Preemies: The Essential Guide for Parents of Premature Babies

Chapter One: In the Womb: Why Premature Birth Happens and What Can Be Done to Prevent It\ For parents trying to grasp the extent of their risk, and what they can do to minimize it. Also for parents looking back, trying to make sense of what happened.\ Introduction\ Questions and Answers\ Bed Rest\ Bed Rest Survival Tips\ High Blood Pressure and Preeclampsia\ Predicting the Birth Date\ Diagnosing and Treating Preterm Labor\ Are You in Preterm Labor?\ Drugs for Preterm Labor\ Cerclage\ Diagnosing an Incompetent Cervix\ Hidden Infections and Preterm Birth\ If Your Water Breaks\ If Your Water Breaks before Your Baby Has Reached Viability\ When Baby Needs to Be Delivered Early\ Checking on a Baby's Well-Being before He Is Born\ Baby's Fighting Spirit\ Steroids\ Are There Medications other than Steroids\ You Can Take to Help Your Baby?\ Multiples\ Likelihood of Prematurity\ A Note If You Considered Multifetal Pregnancy Reduction\ Twin to Twin Transfusion Syndrome\ One Twin Needs Early Delivery\ In Depth\ Risk Factors for Prematurity:\ Are You at Risk?\ Introduction: In the Womb\ A normal pregnancy that leads, nine months later, to the birth of a healthy baby is a natural life experience in which doctors are mostly watchful bystanders, until the time of delivery comes. But if you're at risk for a premature birth, your experience is going to be different. Some women will be aware of their risk before they conceive. For many others, suddenly becoming a patient comes as a shocking surprise.\ If you're likely to have a preterm birth, you'll probably get assistance from an obstetrician who specializes in high-risk pregnancies (called a perinatologist). Your doctor's efforts will be directed at preventing a premature birth, or postponing it as much as is possible and advisable.\ Why prematurity happens is still a puzzle. In fact, experts believe most preterm births result not from a single cause, but from several risk factors interacting throughout pregnancy. Doctors know many reasons for preterm birth (as you'll see from the list on page 33), and can identify many pregnancies at risk. But about half of the expectant mothers who go into preterm labor have no known risks for it. If you've already given birth to a preemie, and you never suspected that it might happen to you, you're certainly not alone.\ Perhaps even more frustrating is that in many cases, premature birth cannot be prevented, even when mothers are known to be at risk. Still, even if a premature delivery cannot be avoided, a lot can be done to delay it for at least a few days (and sometimes much longer) — enough time to take some precautions that can greatly reduce the health risks for both you and your baby. For example, you may be admitted to a hospital, where you and your baby can be monitored twenty-four hours a day, or transferred to a facility with more expertise in perinatology and newborn intensive care. If you have an infection, you'll be started on antibiotics, to help prevent your baby from getting it, too. And you may be given steroids to help your baby's organs mature faster before birth.\ Sometimes, your doctor may decide to purposely deliver your baby before term, because he is not growing or doing well in the womb, or because it has become too dangerous for your own health to continue the pregnancy. About 20 percent of all preterm births are such so-called "elective," or medically indicated preterm births. The rest occur spontaneously — about 30 percent after a woman's water breaks too early, and about half after preterm labor.\ As you read through the information below, remember that only an experienced obstetrician can evaluate your own individual case. It's important for you to develop a good, trusting relationship with your obstetrician, so that you can count on her for support, as well as for state-of-the-art medical care, as you travel the demanding road of a high-risk pregnancy.\ Questions and Answers\ Bed Rest\ My doctor told me to go on bed rest, but I have so many things in my life I need to do. Will bed rest really help prevent an early birth?\ Nobody knows for sure. Bed rest is probably the oldest prescription for a high-risk pregnancy. Yet despite its widespread use — one out of every five pregnant women in the United States is put on bed rest — it has not been studied extensively. Although more research is needed before anyone can answer your question for sure, so far, the few studies that have been done have produced no convincing evidence that bed rest helps reduce preterm births.\ So, why do almost all obstetricians prescribe it to women with preterm labor, premature rupture of membranes, preeclampsia, bleeding, or other pregnancy problems, and sometimes even as a preventive measure to women who are expecting multiples? Because even without proof, there are situations where bed rest makes sense to doctors, for some solid, scientific reasons.\ For example, say your baby isn't growing as well as she should in the womb. Fetuses depend entirely on blood flowing through the placenta for their supply of nutrients and oxygen, and a mother's blood flow to the placenta is greatest when she is lying down. So, it makes sense that your baby will have the best chance of growing better if you spend a few extra hours in bed each day.\ Or say your water has broken early. It makes sense that you could maximize the amount of fluid remaining around your baby by spending more time off your feet, since increased blood flow to the baby leads to greater production of amniotic fluid. Also, the fluid is less likely to drip out when you're lying down.\ Bed rest also makes sense when gravity may be dangerous for a pregnancy. For example, once a woman's membranes have ruptured, there is a risk that the umbilical cord could slip down through her cervix — an absolute emergency, because the cord could get caught there and squeezed, cutting off blood flow to the baby. Gravity also can be risky when a woman has a weak, or "incompetent," cervix, which could open if the fetus presses down on it too hard.\ There is also good evidence that blood pressure is higher in women who are walking around. So, it is assumed that bed rest is helpful to pregnant women with preeclampsia, a condition involving high blood pressure which, when it's severe, can necessitate a premature delivery. Although research hasn't demonstrated so far whether bed rest itself makes the difference, we know there has been a dramatic improvement in the outcomes of pregnancies with pre-eclampsia. It may well have to do with the increasing use of hospitalization, which allows for both intensive monitoring and more bed rest than most women can get at home.\ But if sometimes there is sound reasoning behind the prescription of bed rest, other times there is simply a mixture of observation and wishful thinking. Take preterm labor. Many doctors believe that women who remain active in the third trimester of pregnancy have more Braxton-Hicks contractions — the normal, "false" labor contractions that don't lead to cervical change and delivery, and are of no concern. It's natural for obstetricians to extrapolate from that and assume that bed rest might reduce the risk of real labor, too. Nobody knows whether the initial observation itself, about Braxton-Hicks contractions, or the extension of it to real labor, is valid.\ So far, studies on pregnant women haven't found that bed rest decreases preterm labor. (Monitoring contractions with a home monitor — another intervention that seems like it should work — doesn't appear to make a difference, either. Research suggests that home monitors don't improve pregnancy outcomes, although they do increase the number of doctor visits — probably meaning they cause a lot of preterm labor scares.) But well-meaning obstetricians want to do something for women with preterm labor, so as long as there is a possibility that bed rest might help, many suggest it.\ Some obstetricians also have observed that a prescription of bed rest can bring a helpful focus to a pregnancy. The thinking is that your pregnancy may have the best chance of succeeding if you, your family, and even your doctor focus more attention on your needs, concerns, and symptoms. Some women say this worked for them: that after trying to juggle a lot of things during the early part of their pregnancies, bed rest actually reduced their stress by allowing them to shift their emphasis away from their many other daily obligations.\ Undoubtedly, obstetricians also prescribe bed rest partly as a holdover from past medical practice. As recently as a decade ago, nearly every woman with a pregnancy risk or problem was put immediately to bed, and told to stay there twenty-four hours a day.\ Today, however, on top of a lack of proof of bed rest's effectiveness, there's a growing awareness of its potential costs. Total bed rest quickly causes bone and muscle loss (much of which is regained after a woman becomes active again). And for plenty of women it causes more stress, rather than less. In fact, it can be really hard on an entire family, especially when there are older children, or job and financial concerns. So, more and more doctors are recommending reduced activity — lying down for a few hours each morning and a few hours each afternoon — rather than complete bed rest, except in a few situations like an already open cervix, ruptured membranes, or severe preeclampsia.\ Thankfully, you'll rarely see the once-common Trendelenburg position, in which a woman lies with her feet raised higher than her head. There's no evidence that it makes a difference, and a general consensus that no one can tolerate that position for long!\ While you nestle in bed, try to stay as optimistic as possible (remember that medical treatments often work best when patients believe they will), and take a look at the practical tips below to make that experience more tolerable.\ Bed Rest Survival Tips\ OK. You've been put on bed rest, and you're feeling understandably miserable. How are you going to make it through the long weeks ahead? These survival tips may help:\ \ Recognize that you are performing a job, one of the hardest you'll ever do. If you are an active person with a tendency to ask "What have I gotten done?" each day, it's easy to feel frustrated and inadequate while on bed rest — unless you give yourself credit for a daily achievement: an investment in your child's and family's future. Whenever you feel like you can't take it anymore, or are about to give in to the many temptations to get up, remind yourself of the job you have to do, and focus on your goal!\ Make your physical comfort a priority. Lying down for long stretches at a time can be very uncomfortable, and aches and pains are going to make your job far more difficult. You may have heard that you should lie on your left side, because blood flow to the placenta will be greatest — but your right side is good for your baby, too. What's most important is simply to avoid lying flat on your back, because blood flow is reduced that way. Rest a pillow under one side of your tummy or back, so you're on a slight tilt. That's fine!\ Do light exercises in bed. To avoid muscle and bone loss, some obstetricians now arrange for a physical therapist to visit their patients on complete bed rest. If your doctor doesn't mention this, don't hesitate to ask. The therapist can teach you light, isometric exercises you can do while lying down. Or you can try to make up your own, very light exercise regime: point and flex your toes, do head rolls, rotate your hands, tense and relax the muscles of your arms and legs.\ Stay clean and attractive. It's amazing how this can affect your mood. Many hospitals have arrangements with hairdressers who will come to your room and expertly wash your hair without ever asking you to sit up. If you're at home, ask friends or the staff of your hair salon if they know of a hairdresser who makes house calls. Put on makeup every morning. Some women find that when they're feeling down, it lifts their mood to pamper themselves with manicures, pedicures, or facials.\ Make your environment attractive, too. It will just take a couple of minutes for a friend or your partner to tape up some family photos or art works by your children. When you're feeling imprisoned, warm touches go a long way!\ Don't expect the household to run as smoothly, or cleanly, as usual. It's a fact of life: women on bed rest don't have clean houses! If your family eats pizza for the seventh time in a week, you're not alone, either. The best thing is to lower your expectations, recognize that these things aren't a priority right now, and plan to fix them later, when you're up and about.\ Organize your space. It's terrible to have to ask for every little thing you need. Instead, ask your partner to put a table next to your bed, with the following items within easy reach: a telephone, books and magazines, grooming items, tissues, and disposable cleansing wipes (to wash your hands), the television remote control, paper and pencil, things you need for your hobby, a water pitcher, and a lunch that your partner sets out for you each morning. No matter how much your partner wants to help, it will minimize tension between you if he doesn't have to act as your constant gofer.\ Be understanding that bed rest is hard on your partner and children, too. Your partner's life is also disrupted. He may be as worried and distressed as you are, and he's probably picking up lots of extra tasks while holding down his usual responsibilities. Try not to be resentful of him for still being able to move around, or for not being able to meet your every need. And give him as much time off as you can. It's important to keep supporting each other. \ It's normal for your children to show some reaction, either behaving badly toward others or toward you. It's also normal for you to worry about them, and to think how long this period feels to them. But believe us, they will forget about it soon afterward. In the meantime, encourage them to spend time with you by making your bedside into a play area with their toys, and putting up a little table where they can eat some meals. Try to arrange special time for them with grandparents. Some mothers say it helped a lot for their child to be present when the doctor explained the need for bed rest; hearing it from an outside authority made the child understand better, and even eager to cooperate.\ \ If you were working, make sure to discuss financial arrangements with your employer. Find out if you are eligible for disability payments, and whether this time is being counted as part of your maternity leave or sick leave. Remember that the Family and Medical Leave Act requires employers with 50 or more employees to give up to 12 weeks of unpaid leave related to pregnancy problems or childbirth. You are eligible if you have been working for your employer for 12 months, and have worked at least 1,250 hours during the last year.\ Get some easy things done from bed. You haven't bought furniture or linens for the nursery yet? There are childcare books you wanted to read and don't have? Shop by catalog or computer. Or give your mother-in-law a list of all of the layette items you need — she'll probably be thrilled to help, and it's like having a personal shopper!\ Don't be surprised if you get depressed, or have ups and downs. Many women say that some days their spirits are up, and then suddenly they find themselves in tears. Irritability, lots of anxiety, anger, and inability to concentrate are all normal reactions. You can expect a few naïve comments from friends, like "I'd love to be on bed rest and catch up on my reading." But most people who have been on bed rest themselves will tell you that it's hard. When you think what you're doing it for, though, it's worth it.\ \ High Blood Pressure and Preeclampsia\ I've always eaten right and exercised. But now, in my pregnancy, I suddenly have high blood pressure. I'm stunned.\ Because high blood pressure is often associated with an "unhealthy" lifestyle, it can be a real shock for a health-conscious pregnant woman to find out that she has it. But there is a kind of high blood pressure that occurs only during pregnancy, and can strike out of the blue. When it is accompanied by other signs and symptoms, like protein in the urine and fluid retention (which shows up as very rapid weight gain, or a puffy face and hands — not the normal leg swelling that many pregnant women have), doctors call it preeclampsia. Luckily, the prognosis is usually very good. Upward of 90% of all women who develop high blood pressure during pregnancy will deliver a healthy baby at term. And because preeclampsia always goes away after delivery, the vast majority of mothers are back to their previous state of health within a few days of their baby's birth.\ Despite the fact that most people haven't heard of it, preeclampsia is actually quite common, affecting nearly 10% of pregnant women. Some women are more at risk for it: those who are pregnant with multiples, are overweight, already have high blood pressure, or have kidney disease or diabetes. Preeclampsia also runs in families, so if your mother or sister had it, the likelihood that you'll get it is increased. But an enormous 70% of women with preeclampsia don't have any risk factor for it at all.\ Most of the time, preeclampsia is an easy diagnosis for your obstetrician to make. He'll measure your blood pressure, check your weight, and possibly do some simple urine and blood tests. But sometimes, it isn't clear whether preeclampsia or some other medical condition is causing the problem. It is important for your doctor to figure that out, because the cure for preeclampsia is delivery. If you have a severe case of it, a time may come when it's best to deliver your baby prematurely.\ The reason preeclampsia is dangerous is that it causes changes in the body that are the opposite of what should happen during pregnancy. Normally during pregnancy, the amount of circulating blood in a woman's body increases, to provide for both her and her fetus, and her blood vessels open wider to accommodate it. But in preeclampsia, a mother's blood vessels tighten, and not as much blood can flow through them. Her blood pressure rises, and all of her organs, including her uterus, receive less blood.\ When preeclampsia is mild, the amount of blood flow is slightly decreased but still adequate. But when preeclampsia is severe, a mother's vital organs may not get enough blood, and serious complications can result. Your doctor will watch you closely for kidney, liver, or intestinal problems (be sure to tell him if you have pain in your belly), and symptoms like blurry vision and headaches, which could indicate that your eyes or brain are suffering. In a very small minority of women with preeclampsia (only about 5%), the symptoms progress to seizures (called eclampsia) or dangerous abnormalities of blood clotting with liver damage (called HELLP syndrome, for hemolysis — destruction of red blood cells — elevated liver enzymes, low platelets). Women with these most severe forms of preeclampsia occasionally have strokes, or even die — that's why your obstetrician takes it so seriously.\ For a fetus, the main consequence of preeclampsia is receiving less blood flow through the placenta and, therefore, getting less oxygen and nutrients. For that reason, babies of mothers with preeclampsia are often small for their gestational age. (See page 70 for what that can mean for a child.) If the restriction of blood flow becomes extreme, or if the placenta separates from the wall of the uterus (a complication called placental abruption, which is more common in pregnant women with high blood pressure), there's a risk of fetal death. But thanks to alert doctors and good fetal monitoring, this is an uncommon tragedy today.\ The earlier that preeclampsia occurs during pregnancy, and the more severe its symptoms, the more it can affect a mother's and fetus's well- being. Most women with mild preeclampsia continue their pregnancies until term, but women with severe preeclampsia usually deliver within a couple of weeks of being hospitalized for it. Some, however, are luckier, and are able to continue their pregnancies for much longer. Your doctor will tell you what you should expect in your own particular case.\ The simplest and most commonly prescribed treatment for preeclampsia is rest, which can lower an expectant mother's blood pressure, and help her baby to get more blood flow. Your doctor may recommend bed rest at home, or admit you to the hospital. You may also get medications to lower your blood pressure, and to prevent seizures. The usual drug to prevent seizures is magnesium sulfate, which is generally safe for both mother and fetus, although it can have bothersome side effects (like making some mothers feel sick, and sometimes, temporarily depressing a newborn baby's breathing. Don't worry about that, though — if necessary, a ventilator can help your baby breathe until the magnesium wears off).\ If it looks like your pregnancy is becoming too risky to continue, your obstetrician will decide to deliver your baby prematurely. In fact, preeclampsia is the most common cause of elective preterm deliveries, done most often to protect the mother's health. When you hear that, you may think, "I don't care about myself, if it would help my baby to stay longer in my womb." It's heroic to be willing to take such risks for your child. But your family, including your baby, needs you. And when preeclampsia gets so severe in a mother, her fetus usually begins to suffer severely too, and is in real danger of dying soon in the womb.\ Women who have had early, severe preeclampsia in a previous pregnancy have about a 40% chance of getting severe preeclampsia again. Unfortunately, efforts to prevent preeclampsia by using medications such as aspirin or calcium, on which researchers once pinned their hopes, have not been very successful. Although these drugs have not proved helpful when prescribed to a wide range of pregnant women, your obstetrician may still use them. They are safe, and there is some evidence to suggest that they may possibly be of benefit to women who are at the highest risk.\ Predicting the Birth Date\ My doctor says I'm at risk for having a premature baby. Is there any way of telling how long my pregnancy will last?\ If pregnancy researchers had a Holy Grail, it would be the ability to predict whether an expectant mother would deliver her baby early, and if so, when. That crucial information would allow doctors to intervene early, when therapies are most effective, and only treat women who really need them. Tests of fetal well-being (see page 23) can help determine how long a pregnancy might last when there's a known medical complication. But those screenings can't predict whether preterm labor, or preterm rupture of the membranes, might cut short a pregnancy that is otherwise proceeding well.\ Most methods adopted so far to help forecast the likelihood of a preterm birth — such as adding up and scoring a mother's risk factors, or closely monitoring the opening of her cervix or her uterine contractions — have had disappointing results. In recent years, though, researchers have been looking at a whole new set of tests that seem to be more useful and effective.\ Many obstetricians have started using ultrasound, in addition to their traditional exam, of the cervix. Doctors traditionally examine a pregnant woman's cervix with their fingertips, to see if it is starting to open (or "dilate"). But this technique evaluates only the outer part of the cervix. Ultrasound can be used to look at the inner part of the cervix, where the earliest sign of dilation — a shortening of its length — can be detected.\ An early answer as to whether the cervix is opening can provide a doctor with useful information. For example, if your cervix is shorter than it should be, your doctor may decide to give you a cerclage (a simple surgical procedure in which your cervix is sewn shut) to try to keep it from opening further. On the other hand, if you're having contractions, but your cervix looks normal on ultrasound, your doctor may decide that you're not in true labor, and instead of prescribing medication to stop contractions, may simply observe you for a while. Ultrasound measurement of cervical length is a quick and painless test that can be done at the same time as a routine vaginal exam.\ One of the most exciting new tests for prematurity measures a pregnant woman's saliva for the presence of the hormone estriol: a kind of estrogen that has an important role in preparing the uterus for labor and delivery. One version, called SalEst (Sal for saliva, Est for estriol), has already been approved by the Food and Drug Administration. In the studies done so far, this test was used weekly to measure levels of salivary estriol in pregnant women at risk for premature birth. When a steep surge was detected, it indicated that labor was likely to occur in two to three weeks. When salivary estriol was low, labor in the following three weeks almost certainly would not occur.\ Unfortunately, what seems like the perfect predictive test for prematurity has some limitations. One of them is that SalEst is more accurate in predicting when premature labor won't occur than when it will. This means that if your salivary estriol level is low, you almost certainly won't deliver soon — valuable information that may save some women from being treated with bed rest or anti-labor drugs unnecessarily. But if your salivary estriol level is high, although you have an increased chance of delivering in the next several weeks, your pregnancy could well go on for much longer. Also, to date, SalEst has been approved only for singleton pregnancies, because hormone levels in multiple pregnancies follow different, more complex patterns. Moreover, some medications that may be given in a high-risk pregnancy (such as steroids) can affect a woman's estriol levels and limit the validity of the test.\ Another marker for a possible early delivery is a protein called fetal fibronectin. Fibronectin helps to keep the placenta and the membranes well attached to the uterine lining. If free levels of this protein inside the uterus rise, it may indicate that the placenta and the membranes are getting loose. Many obstetricians now use fetal fibronectin testing to help predict a preterm delivery. If on a simple swab of the vagina or cervix, the level of fibronectin is low, it's very unlikely that you'll deliver within the next two weeks.\ Other tests look for inflammatory substances in a pregnant woman's body to signal that a premature birth may be approaching. That's because some of the substances the body naturally produces to help combat infection or repair damaged tissues can also cause uterine contractions, loosening of the cervix, and weakening of the membranes, making them more prone to rupture. (Up to 25% of women who deliver prematurely have low-grade vaginal infections, and any damage to the placenta or umbilical cord, even if minor, can lead to inflammation.) One sign of infection or inflammation in the uterus is a protein called interleukin 6: if it is found in high levels in a mother's blood and in her amniotic fluid (which would require an amniocentesis to detect), it indicates that she may have a uterine infection, which could lead to preterm labor and delivery. But more studies are needed before doctors know exactly how to use "IL-6" as a routine test.\ Your obstetrician will decide what tests to use to monitor your pregnancy, and when. None of the new tests is a panacea, and experts warn that they are more effective in predicting which women won't deliver prematurely than they are at picking out all of the women who will. But awareness of new risk factors and more effective ways to detect them, combined with more traditional tools, such as your obstetrician's knowledge of your medical history, physical examina- tions, and tests of your baby's well-being, can give your doctor a better perspective into your future.\ Diagnosing and Treating Preterm Labor\ I've been feeling some tightening in my stomach. Should my doctor treat me for preterm labor?\ There's always a mixture of science and art in the practice of medicine, but when it comes to treating preterm labor, the balance tilts solidly to art. Your obstetrician has to make a judgment call as to whether you are having "true" labor or "false" labor. Some women just have unusually active uteruses, well before real labor starts. It's not always easy to tell whether your contractions are the real McCoy — ones that will lead to cervical change and birth — or just harmless ones whose only consequence is to give you and your doctor a dose of anxiety. That means that if you're having contractions, but your cervix hasn't begun to change yet, you may not need anti-labor drugs at all. On the other hand, you may be in the very early stages of real labor, when treatment has the very best chance of succeeding.\ If real preterm labor is suspected, a mother is generally sent to the hospital, the safest place to be in case she is about to deliver. There, her contractions are monitored, along with her baby's heartbeat, to make sure the baby is not sick or in distress. She is put on bed rest and given intravenous fluids while her doctor tries to determine whether there's a treatable problem, like dehydration or infection, that is causing the contractions. About half the time, if preterm labor is not accompanied by bleeding or ruptured membranes (if your water hasn't broken yet), fluids and bed rest alone are enough to stop it.\ If bed rest and fluids are not enough, and you and baby are doing well otherwise, the doctor will probably prescribe anti-labor drugs (which in medical parlance are called tocolytics) to relax your uterus and halt the contractions. Most of the time, these drugs put a quick stop to preterm labor in women who don't have bleeding, infection, or whose labor isn't already far along (whose water hasn't broken, and whose cervix is open less than four centimeters).\ Whether or not labor will return (even if you continue taking medications), and what will happen during the rest of your pregnancy, is unpredictable. Having an episode of preterm labor doesn't necessarily mean you'll end up having a premature birth. Very often, the labor passes, the medication is stopped, and your uterus is quiet and calm again. Sometimes, the doctors never know why the preterm labor came and went — whether it was an infection that flared up fleetingly, dehydration, or some other cause.\ In other cases, preterm labor returns in a few days or at some later point in the pregnancy, and can result in a premature birth. If your preterm labor recurs while you are being weaned off the anti-labor medication, the first thing your doctor will do is reassess whether it is safe for you and your baby for the pregnancy to continue. If he thinks it is, he will restart anti-labor drugs, possibly switching you to one that can be taken orally, or that may have fewer side effects.\ If this happens, you may be confused. Why do these medications seem to be working for you, when the studies say they only prolong pregnancy for a couple of days? That's a hard question for anyone to answer. It's possible that the drugs are making much less difference than it seems: that your contractions, scary as they are, are not the kind that would cause imminent delivery anyway, so your pregnancy would last just as long without the medication. It's also possible, since drugs can be more or less effective for different people, that they are helping your pregnancy more than average.\ The two most commonly prescribed drugs to inhibit labor are magnesium sulfate and terbutaline. Of the two, magnesium is thought to have fewer serious side effects. But it must be given intravenously, so it is rarely used long-term. Many, although by no means all, women feel horrendous while they're on it, with symptoms like nausea, hot flashes, headaches, palpitations, paranoia, muscle weakness, and visual disturbances, among others. When a woman remains on magnesium for more than a few days, the symptoms sometimes ease up or go away. Your doctors will keep a close eye out for potentially dangerous complications such as pulmonary edema (a buildup of fluid in the lungs) or abnormal heart rhythms. With careful monitoring, these occur rarely.\ Terbutaline can be administered by injections, pills, or a tiny pump that is implanted under the pregnant woman's skin. It's common for women to start with shots, and then, if they'll be staying on terbutaline long-term, to be switched to pills or the pump, both of which can be used at home. Some women tolerate terbutaline very well. But in others, terbutaline is associated with some of the same, unpleasant side effects as magnesium sulfate. The most common symptoms are palpitations, nausea, headaches, jitteriness, fever, and hallucinations. Doctors must also watch out for dangerous complications, including pulmonary edema, abnormal heart rhythms, and high blood sugar. Since serious complications occur more frequently from terbutaline than from magnesium, terbutaline is generally not prescribed to women with high blood pressure, heart disease, diabetes, or hyperthyroidism, who are at particular risk.\ After two or three weeks on terbutaline pills, a woman's uterus can become less sensitive to them, and contractions can start up again. A break of a few days (during which you may take a different anti-labor drug) is needed before terbutaline can be effective again.\ Obstetricians have other anti-labor medications they can use, such as indomethacin, nifedipine, or atosiban. All work somewhat differently, but have the same effect of relaxing the muscles of the uterus. Because their advantages and disadvantages are less well known than magnesium's and terbutaline's, you should ask your doctor for the latest information available.\ Are You in Preterm Labor?\ Just because you are having contractions before term, it doesn't necessarily mean that you are in preterm labor. Contractions throughout pregnancy are normal and expected, and are considered "false" labor unless they occur frequently (usually defined as more than once every ten minutes). Generally, real labor is accompanied by the thinning and opening of your cervix. What signs should you look for, to know if you are in preterm labor? As you read this list, keep in mind that many of these signs are present in perfectly normal pregnancies. You should call your doctor if their appearance represents a change for you:\ \ Uterine contractions, painful or not, that occur more than four times an hour. You may feel these as a tightening sensation in your belly. If you place your fingertips over your uterus when one is happening, it will feel firm. (If you think you are feeling some contractions, but they aren't that frequent yet, you can try drinking two or three large glasses of water and lying down for half an hour. Often, the contractions will gradually decrease in frequency.)\ A dull ache or sharp pain in your lower back.\ Menstrual-like cramps.\ Upset stomach-like cramps, possibly with gas pains or diarrhea.\ Pressure in your pelvis.\ An increased or changed vaginal discharge. (A blood-tinged discharge could mean the loss of the mucus plug that's like a stopper for the uterus. A greater than usual, clear leakage of fluid could be your water breaking.)\ \ If you think you have any of these symptoms, or have any doubt, do not hesitate to call your doctor. Don't worry about being a pest. First of all, the people who worry about being pests rarely are. Also, you have obligations: to your doctor, who can't be with you all the time and counts on you to call with your concerns, and to your baby, whose well-being is at stake and who counts on you to represent him!\ Drugs for Preterm Labor\ I've been put on a drug to stop preterm labor, but I can't stand the awful way it makes me feel. Will it really make a difference?\ No matter how stiff an upper lip you usually keep, the side effects from anti-labor medication can be hard to endure. Many women are lucky enough to be spared them, but others experience nausea, jitteriness, and other unpleasant symptoms that make them wonder whether the medication is really worth it.\ For most women, anti-labor drugs make little difference in whether they deliver prematurely or not. Most studies suggest that the medications delay delivery for only two days, on average. But even a couple of days can be long enough to allow an expectant mother to get a course of prenatal steroids, which can boost her preemie's maturity and give him the best chance of doing well. That alone can be a real benefit.\ Because of their side effects, and the inconvenience and questionable value of staying on anti-labor medications for long periods of time, some obstetricians won't prescribe these drugs to pregnant women for more than a week or so. But others, who believe that they may be beneficial in some circumstances for certain women — especially those whose labor starts up again when the drugs are discontinued — may prescribe them for longer.\ If the medication you're taking is making you feel terrible, you should certainly talk to your doctor about whether you need to stay on it. He may have good reasons to believe that in your case, the drug is more effective than average, and that its benefits outweigh its risks. He may be able to prescribe another medication that will work for you, which won't bother you so much. Or he may reconsider, and agree that given your discomfort, it makes more sense to wean you off the medication now.\ Cerclage\ My doctor is recommending a cerclage. What is it, and what will it do?\ A cerclage is a minor surgical procedure, usually done in the hospital by an obstetrician, in which the cervix — the opening at the base of your uterus through which your baby emerges — is temporarily sewn shut. Obstetricians recommend a cerclage when they conclude that a woman has a weak (or, in medical language, "incompetent") cervix. (What a word! Whoever thought your cervix would get a performance rating?) This means that instead of staying tightly closed until labor begins, the cervix tends to open at an earlier stage of pregnancy. Once the cervix has opened, the membranes of the amniotic sac can bulge out into the vagina, where they can become infected or rupture, leading to a miscarriage or a preterm birth. If you have an incompetent cervix, a cerclage could help prolong your pregnancy to a point when your baby, even if born before term, has a good chance of being fine.\ Most of the time, a cerclage is a short and safe procedure, and a woman is in and out within a few hours. First you'll be given local anesthesia or light sedation. Then, your obstetrician will reach through your vagina, and sew four or five stitches around your cervix in a circle (in French, cercle), pulling them tight and knotting them to seal your cervix shut. The stitches are generally removed in your doctor's office when a preterm birth is no longer feared (at about 37 weeks of gestation). If you go into labor or develop an infection, however, the cerclage will be taken out earlier, in the hospital.\ After a cerclage, most women are told to reduce their activity, or to remain in bed. You'll be advised not to have sexual intercourse, so as to avoid stimulating the cervix and to reduce the risk of infection (which is higher than normal with a cerclage in place). Periodically, your obstetrician will examine you, to look for changes in your cervix and for any signs of infection.\ You may be wondering why your cervix may be "incompetent." The most common cause is an injury from a previous obstetric or gynecological procedure. For example, if you've had any surgery on your cervix it could have caused incompetence, as could a second trimester abortion. First trimester abortions done before 1973, with dilation techniques that have since been discontinued, also could damage the cervix. If your cervix tore during a previous, difficult vaginal delivery, you may have been left with some cervical incompetence. Some women may have an incompetent cervix because they were exposed, in their own mothers' wombs, to DES, a medication given to pregnant women in the 1950s and '60s to avoid miscarriage, which sometimes caused malformations in the reproductive organs of their fetuses. Often, however, the reasons for an incompetent cervix are unknown.\ Obstetricians don't have reliable statistics on how likely a cerclage is to help you, because the research isn't definitive. The good news is that nowadays, 80% to 90% of women with classic signs of cervical incompetence who get a cerclage deliver a baby who survives, compared to only 13% to 38% of similar women who were pregnant in the past, before cerclages were done.\ If a cerclage is put in early (before 18 weeks), it rarely causes any problems. Occasionally, after a cerclage is removed, there is some scar tissue left in the cervix that prevents it from opening fully during labor, causing the cervix to tear during delivery, or requiring a C-section. And if you go into labor and your cervix opens before your cerclage is taken out, the stitches could tear your cervix. But these are complications that your obstetrician can usually manage well. What probably matters most to you now is to bring your baby closer to term. A cerclage may help you reach that crucial goal.\ Diagnosing an Incompetent Cervix\ My last baby was born way too early. Now I'm pregnant again and my doctor thinks a cerclage will help. Why didn't they do that the last time?\ In most cases, doctors can't diagnose cervical incompetence in advance. Most women have your experience: they are found to have a weak cervix only after it has already opened too early. To help diagnose an incompetent cervix ahead of time, some obstetricians are now using ultrasound to detect changes (shortening and thinning) which occur in the inner part of the cervix shortly before it begins to open. But ultrasound testing, like most medical tests, is not 100% reliable. The diagnosis of cervical incompetence is further complicated by the fact that small amounts of cervical dilation don't necessarily lead to preterm birth, so it's not always clear if it's worth the risk of doing a cerclage. Possible, if rare, complications of a cerclage are injury to the cervix, scar tissue left in the cervix, infection, and premature rupture of the membranes.\ Even with hindsight, cervical incompetence can be difficult to determine. Doctors generally suspect an incompetent cervix if your cervix opened painlessly, without any preceding signs of preterm labor or infection. But sometimes, an infection of the exposed membranes, with preterm labor, is the first noticeable sign that a woman's cervix has been open. And a pregnant woman can have uterine contractions or an infection without being aware of them — both of which can cause even a perfectly "competent" cervix to loosen and open up. Furthermore, many women who are diagnosed with cervical incompetence in one pregnancy won't have it again in another pregnancy. As a result, even with the best medical care, cerclages are given to some women who don't really need them, and are not given to all women who do.\ Unfortunately, both a woman and her doctor may not know that her cervix is beginning to open. By the time they're aware of it, it's often too late to perform a cerclage. A cerclage is safe and effective only if you don't already have an infection or ruptured membranes (because the procedure could carry bacteria into your uterus, and make an infection more difficult to treat), if your cervix is not already dilated too much (there would be a high risk of damaging the exposed membranes of the amniotic sac, and infecting or rupturing them), and if you're not in labor (in which case it would be too risky, and not helpful anymore). The best time to do it is by 18 or 20 weeks of gestation, and before your cervix has opened. Most obstetricians, no matter what, would not perform a cerclage after 26 weeks of gestation, when the risks that the procedure itself could cause a preterm birth become very high.\ So, there could be many possible reasons why you didn't get a cerclage in your last pregnancy. You can ask your doctor what factors were important in your particular case.\ Hidden Infections and Preterm Birth\ Do I really need to take medicine for an infection that doesn't bother me? If it isn't causing me any problems, how dangerous to my pregnancy could it be?\ There's an increasing awareness that screening for and treating low-grade, often asymptomatic, infections in pregnant women may significantly reduce their risk of a preterm birth. It has long been known that some infections during pregnancy can cause a premature delivery, as well as congenital problems in the fetus. Substances that a mother's immune system produces as a reaction to infection can trigger changes in the uterus, cervix, and amniotic membranes that can lead to preterm labor. But obvious infections don't occur very often — certainly not frequently enough to explain why the membranes of the amniotic sac are found to be infected at delivery in up to one-half of all preterm births, and up to 80% of births before 30 weeks of gestation.\ Of course, simply finding an infection at the time of delivery doesn't tell you whether it came before, and maybe caused, preterm labor, or whether it came afterward. (During labor, when the cervix opens and the membranes of the amniotic sac rupture, some natural barriers to infection are removed.) But an abundance of new data indicates that hidden infections in expectant mothers' genital and urinary tracts may play a much bigger role than was ever thought in causing preterm births.\ In an effort to figure out how important hidden infections were in causing preterm births, one of medical researchers' first targets was urinary tract infections. Bacteria in the urine are more common during pregnancy, and are often present without the symptoms of burning, itching, or fever that make an infection apparent. Many studies have now shown that the risk of delivering prematurely is much lower if pregnant women with asymptomatic urinary tract infections are treated with antibiotics.\ More recently, researchers pointed their finger at a hidden infection called bacterial vaginosis, or "BV." BV is caused by an overgrowth of common bacteria that normally live in the vagina. According to some new findings, BV may double some women's risk of delivering prematurely. It is silently present in about 10% of Caucasian women and about 25% of African-American women. It is not a sexually transmitted disease, although women who become sexually active at an early age are more prone to it, as are those who douche (douching can destroy the useful bacteria of the vagina, which help to keep other bacteria under control).\ Luckily, BV is easy to diagnose (your doctor painlessly swabs your vagina with something like a Q-tip), and it can be treated effectively with oral antibiotics. Several studies have shown that treating BV in women at high risk (mainly those who had a previous, unexplained preterm birth) can lower their risk for another preterm delivery by up to 70%. But in women who haven't had an unexplained preterm birth, it's not clear that having BV is harmful, or that treating it will help. There's even a small chance that treating it could hurt — any time you take antibiotics, there's a small risk of an allergic reaction, or of developing an overgrowth of other bacteria that may be hard to treat. You can talk to your obstetrician about the pros and cons in your particular case.\ Another hidden infection that is emerging as a possible cause of prematurity is gum disease. So don't be surprised if your dentist — and your obstetrician — tell you to floss to prevent prematurity, as well as cavities! If you've been diagnosed with gum disease, it is probably wise to get it treated by a dentist as soon as possible.\ There are several other infections that can cause serious illness in a fetus, and occasionally lead to preterm birth, but which are sometimes so mild that a mother doesn't realize she has them. It will be your doctor's responsibility to decide if you need to be treated for any of these. Most obstetricians screen for sexually transmitted diseases like syphilis, gonorrhea, and chlamydia, and for viruses like hepatitis B, HIV, and rubella. Depending on your situation and exposures, your doctor may also add tests for other infections.\ For most of these infections, prevention is the key: you'll be advised by your doctor to practice safe sex, not to eat raw or undercooked meat, fish, or shellfish, and not to touch dirty kitty litter (a great excuse to let your partner do that job!). You should try to stay away from anyone who's sick with something contagious. If you have Lyme disease in your area, try to follow even more carefully the precautions you already know: from late spring to early fall, whenever the temperature exceeds 40 degrees (when deer ticks are active), if you have to go near bushes or in the woods, wear light-colored clothes with a tight weave (to better spot ticks), socks over long pants, and long sleeves; keep long hair pulled back; spray tick repellent on your clothes (ask your obstetrician which product is safe for pregnant women); keep pets outside your house, or at least far from you, in a rug-free area that can be easily cleaned; and carefully check yourself for ticks every night. (If a tick is removed before it attaches to your skin, you will not become infected. If a tick is removed within 36 hours after it attaches to your skin, you have only a small chance of contracting Lyme disease: ask your doctor what to do next.)\ Before your next pregnancy, if you haven't had rubella, mumps or chicken pox, you should get vaccinated for them. (These vaccines usually aren't given to women who are already pregnant, for fear they could harm the fetus.) You may have also heard about new vaccines for Lyme disease that are under investigation. It will be great news if these products are found to be safe and effective, but at this point it's too early to recommend them to a woman who is planning to get pregnant. Talk to your doctor about any recent developments, though.\ If you had a preterm birth in the past, it may be tempting, but painful and probably useless, to go back and torture yourself about a hidden, undiscovered infection that may have been to blame for what happened. Even if you or your baby had signs of infection after delivery, there's no way to tell, in retrospect, if it was a cause or a consequence of your preterm labor. It is also impossible to know what would have happened if you had been diagnosed with an infection and treated with antibiotics during your pregnancy — everything, or nothing, might have changed. Right now, if you can, try to focus on the present and future, putting your knowledge to good use, with the help of a trusted, expert obstetrician.\ If Your Water Breaks\ My water broke. Have we lost the battle?\ Not necessarily. It's true that you may have to be in the hospital for a while, and it's likely that you'll deliver prematurely. But pregnancies often go on for some time after premature rupture of membranes (the medical term for water breaking), and it's quite possible that your baby will gain some additional, very valuable time in the womb.\ It's understandable that you would feel scared at this point. There's something about the rush of fluid out of the womb that creates a feeling of great helplessness: there's nothing you can do to stop it while it happens, and nothing you can do to put it back. All you can do is wait and hope. One thing you should not do is blame yourself, or your partner, for what happened. We've known mothers who believed they brought it on by getting up from bed rest, and fathers who thought they were to blame for not carrying that last bag of groceries. In fact, nothing so simple has been found to be the cause of premature rupture of membranes.\ Researchers don't have a full understanding of why some women's water breaks early, but most believe it's the culmination of a long-term process in which many medical factors combine. Women who smoke cigarettes are at increased risk, along with women who have had bleeding during the pregnancy, and those whose water broke before they went into labor in a previous pregnancy (at term or before). Uterine contractions, too much amniotic fluid, stress from the baby's growth, or the presence of more than one baby can all cause the membranes to weaken. Certain nutritional deficiencies may play a role. Experts suspect that infections (some without any symptoms) are often a key part of the story, with bacteria from a mother's genital tract climbing up through the cervix and irritating the membranes. Although it has been suspected that sexual intercourse might contribute to early rupture of membranes, studies have produced no clear evidence of that.\ The first thing your doctor will want to do is to test the fluid that leaked out, to confirm that it was indeed amniotic fluid, rather than urine or vaginal secretions. Usually, when membranes rupture, there's a large gush of fluid, followed by a continuing trickle. In a few cases, though, women have some less dramatic dripping that goes on for a while. Once the doctor establishes that your water did break, he'll decide whether to deliver your baby right away or to wait.\ Why shouldn't every pregnancy go on as long as possible? Because after membranes rupture, there are some real risks:\ \ Infection. The membranes that surround your baby act as a barrier to the bacteria that normally live in the vagina. When the membranes are broken, the bacteria can swim up into the uterus, infecting the mother, and possibly infecting the baby as well. A mother's infection can almost always be effectively treated, but for a fetus or newborn, an infection can be life-threatening, or cause long-term health and developmental problems. A premature baby who is born a little younger, but not infected, is often better off than an older preemie who is infected. \ Fortunately, less than 20% of fetuses become infected after premature rupture of membranes, and usually not until after their mothers have symptoms themselves, like fever or abdominal pain. So your obstetrician may not feel that it's necessary to deliver your baby unless you or your baby shows signs of infection.\ \ Inadequate growth of a fetus's lungs. Called pulmonary hypoplasia, its causes aren't fully known, but it is thought to occur because without much amniotic fluid, the uterus presses tightly against the fetus and prevents the lungs from expanding well. Lung expansion is one of the signals that prompts a fetus's lungs to grow and develop. (It's one reason fetuses, in the womb, practice breathing movements). There may also be growth hormones in amniotic fluid that are no longer getting into the fetus's lungs. No matter how old a baby is at birth, if her lungs are too small, it will be difficult, or impossible, for her to breathe. \ The risk that a baby's lungs won't grow large enough for her to survive outside the womb is greatest when a mother's water breaks early in the second trimester of pregnancy. The longer a baby is in the womb without much amniotic fluid, the greater the risk. The outlook is far better for a baby whose mother's water breaks after 26 weeks.\ \ A greater risk that the umbilical cord could slip into a dangerous position. This could cut off some oxygen and blood flow to the fetus.\ A baby's movements can be constrained. With little amniotic fluid to expand it, the uterus may press tightly against a fetus, constraining her movements. Lack of movement could cause her joints to become stiff and contracted, so that she can't bend or straighten some of them fully. Over time, these contractures may resolve, sometimes with the help of orthopedics or physical therapy.\ \ You can see that these risks have to be balanced against the risks of your baby's prematurity, to come up with the right timing for delivery. In some situations, the decision is easy: as soon as there are obvious signs of infection or fetal distress, your baby will be delivered immediately. Before 32 to 34 weeks of gestation, in the absence of infection or fetal distress, most obstetricians believe that the risks of prematurity outweigh the risks of continuing the pregnancy. Most believe that the reverse is true once a baby reaches 34 weeks, when most preemies are practically as mature, if a bit smaller, than full-termers.\ So how long can you expect your pregnancy to last? There's nothing more frustrating for parents to hear, but it is impossible to predict what nature will do in any, individual case. Occasionally, you're lucky, and the best possible outcome occurs: your membranes reseal within a few days, and amniotic fluid builds up again around your baby. No one knows why this sometimes happens, but when it does, the pregnancy can go on with nearly the same risks and benefits as if the membranes had never ruptured in the first place. Sometimes, the membranes partially reseal, leaving the door still open to infection, but providing the important advantage of an adequate amount of amniotic fluid around the fetus.\ A majority of women give birth within a few days after their water breaks. But if labor doesn't occur within a few days, your pregnancy has a good chance of lasting considerably longer. Typically, pregnancies tend to last longer the earlier that membranes rupture. Some recent statistics from a small but heartening study reveal that women whose water broke between 14 and 19 weeks of gestation lasted a median of 72 days until delivery, while those between 20 and 25 weeks of gestation lasted a median of 12 days, and those between 26 and 28 weeks of gestation lasted a median of 10 days. Most women whose membranes rupture between 28 and 34 weeks of gestation, who were outside the scope of this study, give birth within a week.\ Between now and delivery, you will most likely be kept in the hospital, where you and your baby can be monitored carefully, and taken care of if delivery occurs very quickly after labor starts. You will probably be kept on bed rest, partly to cut down on the amount of amniotic fluid that leaks out. Don't be alarmed, though, no matter what position you're in, if there is some continued leakage. Unless your membranes reseal, it's normal and unavoidable. Bed rest can also improve blood flow to the baby, which may help produce more amniotic fluid, and can lower the chance of the umbilical cord's falling into a dangerous position through the cervix. A few doctors occasionally use a technique called amnioinfusion (infusing fluid into the womb with a catheter), particularly to help a fetus tolerate labor, but the fluid tends to leak out so quickly that it doesn't seem to help with lung growth.\ You will probably be given antibiotics to treat any infections you may have, and to prevent them in your baby. Antibiotics given after preterm rupture of membranes have been found to lengthen pregnancies and to give preemies a health advantage after birth. You may be given steroids to speed up your baby's maturation. You probably will not get anti-labor medications, which have not been proven to lengthen pregnancies after a woman's water breaks, and may mask signs of infection. You will need to abstain from sexual intercourse, which could introduce infection or bring on preterm labor.\ To monitor for infection and fetal distress, your temperature and your baby's heartbeat will be checked several times a day. Your doctor may suggest an amniocentesis (taking a tiny bit of amniotic fluid out with a needle), if there's enough fluid left to do it safely. The fluid can be checked for infection, and can show how mature your baby's lungs are. You will probably get an ultrasound every few days, to observe your baby's breathing, heartbeat, and body movements, as well as to measure the amount of amniotic fluid.\ One thing of which you can be sure: this period, when you have so little ability to predict or control the future, is going to be difficult for you and your partner. Taking one day at a time is the best strategy. Remember, every day you gain is valuable.\ If Your Water Breaks before Your Baby Has Reached Viability\ Sometimes, a woman's water breaks very early, before the baby would be ready to survive if she were born. If this happens to you before, say, 23 weeks of gestation, your doctor may present you with an excruciating decision. He may ask whether you want to try to go on with the pregnancy, or think it would be better to go through with delivery immediately. Choosing delivery now means that you know your baby will not survive. Choosing to go on means that you are willing to accept the risks that your baby may not thrive in the environment she's in, even if the pregnancy lasts much longer. Many babies who are born after extremely early rupture of membranes have poor outcomes, dying shortly after delivery, or suffering from short-term or long-term health problems, or even lasting disabilities.\ Don't hesitate to ask your doctor for his recommendation, and for all of the information you need, such as: what gestational age range your baby is likely to reach by the time she is born, what the outcomes are like for babies in her situation (how great her chances of survival and living a healthy and normal life will be), and how much intensive medical care she is likely to need. When you read about general outcome statistics for babies born at various gestational ages on page 49, keep in mind that your baby is facing additional hurdles, such as lung hypoplasia , which can make her situation worse.\ After weighing the facts, along with their deep feelings and beliefs, some parents conclude that the decision to deliver now, although incredibly painful, is the right one for them and their baby, given the risks ahead. Others want to try for more time. Either choice can be the right one for you and your family.\ When Baby Needs to Be Delivered Early\ My doctor says my baby isn't doing well in the womb, and he may decide to deliver him early. How does he know when the right time has come?\ Few things are harder for an expectant mother than hearing that your baby would be better off being born prematurely than spending more time in your womb. Along with worrying about your baby's health and your own, you may feel inadequate, or betrayed by your own body. At a time when you should have been cheered by the tumbling presence of your baby inside you, instead you're undergoing checkups and tests — observing him with trepidation and alarm.\ It may help you to know that you're far from alone in this difficult experience. Elective, preterm deliveries — done early for medical reasons — bring nearly one-quarter of all preemies into the world. The most common reason for an elective preterm delivery is preeclampsia, which usually is done primarily to protect the health of the mother. But preeclampsia, and many other maternal medical conditions, also can adversely affect the health of a fetus. Sometimes, even when a mother is well, her uterus may not be the best environment for her baby.\ These are the major reasons that an obstetrician might decide that the time has come — sooner than expected — when your baby would do better outside the womb:\ \ His growth has become very poor. If a baby isn't growing well in the womb, he may not be getting enough nutrients and oxygen, which can affect his long-term development. If your baby's growth is already slow, and it slows down even further or stops altogether, most obstetricians would decide that it's time to deliver him.\ He has signs of fetal distress. Fetal distress is a signal that a baby's supply of blood or oxygen is inadequate. It can be caused by problems with the placenta, anemia, an infection, or a severe illness of the mother or baby. Doctors recognize fetal distress when a baby moves a lot less, is unresponsive to stimulation, or has an abnormal heart rate. Obstetricians usually decide to deliver a baby urgently in that case, because fetal distress usually means that conditions in the womb are dangerous enough to jeopardize your baby's life or health right now.\ Congenital conditions. Babies with congenital conditions may sometimes do better if they get prompt medical or surgical treatment. If so, your doctor may opt for an elective preterm delivery.\ \ Your doctors will assess how your baby is doing in the womb using one or more of the tests described in the box "Checking on a Baby's Well-Being Before He Is Born." To decide whether he would be better off if he were delivered now and cared for in a newborn intensive care unit, they'll take into account your baby's gestational age and size (crucial elements affecting how he will do after birth), and weigh the risks he'll face if he's born prematurely against the risks he faces by staying inside the womb. If your baby is still very immat

Contents Introduction A Note to the Reader: How to Use This Book Part I Before Birth 1 In the Womb: Why Premature Birth Happens and What Can Be Done to Prevent It For parents trying to grasp the extent of their risk, and what they can do to minimize it. Also for parents looking back, trying to make sense of what happened. Part II In the Hospital 2 Welcome to the World: Your Baby's Delivery Your baby's transition from the womb to the world. Preparing for, and understanding, a premature birth. 3 The First Day Entering the foreign world of the neonatal intensive care unit. Why it's the best place for you baby to be. 4 The First Week A time of crucial test results and waiting. Understanding that things sometimes get worse before they get better. 5 Settling Down in the Hospital Making the NICU the best possible home-away-from-home for you and your baby. 6 If Your Baby Needs Surgery Guiding parents through an event that is usually scarier than it needs to be. Part III A Life Together 7 Finally Taking Your Baby Home Decisions and preparations for the moment you've been waiting for. 8 From Preemie to Preschool (and Beyond) A time to watch you baby's health and development — and gradually begin to relax and enjoy! 9 When Parents Have Something Special to Worry About Learning more about some possible consequences of prematurity. Part IV Other Considerations 10 Losing a Baby Helping you deal with a profound grief, and guiding you through the necessary arrangements. Appendices Appendix 1: Conversion Charts Appendix 2: Growth Charts Appendix 3: A Schedule for Months Appendix 4: Cardio-Pulmonary Resucitation — Birth to One Year Appendix 5: Resources for Parents of Premature Babies Glossary Index

\ From Barnes & NobleWhen my baby was born a month early, I suddenly had a hundred questions that weren't covered in any of the pregnancy books I'd scoured. Prematurity is not something you plan for. I found all my answers in Preemies (better late than never!). The book starts with pregnancy -- why prematurity happens and what you can do to prevent it -- and takes you through delivery and hospital tests to the first months at home and beyond. More than 500 pages of accessible, useful information is here, including growth charts, a glossary of terms, and a list of resources for parents. \ Probably the best thing about this book, though, is its format -- good, practical information delivered in easily digested and easy to find pieces. Along with expert information and advice on every possible medical condition that babies (and their mothers) might experience, Preemies includes countless questions and answers about specific problems you might have -- a bit like a What to Expect... for parents of premature babies. My baby's a lot smaller than the doctors said he'd be -- how could they have gotten that wrong? Why does my baby need so many IVs? How serious is high blood pressure for my baby? What do I say when people ask me how old my baby is? The authors, all parents of preemies themselves and one a neonatologist, give succinct, authoritative answers to each.\ If there's a chance that your baby will be born premature, or if you've just delivered a baby prematurely, look no further than Preemies for all the information, advice, and support you'll need to have a safe delivery and successful transition.\ \ \ \ \ \ Publishers Weekly\ - Publisher's Weekly\ Linden and Paroli, mothers who met in the hospital when their preemies were born, and neonatologist Doron present a comprehensive guidebook for parents whose babies are born prematurely. One out of 10 babies in the U.S. is born early, but in half of these cases the mothers have no known risk of giving birth prematurely, so they can't prepare for the whirlwind of unexpected events and emotions they will experience in the neonatal unit. The authors fulfill the need for information with remarkable clarity, offering answers to a multitude of questions. Divided into four sections (Before Birth, In the Hospital, A Life Together and Other Considerations), the book covers risk factors, the first day, the first week, surgery, taking the baby home and many other topics. Each section contains personal observations from parents of preemies, insightful comments from "the doctor's perspective" and information on procedures, equipment, common problems and other issues. While medical information is presented in detail, the book maintains a personal, reassuring tone, explaining that, though their organs and body functions are immature, most preemies are basically healthy. Since parents can't always plan ahead for the possibility of a preemie, this book provides a valuable crash course and serves as a useful tool for communicating with medical staff. Includes a helpful resource guide and glossary. (Aug.) Copyright 2000 Cahners Business Information.\|\ \ \ Library JournalAlthough one out of ten children born in this country is born prematurely, until now there has never been an authoritative, practical, and encouraging reference tool for their parents. This book is just that, a work in the "Dr. Spock" genre that will prove to be a bible for parents of "preemies." Linden and Emma Paroli, who each have children born prematurely, have joined forces with Mia Weschler Doron, a physician whose specialty is neonatology, to produce the book they wish had been available to them when they needed it. The authors cover myriad issues, ranging from a discussion of risk factors for prematurity, through possible and probable problems in the newborn's life and early years, to long-term prognoses. They do this primarily in a question-and-answer format, with lots of accompanying information. Their book should handsomely meet the needs of families dealing with premature infants and in fact is certain to be a blessing to them. Enthusiastically recommended for all public library collections.--Linda M.G. Katz, Florence A. Moore Lib. of Medicine, MCP Hahnemann Univ., Philadelphia Copyright 2000 Cahners Business Information.\\\ \ \ \ \ From the Publisher"This extremely comprehensive and informative book, written in plain language, will serve as a comforting companion for parents and health-care professionals alike."\ —Avroy A Fanaroff, M.D., FRCP[E]\ Professor, Pediatrics and Neonatology,\ Case Western Reserve University School of Medicine\ Co-director, Division of Neonatology,\ Rainbow Babies & Children's Hospital, Cleveland\ “A practical and reassuring source of information”\ - Liza Cooper, LMSW; Director, NICU Family Support; March of Dimes Foundation\ “This is the best book I’ve ever read for parents of premature infants. It’s accurate, up-to-date, and contains the answers to just about every question I’ve ever been asked….” - Jerold F. Lucey, M.D., F.A.A.P.; Editor Emeritus, Pediatrics; Professor of Pediatrics and University Scholar; Henry Wallace Professor of Neonatology; University of Vermont College of Medicine\ “The book is packed with the kind of information that parents really want….It’s a trustworthy resource to aid parents through the uncertainties of very special deliveries.” – Parenting Magazine\ \ \