Baby steps when it comes to advances in preterm care

Recent advances in maternal and foetal medicine have undoubtedly saved lives and improved the well-being of preterm babies and their families.

The preterm surveillance clinic at the National Maternity Hospital (NMH), Holles Street in Dublin – which helps mothers carry their babies to term – is part of that charge. And, in tandem with advances at the clinic, is the work of the hospital's neonatal intensive care unit, which has been able to save babies who are younger than had been possible before.

Until recently, babies who were younger than 24 weeks’ gestation (or under 500g) had low survival rates.

Holles Street has now recorded their lowest birth weight ever after a baby girl weighing just 350g at birth – less than the weight of a can of Coke – has survived and thrived.

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The longer babies stay in the womb, the better chance of survival they have. Among those working to help babies remain inside their mothers until they reach full term (37-40 weeks) is Dr Shane Higgins, master of the NMH. Dr Higgins, a consultant obstetrician and gynaecologist specialising in maternal and foetal medicine, established the preterm surveillance clinic at Holles Street in 2012, after working at a similar unit in Melbourne. The unit was the first stand-alone preterm birth clinic in Ireland. "My interest in preterm birth began in Melbourne," he says, "and I essentially brought their preterm surveillance package back with me."

Host of causes

Predicting preterm birth or determining the causes for first time mothers remains challenging, as there are a host of issues that can bring on early labour.

But groups that are known to be at risk of preterm birth are mothers who have previously given birth before 37 weeks and those who have had two or more surgical procedures on their cervix, including Lets or biopsies. Those with a congenital uterine anomaly are also at risk.

This is where the preterm surveillance clinic comes in, offering specialised, individualised healthcare for women who fall into these demographics. The clinic allows hospital staff to put in place care pathways and processes that allow them to provide care for women throughout their pregnancies.

Expectant mothers can attend the clinic on a weekly basis, meeting with a team of consultants, midwives and junior doctors. The clinic offers a range of therapies such as a cervical stitch or progesterone, which can reduce the chances of preterm birth. Reducing the incidents of babies born before 37 weeks, or helping them remain inside their mothers for as long as possible, means better outcomes for mothers, babies and their families. “If you reduce the incidents of preterm birth, even in that group of women who have already had one, then you reduce all that morbidity and mortality,” says Dr Higgins.

“Remember, a lot of babies born prematurely will still die, particularly the extreme preterm – so if you can reduce that, there’s a hugely beneficial impact on the life of the baby, and on the outcome of the pregnancy.”

Continuity of care is also hugely important to the mothers.

“We have patients who come here on a weekly basis for most of their pregnancy, and they are absolutely delighted,” says Dr Higgins. “They feel like the care package that they get by being seen every week by the same clinicians, doctors and midwives is hugely reassuring.

“There’s something about it that’s something more than pure medicine. It’s patients feeling that they are being really well looked after. This is a very vulnerable group who don’t know when the birth is going to happen, don’t know from one week to the next whether they’re going to be delivering a baby or not. There’s also a group of women who won’t require any treatment – but they will comment categorically on the benefit of coming to the clinic once a week.”

Dr Higgins encouraged all women who are at risk of preterm birth, no matter where they live in Ireland, to get in touch with the clinic, which has just been taken over by Dr Siobhán Corcoran, so Dr Higgins can focus on his duties as master. “If I can prevent one preterm birth in a year, that’s a success to me,” Dr Higgins says. “But I think we prevent a lot more than that.”

Neonatal intensive care unit

Along with the treatment and care provided by the preterm surveillance clinic, ongoing advances in neonatology is leading to better outcomes for those babies who do survive. Helping those babies who are born preterm is Dr Claudine Vavasseur, a consultant neonatologist, and her team at the neonatal intensive care unit.

As indicated by the recent birth of the baby at 23 weeks, the gestational age of the babies that can be resuscitated becomes lower with each decade. “The age of those we can offer resuscitation to drops approximately a week with each decade,” says Dr Vavasseur. “JFK had a preterm baby, and he would have been about 32 or 33 weeks’ gestation and that would have been in the 1960s. So that would have been 60 years ago, and now we resuscitate babies from 23 weeks gestation. It’s a very exciting area because we’re always improving and always improving our survival rates.”

In caring for preterm babies, healthcare professionals and parents must look at both size and birth weight – and nutrition is key to bringing up a baby’s birth weight, and thus increasing their chances of survival. “It comes down to the techniques that we need to employ to provide nutrition to the baby,” says Dr Vavasseur.

Providing the young babies with breast milk from their mothers is a very important part of their nutrition plan. “We use their umbilical cord to give proteins, liquid, glucose, all of these things, until we can establish baby is on full breast milk,” says Dr Vavasseur. “And that’s what we aim to do, is to get these babies breastfeeding. They won’t be able to suck or swallow until they’re about 34 weeks’ gestation. So in that 10- or 11-week period that we have, we feed them intravenously and then slowly, with mum’s breast milk. We have all these mums expressing and we feed the babies down the nasal-gastric tube in very slow increments.”

Breathing

Caffeine is another important part of the treatment plan for preterm babies. “We give the babies huge amounts of caffeine, because they essentially forget to breathe, because the brain is so immature,” says Dr Vavasseur. “The caffeine works on the brain stem to stimulate the respiratory centres there to remind the baby to breath, and we continue with it until they can breathe on their own.”

The preterm babies are often anaemic and rely heavily on blood donations from the public. For them, a little blood can go a long way towards helping them reach full viability.

Another positive development is improvements in national transport and transferring systems. With these in place, mothers have a better chance of getting to Holles Street before they give birth. “The best way for babies to travel is in the uterus,” said Dr Vavasseur. “In the majority of cases, we get the babies here before the birth, and that really matters, because being born outside a tertiary referral unit has prognostic significance for morbidity and mortality.”

Trends in pregnancy and childbearing, such as an increase in maternal age and the use of IVF treatments, has had a trickle-down effect on gestational age and thus the work that Dr Vavasseur and her colleagues do.

Multiple gestations, when a woman is pregnant with two (or more) babies, can often lead to preterm births. As the number of women using IVF treatment increases, the number of multiple gestations also does – which means the neonatal unit has become busier.

In September, nearly half of the 40 babies in the unit were part of a multiple gestation pregnancy. In August, three sets of triplets were born.

“With assisted reproductive techniques advancing, there is a consequence to the neonatal intensive care,” Dr Vavasseur says. “When we’re looking at planning into the future, it’s really important to consider the effect of an aging maternal population has on us.”

Read: Born at 23 weeks