Seek appropriate antenatal care
PREGNANCY
Evidence
https://pubmed.ncbi.nlm.nih.gov/24625215/
Jennifer Requejo, Mario Merialdi, Fernando Althabe, Matthais Keller, Joanne Katz, Ramkumar Menon
Pregnancy and childbirth represent a critical time period when a woman can be reached through a variety of mechanisms with interventions aimed at reducing her risk of a preterm birth and improving her health and the health of her unborn baby.
https://www.pretermalliance.com.au/Our-Research/Clinical-Guidelines
Education
Timely and accurate antenatal screening is believed to be an important factor in preventing preterm birth. Antenatal screening also has a positive influence in detecting some pregnancy complications, and this can trigger the offer of perinatal treatment to improve the outcomes and prognosis for preterm infants.
What is Preterm Birth?
Preterm is defined as babies born alive before 37 weeks of pregnancy are completed. There are sub-categories of preterm birth, based on gestational age:
- extremely preterm (less than 28 weeks)
- very preterm (28 to less than 32 weeks)
- moderate to late preterm (32 to 37 weeks).
Babies may be born preterm because of spontaneous preterm labour or because there is a medical indication to plan an induction of labour or caesarean birth early.
https://www.who.int/news-room/fact-sheets/detail/preterm-birth
What is antenatal care?
Antenatal care is the care you receive during pregnancy. You will have antenatal appointments throughout your pregnancy. The Australian Pregnancy Care Guidelines (Department of Health and Aged Care 2020) recommend that first-time mothers with an uncomplicated pregnancy have 10 antenatal care visits during pregnancy (7 visits for subsequent uncomplicated pregnancies)
Changes to routine antenatal care may be necessary if you have had a previous premature baby or a high-risk pregnancy or if you have been told this pregnancy is high risk. This may mean more medical checkups for you and your baby during pregnancy, or more scans or blood tests.
For women at very high risk of preterm birth, you may speak to your doctor about being referred to specialists in the field of preterm birth prevention. Typically, a management plan is developed, and the woman is then referred back to her referring practitioner when the high-risk period is concluded.
What happens to your antenatal care if you are at risk of preterm labour?
Most states in Australia have clinics called Preterm Birth Prevention Clinics or Pregnancy Assessment Centres who aim to reduce the number of babies who are born prematurely (also referred to as preterm birth). Preterm birth is when you have your baby between 20 and 37 weeks into your pregnancy. Preterm birth can be a severe condition, but many cases can now be prevented.
Mothers who are at risk of preterm labour will receive a specialist assessment and a management plan regarding recommended intervention, monitoring and most appropriate place for antenatal care and birth.
The clinics/centres are staffed by specialist obstetricians (doctors), midwives and ultrasound technicians (sonographers).
When you come to a clinic you may meet with an obstetrician, or a midwife or a sonographer or all three on different occasions. They will help develop a management plan from options that are best for you.
To reduce the risk of your baby being born early, your management plan may include:
- regular ultrasounds to check the health of your baby and measure the length of your cervix. This may need to be by an ultrasound probe inserted into your vaginal canal, with your consent. The obstetrician, midwife or sonographer will fully explain this procedure to you.
- prescribing progesterone pessary supplementation (link to Progesterone document)
- placing a suture (stitch) in your cervix (link to Cervical Suture document)
- discussing lifestyle choices including helping you quit smoking and
- treating any medical disorders, you may have.
Some of these will occur at the Preterm Birth Prevention Clinics while others may be available at a hospital closer to your home.
Preterm Birth prevention interventions
There are many reasons for having a preterm baby, some are unknown, but others can be avoided. In Australia, 1 in every 12 pregnancies end too early – leading to more than 26,000 preterm births every year. Most children born too early go on to lead normal and productive lives. But for many others there may be serious medical problems followed by life-long disability. The following preterm birth prevention interventions are recommended for application into all clinical practices.
- Your mid-pregnancy ultrasound scan
Make sure that the length of your cervix is measured whenever you have an ultrasound scan between 16 and 24 weeks of pregnancy. This is now recommended by the WA Preterm Birth Prevention Initiative as standard practice within Western Australia and all sonographers should be fully trained to perform the measurement. The length of your cervix in mid-pregnancy is a strong predictor of your risk of preterm birth. There are no symptoms to tell you that this may be happening. If the cervix is shortened then your doctor needs to be consulted urgently to prescribe the appropriate treatment to reduce your chance of preterm labour.
- Measuring the length of your cervix
In those cases in which the cervix can be imaged clearly on trans-abdominal scan (the routine method of scanning) a length of 35 mm or more is adequate. If the operator cannot image your cervix clearly, or if the measurement is less than 35mm, then an internal (trans-vaginal) scan needs to be performed. The length of the cervix on trans-vaginal scan below which treatment is required is 25 mm. This length is less than required at trans-abdominal scan because routine (trans-abdominal) scans have a full bladder which can stretch the length of the cervix, while internal scans are performed with an empty bladder at which time the true (unstretched) length of the cervix is measured.
- If your cervix is shortened
If your cervix is less than 25mm on an internal scan your doctor needs to prescribe natural vaginal progesterone 200mg given as a pessary. This pessary (like a simple tablet) is inserted into the vagina each night at bedtime. This treatment should continue until 36 weeks gestation and is expected to halve the risk of preterm birth. In cases in which the cervix length is less than 10mm on internal scan, or in some cases where there is a history of previous preterm birth, the cervix may need to closed surgically by placement of a stitch. This technique is known as cerclage of the cervix and the decision requires specialist opinion and treatment.
- If you have a history of preterm birth
Vaginal progesterone 200mg pessaries are also to be prescribed for any case in which there is a history of spontaneous preterm birth in a previous pregnancy between 20 and 34 weeks gestation. The treatment is used each night from 16 to 36 weeks’ gestation.
- Go as close to completing 40 weeks of pregnancy if possible
No pregnancy is to be ended prior to 38+ weeks’ gestation unless there is medical or obstetric justification. While most babies born in the days and weeks before this time can be expected to survive and live a healthy life, there are definite risks to the child of being born before 38 weeks of pregnancy, including learning and behavioural problems at school age. If, however, there are risks to the pregnancy then your doctor may advise earlier birth on safety grounds.
- Do not smoke cigarettes
Women must not smoke, or be exposed to cigarette smoke, during pregnancy. Smoking is a major and totally avoidable cause of preterm labour. There are excellent services available through the Western Australian Department of Health. Speak to your doctor about ways you can quit and look on-line at the Quitline website.
- 7. Use fertility treatments with appropriate caution
In vitro fertilization (IVF) and ovarian stimulation increase the risk of preterm birth. Part of this increased risk results from multiple pregnancies, part results from the cause of the underlying sub-fertility, and part results from other factors that remain unclear. The PTBP Initiative recommends that fertility treatments be used with appropriate caution and applied with a full understanding of the potential to increase the risk of early birth.
- 8. Pre-conception care and planning a pregnancy
Medical professionals will be encouraged to advise women to prepare for a future pregnancy by optimising their health and seeking pre-conception counselling. This is especially important for women who have an increased risk of preterm birth resulting from a personal or family history of early birth, prior surgical intervention on the woman’s cervix, or recurrent miscarriages, or those at the extremes of maternal age or where the inter-pregnancy intervals may be less than 18 months.
Other health optimising strategies will be encouraged such as the normalising of body weight, avoidance of alcohol consumption and recreational substance abuse, the taking of supplementary folate daily for at least three months before conception, the stabilisation of autoimmune conditions and the control of blood glucose levels or blood pressure in women with diabetes or hypertension respectively.
Empowerment
Until quite recently, preterm birth has been considered to be an unavoidable and accidental consequence of pregnancy. Thankfully, those times have changed and preterm birth is now considered to be preventable, at least in a proportion of cases.
A high-risk pregnancy or preterm birth can impact on how you and your partner feel. Be kind to yourself. It is natural to feel some anxiety about how this pregnancy will progress.
If you are struggling with negative feelings, you may need help. Tell your GP and midwife how you feel. You can also talk to another parent who has had a premature birth on our Nurture Line which is a free 24hr family support helpline for families of a premature or sick newborn on 1300 622 243.
Useful Links
NSW Health
https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2022_006.pdf
World Health Organisation
https://www.who.int/news-room/fact-sheets/detail/preterm-birth
The Whole Nine Months
http://www.thewholeninemonths.com.au/wp-content/uploads/2014/11/1507_booklet_interventions.pdf
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
https://ranzcog.edu.au/wp-content/uploads/2022/01/Maternity-Care-in-Australia-Web.pdf
Australian Government – Health Department
Australian Pre-term Alliance
https://www.pretermalliance.com.au/Mothers-to-be/How-To-Prevent-Preterm-Birth
Every Week Counts
https://everyweekcounts.com.au/
Mental Health Supports
PANDA - Perinatal Anxiety & Depression Australia
For When – Perinatal Mental Health and Wellbeing
Need support? NurtureConnect allows you to connect with our NurtureProgram support team, or call our 24 hour NurtureLine 1300 622 243 or join our Facebook community.
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Need support? NurtureConnect allows you to connect with our NurtureProgram support team.
Nurture Connect
Disclaimer: This publication by Miracle Babies Foundation is intended solely for general education and assistance and it is it is not medical advice or a healthcare recommendation. It should not be used for the purpose of medical diagnosis or treatment for any individual condition. This publication has been developed by our Parent Advisory Team (all who are parents of premature and sick babies) and has been reviewed and approved by a Clinical Advisory Team. This publication is not a substitute for professional medical advice. Miracle Babies Foundation recommends that professional medical advice and services be sought out from a qualified healthcare provider familiar with your personal circumstances. To the extent permitted by law, Miracle Babies Foundation excludes and disclaims any liability of any kind (directly or indirectly arising) to any reader of this publication who acts or does not act in reliance wholly or partly on the content of this general publication. If you would like to provide any feedback on the information please email [email protected].
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