Prematurity

Subject: Midwifery II (Theory)

Overview

Prematurity is described as the spontaneous commencement of labor between the 28th and 37th weeks of pregnancy, counting from the first day of the last menstrual cycle. However, some of the factors associated with an increased prevalence of preterm are maternal disease, pregnancy complications, placenta previa, uterine malformations, placenta abruption, and so on. Stabilization in the delivery room, together with prompt respiratory and thermal care, is critical to the immediate and long-term outcome of premature children, particularly severely premature infants. Radiant heaters may be utilized in the intensive care nursery to compensate for the premature infant's heat loss. Preterm newborns require close monitoring of their fluid and electrolytes due to increased transdermal water loss and immature renal function, as well as a variety of environmental factors.

Prematurity is defined as the spontaneous onset of labor between the 28th and 37th weeks of pregnancy, beginning with the first day of the last menstrual cycle.

Causes

More than half of the causes are unknown. However, the following factors are linked to an increased risk of prematurity:

  • maternal disease
  • pregnancy complication
  • abruption placenta
  • placenta previa
  • uterine anomalies
  • fetal causes
  • iatrogenic
  • idiopathic

Management

Stabilization in the delivery room, as well as appropriate respiratory and thermal care, is critical to the immediate and long-term outcomes of premature children, especially extremely premature infants.

Respiratory Management

  • Recruitment and maintenance of adequate or optimal lung volume; in infants with respiratory distress, this step can be accomplished with early continuous positive airway pressure (CPAP) administered nasally, through a mask (Neopuff), or through an endotracheal tube when ventilation and/or surfactant are administered.
  • Avoiding hyperoxia and hypoxia by attaching a pulse oximeter promptly and employing an oxygen blender to keep the oxygen saturation (SaO2) between 86 and 93 percent.
  • Preventing barotrauma or polytrauma by utilizing a ventilator that allows for the measurement of expired tidal volume and maintaining it at 4-7 mL/kg.
  • The surfactant should be given early (2 hours) and prophylactically in all severely preterm infants (29 weeks).

Thermoregulation

Radiant warmers may be utilized in the intensive care nursery to compensate for heat loss in premature infants. Because the heated atmosphere reduces heat loss owing to conduction, convection, and radiation, incubators are more efficient than radiant warmers. The environmental temperature in all nurseries should be kept above 70°F (>21°C).

Fluid and Electrolyte Management

Preterm newborns require close monitoring of their fluid and electrolytes due to increased transdermal water loss and immature renal function, as well as a variety of environmental concerns (eg, radiant warming, phototherapy, mechanical ventilation). Initial fluid therapy is dictated by the infant's preterm and specific drug concerns. The following general guidelines, however, apply to all premature infants:

  • The initial fluid should be a glucose-water solution.
  • Electrolytes should not be provided until the infant is 24 hours old and has appropriate urine output.
  • Fluid restriction equivalent to insensible water loss + urine output should be used to treat infants with acute tubular necrosis (ATN).
  • Reduced fluid administration should be used to treat hyponatremia and weight gain.
  • Every 24 hours, the patient's weight should be checked. Variations in fluid and electrolyte support are dictated by laboratory monitoring and weight changes.

References
Things to remember
  • Prematurity is defined as the spontaneous onset of labor between the 28th and 37th weeks of pregnancy, beginning with the first day of the last menstrual cycle. More than half of the causes are unknown.
  • However, some of the factors associated with an increased prevalence of preterm include maternal disease, pregnancy complications, placenta previa, uterine malformations, placenta abruption, and so on.
  • Stabilization in the delivery room, as well as appropriate respiratory and thermal care, is critical to the immediate and long-term outcomes of premature children, especially extremely premature infants.
  • Radiant warmers may be utilized in the intensive care nursery to compensate for heat loss in premature infants.
  • Preterm newborns require close monitoring of their hydration and electrolytes due to higher transdermal water loss and undeveloped renal function.
Questions and Answers

Prematurity is defined as the occurrence of spontaneous labor between the 28th and 37th weeks of pregnancy, beginning on the first day of the last menstrual cycle.

Causes

In more than 50% the causes are unknown . the following are however related with increased incidence of prematurity.

  • Maternal disease,
  • Pregnancy complication,
  • Abruption placenta,
  • Placenta previa,
  • Uterine anomalies,
  • Fetal causes,
  • Iatrogenic,
  • Idiopathic.

Management

Stabilization in the delivery room with prompt respiratory and thermal management is crucial to the immediate and long-term outcome of premature infants, particularly extremely premature infants.

Respiratory Management

  • In newborns with respiratory distress, this stage can be completed with early continuous positive airway pressure (CPAP) provided nasally, via mask (Neopuff), or by utilizing an endotracheal tube in conjunction with the administration of ventilation and/or surfactant.
    Immediately attaching a pulse oximeter and utilizing an oxygen blender to maintain the oxygen saturation (SaO2) between 86% and 93% can help prevent both hyperoxia and hypoxia.
    Utilizing a ventilator that allows measurement of the expired tidal volume and maintaining it at 4–7 mL/kg can prevent barotrauma or volutrauma.
    Surfactant should be given early (before 2 hours of age) when necessary and as a preventative measure to all extremely premature neonates (before 29 weeks).

Thermoregulation

In the intensive care nursery, radiant warmers may be used to compensate for heat loss in the premature infant. Incubators are more efficient than radiant warmers because the heated environment decreases heat loss due to conduction, convection, and radiation. In all nurseries, the environmental temperature should be maintained at more than 70°F (>21°C).

Fluid and electrolyte management

Preterm infants need intense monitoring of their fluid and electrolytes because of increased transdermal water loss and immature renal function in these infants, as well as various environmental issues (eg, radiant warming, phototherapy, mechanical ventilation). The degree of prematurity and the infant's specific medication problems dictate initial fluid therapy. However, the following general principles apply to all preterm infants:

  • Initial fluid should be a solution of glucose and water
  • Electrolytes should not be added until the infant is 24 hours of age when urine output is adequate
  • Infants who develop acute tubular necrosis (ATN) should be treated with fluid restriction that equals insensible water loss plus urine output
  • Hyponatremia and weight gain should be treated with decreasing fluid administration
  • The patient's weight should be followed up every 24 hours. Results of laboratory monitoring and change in weight dictate changes in fluid and electrolyte support.

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