#Background
As described within this ‘Preparing for preterm birth when it is anticipated or planned’ section, there are a number of evidenced-based interventions used in preparation and at the time of birth that can improve outcomes for preterm pēpi. In addition, there are some practical considerations including equipment and staff that when provided within the overall package or bundle of care are likely to contribute to improved outcomes. These should be considered and planned for by services and individuals providing pregnancy care, including for scenarios where preterm birth may occur or be required rapidly without opportunity for transfer to the appropriate level of care.
#Recommendations and Practice
Attendants for preterm birth
Good Practice
Attendants for preterm birth
- Wherever possible, counselling should be provided prior to preterm birth, even if in advanced labour, and this should be provided by an obstetrician (level of seniority dependent on the gestational age at birth, ideally specialist level for all births <32 weeks) in consultation with a neonatologist, paediatrician or neonatal nurse practitioner.
- A specialist consultation should be recommended for wāhine/people in preterm labour at 34+0 to 36+6 weeks and being cared for by a LMC.
- A transfer of clinical responsibility for care should be recommended for wāhine/people in preterm labour at <34+0 weeks and being cared for by a LMC.
- Wherever possible, care in preterm labour should be supported by the LMC (especially when known to the wāhine/person) alongside the hospital midwifery and obstetric team.
- An obstetrician (specialist or registrar) should be present for all preterm vaginal births <32 weeks.
- An obstetric specialist should be present for all preterm caesarean section births <32 weeks.
- The neonatal/paediatric team (neonatology specialist, neonatology registrar, paediatric specialist, paediatric registrar or neonatal nurse practitioner) should be present at the time of birth. The level of seniority and experience will be dependent on gestational age at birth, estimated birthweight and other relevant neonatal factors, as well as site specific staffing availability.
- Neonatal and paediatric care providers should be given as much warning as possible, to allow for equipment set-up and to be present at the time of birth.
Equipment for preterm birth care
The majority of early neonatal care of pēpi born preterm will be provided and directed by neonatal/paediatric teams. Midwifery and obstetric teams should ensure there is access to appropriate equipment for use.
Good Practice
Equipment for preterm birth care
- All maternity units should have access to appropriate equipment to support newborn pēpi care including that required for resuscitation. This will usually include a resuscitaire, humidified air/oxygen blender for flow driven resuscitator (e.g. Neopuff or NeoPIP) self-inflating bag with appropriately sized face masks, saturation monitor and Vitamin K.
- Neonatal/paediatric teams should bring additional equipment when attending a preterm birth where resuscitation and stabilisation of the pēpi may be required. The neonatal resuscitation bag should include equipment for advanced airway management, intravenous/umbilical lines, surfactant and adrenaline.
- Neonatal/paediatric teams should ensure they have access to incubators and other equipment required for safe transport of the pēpi to a neonatal unit.
- All equipment should be checked before birth.
Thermal care for preterm birth
Prevention of hypothermia is important for all pēpi, and is of particular importance for those born preterm as they have high evaporative losses especially around the time of resuscitation. Hypothermia is associated with increased rates of morbidity and mortality.
A 2018 Cochrane review of interventions to prevent hypothermia included 18 studies on barriers to heat loss (plastic wraps or bags).13 Moderate-quality evidence showed that the use of plastic wraps or bags was associated with fewer pēpi having hypothermia on admission to neonatal intensive care or up to two hours after birth (RR 0.67, 95% CI 0.62-0.72). There was insufficient evidence to suggest any significant reduction in death or most major morbidity, although plastic wraps or bags did reduce the risk of pulmonary haemorrhage and there were no concerns of harm.13
Guideline Recommendations
Thermal care after preterm birth
- Plastic wraps should be considered as part of the package of care to provide thermal care for preterm pēpi immediately after birth.
Good Practice
Thermal care after preterm birth
- Warm the birthing room prior to birth (minimum 24°C).
- Use radiant overhead warmers, pre-warmed linen (37°C), prewarmed incubators and occlusive plastic wraps to keep pēpi warm and prevent hypothermia.
- If a plastic wrap is used, the pēpi should be placed directly on the wrap, without drying, and the wrap folded over their entire body excluding the head, which should be gently dried and kept within the radiant warmer output range.
- Active resuscitation measures should continue whilst the pēpi is in an occlusive plastic wrap, opening only when necessary for interventions.
The Carosika Whānau Information on Care in Preterm Labour may be used to support conversations with wāhine/people and whānau.
Published: October 2024 | PDF
Cord blood sampling and placenta investigations after preterm birth
After preterm birth has occurred ongoing consideration of pēpi wellbeing and investigation of contributing factors to preterm birth should be made by the midwifery and obstetric teams providing care to wāhine/people. Arterial and venous cord blood gas analysis provides information about condition at birth, particularly if there is concern regarding antenatal/intrapartum asphyxia. Examination of the placenta and umbilical cord will provide information about presence of infection and responsible microorganisms, and may contribute to understanding of the underlying causes of preterm birth and therefore risk of recurrence, and hence may inform management for future pregnancies.
The whenua (placenta) and pito (umbilical cord) have special significance for Māori. Traditionally, the whenua and pito are returned to the land and are often buried in a place of ancestral significance. This tikanga should be acknowledged and respected in any discussions around investigations on the whenua. Furthermore, collection and storage of blood and other samples may be considered tapu for whānau Māori; careful and respectful discussion on the purpose and process of these investigations including return of samples should be made.
Good Practice
Cord blood sampling and placenta investigations after preterm birth
- The utility of cord blood sampling and placenta investigations after preterm birth should be discussed with wāhine/people and whānau.
- Arterial and venous cord blood gas analysis should be undertaken for all preterm births. Assessment of point of care cord blood lactates may be considered as an alternative.
- Additional cord blood samples such as full blood count assessment, and blood group and Coombs test, may be recommended by the neonatal/paediatric team.
- Placental histological examination should be recommended after all spontaneous and provider-initiated preterm births to contribute information that may affect care of the preterm pēpi and/or wāhine/people, and for management of future pregnancies, including counselling on the cause of preterm birth and chance of recurrence.
- In units without perinatal trained pathologists, the placenta may need to be transferred to complete the examination. This should be explained to whānau in advance.
- All whānau should be offered the return of the placenta and cord after examination is complete.
- All units should have clear processes that enable reliable, safe and timely return of the placenta and cord after examination is complete.
- Microbiology swabs should be taken from both wahine/person and pēpi surfaces of the placenta after all spontaneous preterm labour and PPROM.
- The tikanga of the whenua (placenta) and pito (umbilical cord) should be acknowledged and respected in all discussions around whenua/pito investigations and sample storage.
- Wāhine/people and whānau should be provided with verbal and written information on placental examination after preterm birth.
The Carosika Whānau Information on Care in Preterm Labour may be used to support conversations with wāhine/people and whānau.
Published: October 2024 | PDF
Early neonatal care in an unexpected place of birth
The early neonatal care of pēpi born preterm should be directed by the attending neonatal/paediatric team and is beyond the scope of this guide. However, there will be times when pēpi are born preterm unexpectedly at home, in birthing centres, during transfer or in hospitals without the recommended level of neonatal team support. In these situations other healthcare professionals including midwives, obstetricians, general paediatricians, anaesthetists, and general practitioners may need to provide early care until transfer to higher level care is undertaken or a neonatal retrieval team arrives.
Good Practice
Early neonatal care in an unexpected place of birth
- Care should be provided by the most appropriate health practitioner available.
- Wherever possible, at least one person skilled in basic newborn life support should be present at a preterm birth.
- Health practitioners (midwives, obstetricians, general practitioners and paramedics, and especially those working in rural settings) who attend births should receive training in newborn life support. The New Zealand Resuscitation Council (Whakahauora Aotearoa) Newborn Life Support Course or equivalent is recommended.
- A request for emergency transport* should be initiated.
- Minimum equipment requirements include warm towels, a radiant heat source, and a neonatal self-inflating bag with appropriately sized masks.
- Additional preferred equipment includes a flow driven resuscitator (e.g. Neopuff or NeoPIP), compressed gas supply with blended air and oxygen, pulse oximetry and suction.
- If appropriate expertise is available, advanced life support equipment includes airway adjuncts, intravenous/umbilical lines, surfactant and adrenaline.
- The room/area should be warmed (minimum 24°C) if possible, prior to the birth.
- The pēpi should be kept warm following the birth using heat sources and warmed towels (if available) and through skin-to-skin contact between māmā/person and pēpi.
- The cord should be left unclamped unless appropriate equipment is available.
- Neonatal resuscitation should be provided as needed and follow recommendations from The Australian and New Zealand Committee on Resuscitation.14
- During transfer and until care is formally transferred to a specialist, the LMC retains clinical responsibility for care.
- Paramedics or ambulance crew should take clinical direction from the LMC.
- If the LMC cannot provide a clinical escort during transport, clinical responsibility is transferred to the paramedic crew for the period of transport only.
* Emergency transport refers to transport used in situations in which wāhine/people and/or pēpi must be moved from the community to a secondary or tertiary maternity facility, or between secondary and tertiary facilities.