When Martha Williams’ daughter Avery arrived seven years ago, she was so tiny that her father’s wedding band could easily slide onto her forearm, all the way up near the elbow. Avery had been born…
When Martha Williams’ daughter Avery arrived seven years ago, she was so tiny that her father’s wedding band could easily slide onto her forearm, all the way up near the elbow. Avery had been born nearly three months too soon, and her first weeks of life were a challenging time for her family.
Williams was 33 years old at the time, and Avery was her first child. An avid marathon runner living near St. Louis, Missouri, Williams says the first 23 weeks of the pregnancy went smoothly. But she has a chronic condition called polycystic kidney disease that causes high blood pressure, among other problems. At the 25-week appointment, Williams’ feet were swollen, her blood pressure had spiked and Avery hadn’t grown as much as she should have. Williams’ doctor was alarmed and wouldn’t let her leave the hospital, consigning her to bedrest in hopes that would delay Avery’s birth. “I only made it a week,” Williams says, before the situation became dangerous and Avery needed to make her own way into the world.
“Those first few days were really critical,” Williams says. “She almost died the second night,” but Avery hung in there, a turn of events Williams characterizes as “a huge answer to prayers. We don’t know what happened and the doctors couldn’t explain it,” she says. There were other scares during Avery’s 128 days in the hospital, and Williams says keeping a positive attitude during the roller-coaster ordeal was important.
Avery’s dramatic entry to the world is not as uncommon as one might hope. The Centers for Disease Control and Prevention reports that preterm birth — which is defined as a birth prior to 37 weeks — affected about 1 in 10 infants born in the United States in 2016. While human gestation typically lasts 40 weeks, babies born between 37 and 40 weeks are considered full-term births. Babies who arrive prior to 37 weeks’ gestation are referred to as preterm deliveries, premature births or preemies.
Babies born at 28 weeks or less gestation are considered extremely preterm and their survival is far from guaranteed. Dr. Daniel F. Roshan, a high-risk maternal-fetal obstetrician-gynecologist at Rosh Maternal & Fetal Medicine in New York City and clinical assistant professor in the department of obstetrics and gynecology at NYU Langone Health, says that while “neonatology science has improved tremendously and these days, many more very early preterm babies are surviving,” there’s a lot of development that still needs to occur in babies born extremely preterm, and that brings opportunity for complications.
He says that survival rates vary by hospital, but prior to 23 weeks, it’s virtually impossible for a baby to survive outside the womb. Each additional week spent in utero corresponds to a higher chance of survival. “At 28 weeks, 90 percent of babies survive. At 31 weeks, 99 percent survive,” Roshan says.
Over the course of a normal pregnancy, the fetus undergoes a staggering amount of growth and development within the mother’s womb, and every day longer inside the mother’s body is usually considered a good thing in terms of giving the baby a chance to thrive in the outside world. However, there are times when, for the health of the mother or the baby, the baby is born earlier than would be considered ideal.
Most full-term babies measure between 19 and 21 inches long and weigh about 5 to 9 pounds, but a preterm infant is much smaller. Babies born at 27 weeks are only about 14.4 inches long and typically weigh just under 2 pounds. By 37 weeks, a baby has usually reached more than 19 inches long and usually weighs over 6 pounds, so a lot of growth and development occurs during that 10 weeks of gestation.
What Causes Preterm Births?
Dr. Jose Perez, medical director of neonatology and perinatal medicine at Orlando Health Winnie Palmer Hospital for Women & Babies, says chorioamnionitis, a bacterial infection within the amniotic sac, is one reason why some women will deliver a baby too soon, and this typically causes a very early delivery. Another cause is related to a structural issue in the cervix, called incompetent cervix, in which “the mom’s cervix is not structurally long enough” to accommodate the growing baby.
Roshan notes that some in some women, the cervix doesn’t “grow or expand the right way,” making it difficult for the pregnancy to continue. Some women also have structural issues with the uterus that make carrying a baby to term challenging. The placenta can also separate too early, meaning that the baby isn’t being fed properly. Genetic disorders can trigger very early preterm births in some women.
Later in the pregnancy, a common reason babies arrive prior to their due date is because of high blood pressure in the mother, a dangerous condition called preeclampsia. Sometimes, “we need to deliver the baby early for the mom’s own health,” Perez says.
Preterm labor is also associated with multiple births, an increasingly common occurrence these days in the age of in vitro fertilization. Perez says twins can typically be carried “pretty close to term,” but “triplets for sure won’t and septuplets won’t get close to term. Every multiple makes it harder for that to happen.”
Who’s at Risk of Premature Delivery?
While it’s difficult to predict who’s most likely to deliver a baby too early, some women seem more likely to deliver preterm, specifically teenagers and those over the age of 35. The CDC also reports that black women have a higher rate of preterm births than white women — 14 percent versus 9 percent. Roshan says women with a history of delivering prematurely may be more likely to deliver a second baby preterm and should seek the support of a high-risk OB-GYN to make sure the pregnancy is progressing properly. Women who have chronic conditions such as diabetes, high blood pressure and autoimmune disorders may also be at higher-risk of delivering preterm.
The CDC reports that “in most cases, preterm labor (labor that happens too soon, before 37 weeks of pregnancy) begins unexpectedly and the cause is unknown.” Signs that you might be going into labor are:
— Contractions or cramps — powerful muscle movements in the abdomen that occur every 10 minutes or more often, or cramping that feels like a menstrual period
— A change in vaginal discharge — either a large amount of fluid or blood coming from the vagina
— Pressure in the pelvis or a backache.
Any of these signs should send you immediately to the hospital or your OB-GYN’s office for evaluation. Perez says you should also seek help if you develop any of the signs of preeclampsia, which are similar to those of high blood pressure: bad headache, blurred vision, nausea or vomiting, swelling in the extremities, reduced or no urine output or rapid weight gain, which may be associated with fluid retention.
How Can I Reduce My Chances of a Preterm Delivery?
Being prepared for a preterm birth should be part of your routine prenatal care program. “Preparation for preterm birth starts before the baby arrives,” Perez says. Your OB-GYN will run certain tests to assess your risk of delivering preterm, and if you are at risk, a team can be assembled to address that need.
No matter whether you’re at risk of delivering preterm, “it’s always good to have good care and follow the doctor’s advice,” Roshan says. “Show up for prenatal care and be proactive. Don’t take it lightly and think, ‘everything is fine, I don’t need to do this or that.'” Instead, pay attention to what your OB-GYN tells you and take good care of yourself.
If you are at high risk, your health care provider will likely want to monitor your pregnancy closely and may order additional tests and scans. Roshan says high-risk specialists may be able to intervene and prevent preterm births or at least delay them a little longer. He also recommends treating bladder or vaginal infections right away and practicing good hygiene. Avoid pushing down hard if you’re having trouble with constipation, and avoid exhaustion as much as possible. While exercise during pregnancy is generally considered a good thing, for some women with high-risk pregnancies, taking it easy might be the better option, and your provider can advise you best.
What Happens After a Preterm Baby is Born?
Neonatal intensive care units across the country help families cope with the too-early arrival of babies all the time, and Perez says if you’re at risk of delivering early, you should make sure that you’re working with an experienced labor and delivery team. “Volume matters, so units that have a lot of premature births because they’re bigger do tend to have better results than smaller units,” he says. Roshan says to look for a hospital that has “a level three nursery.”
Once the baby arrives, he or she will be placed into the neonatal intensive care unit where a team of doctors, nurses and other caregivers will carefully monitor the baby’s progress and watch out for known potential problems, such as brain bleeds and lung issues. The room needs to be heated to the right temperature, and the baby will usually need specialized equipment such as a ventilator and heat-retaining hat. Often, the baby is not crying when first delivered and may need to be resuscitated or intubated, “which is difficult for the parents,” Roshan says. “They can’t bond right away and the baby is very small.” To help reduce some of the fear that often occurs in those moments, he recommends visiting the ICU ahead of time so you can meet the team and get “an idea of what to expect.”
Perez says the length of time the baby will remain in the hospital is “inversely proportional to the term,” meaning that babies that arrive after just 25 weeks are likely to remain in the hospital for about 12 weeks while babies who arrive around week 30 may only need 6 to 7 weeks in the hospital. This is because they need time in a controlled and sterile environment to develop further, and the earlier they arrive, the longer they need for that growth. During this time, the baby’s breathing is closely monitored, and ensuring adequate nutrition is very important. Roshan says that monitoring the baby’s organ development, particularly the lungs, heart and kidneys, is a big part of what happens in the NICU after a baby is born preterm.
Williams says when she was placed on bedrest, her health care team did a great job of clearly communicating all the many things that would and could happen. “They explained all these things that could go wrong with my baby and it was really overwhelming. I just started crying. It was terrifying. They almost over-prepared me,” she says, a fact she ended up feeling grateful for later on, as she was able to look at the positive aspects of potential problems Avery had avoided. As she passed each milestone without a certain potential complication, Williams could breathe a small sigh of relief.
As Williams’ experience shows, the days and weeks following the birth of a preterm baby can be very difficult emotionally for families. Most mothers who deliver preterm via Cesarean section (a surgical procedure where the baby is removed via the abdomen) are sent home from the hospital after about 3 or 4 days. Those who deliver vaginally may be discharged even sooner, usually after a day or two if there are no other complications or health issues that need to be addressed. But the baby must remain in the hospital sometimes for months afterwards, causing considerable stress on families. This can disrupt the family’s ability to bond normally and the sheer fear of all that could still go wrong puts new parents on a scary roller coaster.
Perez says that to help alleviate some of this stress, most neonatal intensive care units now use a family-centered approach, in which parents can stay at the hospital with their baby for as long as they want. “Parents are involved in the entire process,” he says, and can have the level of involvement that feels best for them.
In Williams’ case, she decided not to use her maternity leave time while her daughter was in the hospital. Rather, after a short recovery period, she went back to work. “You want to be helping take care of your baby, but the only thing I could really do was pump breast milk,” which she did like a champion. Preferring to let the nurses and doctors have the room to work as they needed, Williams went back to her job and split her time between the hospital, home and work. Her employer allowed her to shift her maternity leave so she could be home for several weeks when Avery finally was discharged from St. Louis Children’s Hospital.
In addition to asking whether you can shift your maternity leave, Williams encourages other moms of preterm babies to assemble a “good support system around you.” She says her family and friends from church were a great source of comfort and assistance during a difficult time. She says connecting with other parents of preterm babies was also helpful, as they were able to provide insight on what to expect.
Over the course of the next few years, Avery was under close care of several doctors to ensure she didn’t encounter developmental delays or suffer other consequences of being a preterm baby. Some children may experience intellectual delays and other challenges as a result of being born too soon, so having the right support can make a big difference in helping them overcome whichever hurdles they may encounter.
Today, seven years on, Avery is a happy, healthy and normal first-grader who carries very few reminders of her perilous entry into the world. “She’s tiny. On a good day she weighs 40 pounds, but I would say being on the small side is the only lingering sign” that Avery was a preterm baby, Williams says. She credits some of that success to a state program in Missouri called First Steps Early Intervention that offers assistance and support for families of preterm babies and children with other disabilities and developmental delays.