Where an extremely premature baby immediately receives care matters

When you think about giving a premature baby the best possible start in life, it is important to consider the hospital where they are born. The care an extremely premature baby receives immediately after birth makes a big difference in outcomes.

A premature baby who is less than 32 weeks gestation or weighs less than 1500 g at birth should be cared for in a level III NICU. These babies also do much better when they are born in the hospital where they will receive their neonatal care.

A study published this year (September 2010, JAMA) is a reminder about just how critical it is for a premature baby to be born in the right place. The study by Lasswell etc al. is a meta-analysis, reviewing outcomes of premature babies from more than 40 studies. The results are not surprising:

  • A baby who weighs less than 1,500 g at birth: odds of dying are 60% higher if they are not born in a hospital with a level III nursery
  • A baby who is less than 32 weeks at birth: odds of dying are 40% higher if they are not born in a hospital with a level III nursery
  • A baby who weighs less than 1,000 g at birth: odds of dying are 80% higher if they are not born in a hospital with a level III nursery

The problem is you don’t always know if you are going to delivery prematurely. For some mothers labor starts all to quickly and there is simply no chance of getting to a hospital with a level III nursery before delivery. In these circumstances there is nothing anyone can do, because it is better for a premature baby to be born in a hospital than in the back of an ambulance. However, there are many times when the risk of delivering prematurely is very high, but many not happen in the next few hours and there may be time for a transport. Examples might include ruptured membranes but no labor, severe preeclampsia and receiving steroids for 48 hours, chronic abruption, growth restriction, a positive fetal fibronectin or a short cervix on ultrasound.

The point is, if you are hospitalized because your doctor is worried you could deliver and you are less than 32 weeks (or your baby is less than 1,500 g) and you are not at a hospital with a level III nursery you need to ask your doctor, “Why not?”

Yes, it is a pain to be physically separated from your family. It you are in a hospital hours from home it will be harder to have visitors and even harder if you have kids who might not be able to visit. However, it is better for your baby if you are in the right place. If you make it past 32 weeks and still haven’t delivered (how great would that be?!) you can always be transferred back to a hospital closer to home. Those kinds of transfers happen all the time.

All I can think of when I read these kinds of statistics are my own boys, who weighed 783 and 842 g. Oliver, the smallest, was an especially difficult resuscitation. He was so compressed against my pubic bone and had absolutely no amniotic fluid –  he needed an immediate blood transfusion as he had lost so much blood into his skin from bruising. At an amazing tertiary care level III where he was resuscitated by an extremely skilled team including a board-certified neonataologist, a respiratory technician, a neonatal nurse, and a neonatal nurse practitioner he was only given a 50% chance of getting through the next few days. I shudder to think what would have happened if I had delivered at small hospital without such a skilled staff waiting to work on him the second he was born.

The statistics are hard. No one wants to read about these risks. But for the lucky few women who have some precious hours before they deliver, this kind of information can make all the difference in the world.

Jennifer Gunter is an obstetrician-gynecologist and author of The Preemie Primer. She blogs at her self-titled site, Dr. Jen Gunter.

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