature rupture of membranes
Vaginal bleeding, esp in the second trimester or in more than one trimester
Periodontal disease
Being underweight prior to pregnancy

19. Objectives: apply your knowledge of term infants and compare and contrast with premature newborns
Discuss the following subjects:
How would this preterm baby’s transition to extrauterine life differ from that of a term infant?
Thermoregulation
Respiratory
Cardiac
GI/Nutrition/Fluids
Immune function
Neurologic
Skin
How can you support Tasheka and BJ while their daughter is in the NICU?

20. How would you expect a preterm baby’s transition to be different from that of a term infant?

21. Compare and Contrast
Thermoregulation
Term newborn
Preterm

22. Respiratory retractions Signs of respiratory distress?
Surfactant deficiency
Tasheka had corticosteroids before delivery - help mature lungs
Fatigue
retractions

23. Cardiac 3 shunts in fetal circulation
ductus venosus - fetal blood vessel connecting the umbilical vein to the IVC
foramen ovale - allows most of the oxygenated blood entering the right atrium to pass into the left atrium
ductus arteriosis - protects lungs against too much blood flow in utero

24. Circulatory problem with prematurity: failure of ductus arteriosis to close
Patent ductus arteriosis
over circulation of blood to lungs
puts burden on heart to pump extra blood
lack of circulation to rest of body (kidneys, gut)
health/info/heart/diagnose/pda.ht m

25. GI/Nutrition/Fluids Term infant about 75% TBW, preterm has up to 90%
31 weeker about 80%
Preemies have increased fluid losses
Jaundice

26. Skin
mature skin layers
premature skin layers

27. Immune Function Placental transfer of immunity (IgG) Breast milk
premature milk higher in protein first 3 weeks
immunologic factors
secretory immunoglobulin A (IgA)
leukocytes

28. Promote breastfeeding
How? Why?
Immature gut - risks?
Feeding ability - oral? NG?
Promote breastfeeding

29. Neurologic - immature brain
Most fetal brain growth is in the 3rd trimester
This baby is at risk for:
Developmental injury
White matter injury from lack of blood flow - is most common problem for preterms & may lead to CP
Intraventricular hemorrhage
Top: normal newborn
Bottom: premature baby

30. Compare tone

31. Attachment: If you were expecting this
How can you support Tasheka and BJ while their
daughter is in the NICU?
Attachment: If you were expecting this
and you got this
how would you feel?

32. Family support

33. Family teaching - isolette (incubator), monitors, “how can I touch my baby?”

34. Facilitated Tuck with Dad’s Hands

35. Helpful websites http://www.meriter.com/living/preemie/m
ery/
(careful with blogs and forums - lots of misinformation)
(NICU RN professional organization)

36. Primary source: Reedy, N. J. (2014). Preterm labor and birth
Primary source: Reedy, N. J. (2014). Preterm labor and birth. In Simpson, K. R. & Creehan, P. A. (Eds.), Perinatal nursing (4th edition) (pp ). Philadelphia, PA: Wolters Kluwer/Lippincott, Williams, & Wilkins.