Premature birth in a regional hospital

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You are the paediatric registrar in a regional hospital when the ED reg informs you of the arrival of a labouring woman who is fully dilated and pushing.  The patient believes she is about 27 weeks.

 

Bottom Line

  • The usual neonatal resuscitation algorithm applies
  • Involve your tertiary referral centre early
  • Keep the baby warm
  • Check the sugar early and regularly
  • If the baby is breathing adequately, intubation is not essential
  • High oxygen concentrations and high inspiratory pressures are harmful,  be careful with them
  • Give antibiotics and vitamin K

What do I prepare for the delivery?

Prepare as for any delivery by warming the resuscitaire and collecting the usual equipment.  In addition you will need a polyethylene bag or some cling film.

Steroids should be given to the mother even if delivery is considered inevitable. Though their effect on lung maturation if given less than 24 hours prior to birth is not clear, they probably reduce the risk of other complications including IVH.

Make contact with your tertiary NICU as early as possible and remind the midwife to cut the cord long as this gives you a second chance at an umbilical line.

If you have chance it is useful to have a conversation with the parents about what to expect with a pre-term baby. Focus on general points such as the baby needing help with breathing and feeding and keeping warm as well as making sure they know the baby will be transferred to another hospital.

If you do not feel equipped to answer specific questions the parents may have, encourage them to write those questions down to be asked later at the tertiary centre.

What do I do when the baby is born?

If the baby is breathing,  wrap them in a polyethylene bag and place them under a radiant heater then cover their head with a beanie or a towel . This will help reduce insensible water losses and keep them warm. Prem babies who get cold, quickly become hypoglycaemic and acidotic.

If the baby is not breathing, then resuscitation with the usual neonatal resuscitation algorithm is appropriate, but be aware of the need to keep the baby warm even during this time.

Do I really need to intubate this baby?

The only absolute indication for ventilation is apnoea. This can be with a bag/mask or Neopuff initially.

The more premature the baby the more likely it is to require intubation.  Most babies under 28 weeks will require an ET tube but mask ventilation done properly will defer the need for an ETT if you are not comfortable with intubating.

For intubation pre-medication is preferred in the active newbornbut not essential. The more vigorous the baby the harder it will be to intubate without medication.

There is no consensus on medication choice, but Monash Medical Centre in Melbourne, recommend fentanyl at 2 mcg/kg given IV over 30 seconds in babies <1000 g. For bigger babies they advocate the same fentanyl dose with the addition of suxamethonium at 2 mg/kg.   If intubation is not possible, it is easier to bag a baby who is muscle relaxed, but spontaneous breathing will be lost until the sux wears off.  A link to the Victorian Newborn Emergency Transport Service neonatal intubation guideline is provided below.  

What about ventilation?

The key is to provide adequate oxygenation and CO2 removal while avoiding high inspiratory pressures and high oxygen concentrations, both of which are harmful to small babies.

For manual ventilation, a self-inflating bag is acceptable and a Neopuff ideal. An anaesthetic bag should only be used if you have done this before and you have a manometer attached to it.  A reasonable place to start, whether by manual or mechanical ventilation, is pressures of 18/6 with a rate of 60 and an inspiratory time of 0.4s.  FiO2 should start at 21% and ideally be titrated with an oxygen blender.  Attach an oximeter as soon as is practical.

Aim for cutaneous oxygen sats of 85-92% (never >95%)  and accept PaCO2 in the high 40s/low 50s.   Inspiratory pressure should be as low as you can get it while still maintaining adequate chest movement and oxygen sats.  Note that lower oxygen saturations are normal in the first minutes of life (see NETSVic resuscitation link below for more details)

Surfactant will be indicated but should not be given until a CXR confirms position of the ETT.  Beware that surfactant can result in rapid changes in lung compliance and consequently reduction in ventilation requirements.  Discuss the timing of surfactant administration with the retrieval service before giving it.

How many lines does the baby need?

Strictly speaking only one.  In a tertiary NICU, small babies will have both umbilical venous and arterial lines inserted, often as well as peripheral IV access.   While it is usually best to leave the umbilical arteries alone for access later at the tertiary centre, the baby will need some form of intravenous access.

If you are familiar with the technique of UVC insertion this can be the easiest method, but peripheral venous cannulation will usually be adequate at this stage as long as the baby does not develop a requirement for inotropes.

If you are struggling to get IV access communicate this with the retrieval service, as no-one will thank you for scuppering their chances of accessing the umbilical vessels later.

Breast is best, right?

In the big picture yes, but at this stage the baby should be kept nil by mouth and started on IV fluids.  Small babies have negligible fat reserves and relatively high metabolic requirements, their kidneys are also not too flash at dealing with salt so 10% dextrose at 80 mls/kg/day is the fluid regime of choice to begin with.

If fluid boluses are required for resuscitation purposes use normal (0.9%) saline in aliquots of 10 mls/kg.

What's the most commonly proven cause of premature labour?

Infection.  Whatever the clinical circumstances of the delivery the baby needs antibiotics.  If you can get a blood culture out when you get IV access that is ideal.  If you can’t get a culture, give the antibiotics anyway.

Ampicillin and gentamicin are a reasonable empirical choice, but it is best to follow your local referral centre’s guideline.

Anything else I need to do?

Put a hat on the baby.  Give some vitamin K, but be careful about the dose.  Encourage the family to take some photos as they are likely to be separated when the baby is retrieved.   Arrange for the mother to follow the baby as soon as she is medically fit to do so and encourage her to express some EBM.

In a nutshell.....

Tiny babies need to be kept warm, sweet and pink (but not too pink!)

References

NETSVic Immediate management of the tiny baby (<1000g)

NETSVic Neonatal intubation guideline

NETSVic Resuscitation

Davies M and Cartwright D. Care of the extremely preterm baby. In Davies, Cartwright and Inglis. Pocket notes on neonatology 2nd ed, Elsevier. (2008)

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About 

Paediatric emergency physician interested in education, retrieval medicine and simulation. Lives in Brisbane where he enjoys falling off his mountain bike and being outsmarted by his pre-teen children.

@paedsem | + Ben Lawton | Ben's DFTB posts

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