What causes premature birth

Doctor's letter : Premature birth

EXPLANATION It usually takes an average of 38 to 41 weeks from conception to a person being born. But the child-to-be does not always have this time to fully develop in the womb. Of the around 702,000 children born in German hospitals in 2014, 70,000 were born before the 37th week of pregnancy. Then doctors speak of a premature birth. For most premature babies, that's not a problem. Because whether these are actually considered premature babies who have to be looked after intensively in special treatment facilities - so-called perinatal centers - depends not only on the week of pregnancy, but also on the birth weight. Babies who were born before the end of the 29th week of pregnancy and weigh less than 1,500 grams at birth - that was around 9,000 children in 2014 - are considered high-risk patients who should no longer be cared for in normal maternity wards, but in specially qualified ones Perinatal centers. And there are differences here too: In Level 2 perinatal centers, children are treated who were born with a birth weight of between 1250 and 1499 grams and between the 29th and 32nd week of pregnancy. The Level 1 centers, which are even more demanding in terms of equipment and qualifications, take care of babies with a birth weight of less than 1250 grams who had an early start before the 29th week of pregnancy.

SYMPTOMS In Germany, a pregnant woman and the developing child are closely medically monitored. That is why in most cases it is noticeable when something is wrong, for example the fetus is not developing at the rate it should because the placenta is diseased. Or if the doctor finds a bacterial colonization in the amniotic fluid. Then, if the doctor decides that the child should be fetched immediately, given the health risks, there will still be enough time to go to a perinatal center.

This also applies if the rupture occurs prematurely or if contractions start. Even if this is a shock at first, there is usually time to transfer the pregnant woman to a perinatal center. There you can first try medication to get the problems under control, but this often only works temporarily. Nevertheless, valuable time is gained to prepare mother and child for a premature birth.

CAUSES Why do children come ahead of time? That seldom has anything to do with influenceable circumstances or lifestyle, says clinic director Christoph Bührer. “In most cases that is fate.” For example, when bacteria colonize the fruit cavity and cause contractions at the wrong time. Or when the placenta that supplies the child with nutrients is damaged. Then the child stops growing and has to be fetched.

TREATMENT Immediately after birth, the premature babies are placed in an incubator. Because their unfinished bodies need much more medical, nursing and medical technical help than mature newborns. An incubator is a box made of plexiglass, with an edge length of 35 by 60 centimeters and large holes in the side through which you can reach inside. The high-tech incubator has it all: It filters the air, enriches it with oxygen and moisture and keeps the children's body heat at a constant 37 degrees - a microclimate that is modeled on the uterus.

The weakest babies in the incubators have tubes in their mouth, nose, head and arms; for breathing, for nutrition, for infusions. They are given medicines to strengthen their lungs or fight bacteria, or they are exposed to intense blue light because they suffer from neonatal jaundice due to their underdeveloped liver. The light accelerates the breakdown of the pigment bilirubin, which triggers the yellowing of the skin.

In addition to the qualified medical staff and high-tech equipment, physical contact with parents is also extremely important, such as “kangaroo”. The child lies on the mother's or father's chest. This physical closeness strengthens the emotional bond between the child and parents, but also has a therapeutic effect: "The baby is calmed down by the familiar heartbeat and the movements of the chest give it constant breathing," says clinic director Bührer.

RISKS Medicine has pushed the limit beyond which a baby can survive to the 24th week of pregnancy through new treatment methods and increasingly sophisticated technology. This point in time mainly depends on whether the lungs are developed enough to be able to breathe. This point in time can now also be influenced by medication. Cortisone-like drugs given to the mother but beneficial to the child can accelerate lung maturity.

And new records follow again and again. Many doctors doubt whether this is also in the children's interest. Because the likelihood that the child will have to torment themselves for a while and then die increases.

But it's not just about survival, it's about survival without disability. “We doctors often work in a gray area here,” says clinic director Bührer. In this gray area, doctors and parents must decide together what is best for the child. In this joint decision, the parents, as representatives of the child, have the last word and the doctors advise them.

The parents' ability to suffer is very different. Sometimes parents want to give up earlier than the doctors, when nothing seems to be going well, when the health problems of the premature babies become overwhelming, when the hope of a happy ending fades. Then it is the task of the medics and nurses to give that hope back.

But sometimes doctors realize that continuing therapy is not in the best interests of the child. Survival at any price is not the goal, says Bührer. You have to respect your limits.

And that can also mean that the doctor and parents give birth to a child that is far too early and then let it go to sleep forever. Then the ward is not about survival, but about care and terminal care.

Doctors say the probability that a premature baby born after the 28th week of pregnancy will survive is 90 percent. From the 32nd week, the risk of death is virtually over.

But there are other complications that threaten the premature child. For example, brain haemorrhage that occurs due to immature blood vessels in the head. At birth, the sudden differences in pressure can overwhelm the blood vessels and cause them to burst. If bleeding spreads into the brain tissue, permanent disabilities are possible.

In premature babies weighing less than 1000 grams, the eyelids are often still fused together and the blood vessels in the eye are not yet fully developed.

Due to the increase in the oxygen content after birth, their further training is interrupted. As a result, “wild vessels” can proliferate in the eye in the first two months, which can lead to retinal detachment. In this case, eye surgeons need to apply laser treatment to the retina.

About three out of 100 children have serious bowel diseases after birth, and one dies from it. Two serious problems can arise. Either the bowel bursts in a small spot or the bowel becomes inflamed. Then bacteria attack the intestinal wall and let it die. If such serious complications arise, an operation must be performed: Pediatric surgeons then temporarily relocate the anus to the front of the abdomen. If an intestinal inflammation is discovered in good time, the premature baby must be treated immediately with antibiotics.

The editors of the magazine "Tagesspiegel Kliniken Berlin 2016" compared the Berlin clinics that treat this disease. For this purpose, the treatment numbers, the hospital recommendations of the outpatient doctors and the patient satisfaction were compiled in clear tables in order to make it easier for the patient to choose a clinic. The magazine costs 12.80 euros and is available in the Tagesspiegel shop.

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