What is Pre-term Labour

Anastasia Baker: The one doze of medicine now mean that many babies can survive being born nearly 15 weeks early, when only a few years ago the baby would have had no chance of survival. Despite these medical miracles nobody wants to see a baby born prematurely. Dr. Patrick O'Brien an expert in Preterm Birth from University College London Hospitals is here to talk about whether anything can be done to prevent premature birth. Thank you for coming in today. Dr. Patrick O'Brien: Thank you! Anastasia Baker: Well can anything be done to prevent premature birth? Dr. Patrick O'Brien: Well, the short answer is probably no. We are a long way from really understanding why most premature births takes place. There is a huge amount of research taking place across the world at the moment. Paper has been published in the medical literature week after week. We are gradually chipping away, we are getting a little bit more knowledge, but the bottomline is still that we are very poor at preventing preterm labor. Anastasia Baker: Can you define for us, what exactly it is premature labor? Dr. Patrick O'Brien: Well in the medical books it has defined as delivery of the baby before 37 weeks of pregnancy and if you remember that pregnancy is 40 weeks. Anastasia Baker: Yeah. Dr. Patrick O'Brien: So more than three weeks early. Although in practical terms nowadays the care of premature babies are so good, that it becomes an issue really only if the baby is born before 34 weeks, in other words six weeks early. Anastasia Baker: At what point do you really concern for the child, what are the statistics? Dr. Patrick O'Brien: Well, really we would like all babies to be born after 37 weeks if possible. Anastasia Baker: Sure. Dr. Patrick O'Brien: At 34 weeks we don't get too concerned because our neonatology colleagues in the special care baby units are so expert these days that really they can do very, very well with babies after 34 weeks. Nowadays in a hospital like mine, just about 100% of babies born at 30 weeks will be absolutely fine. At 28 weeks perhaps 95% of babies will survive, at 26 weeks maybe 70% and even as early as 24 weeks about half of babies will survive. Although you have to take into account that a significant proportion of those babies may have some serious problems as well. Anastasia Baker: What can you do to avoid this happening, is there anything that women can do? Dr. Patrick O'Brien: Well, there are very few things that the women can actively do. I mean certainly having a healthy pregnancy, eating well so on, not smoking makes a big difference, not having too much physical hard labor during pregnancy seems to reduce the risk of preterm labor. But apart from that there isn't the huge amount that the women can do, no. Anastasia Baker: Is it a hereditary thing, sometime like if your mother had a premature birth, is it likely that you will? Dr. Patrick O'Brien: Well, until recently we didn't think so, but we are beginning to think, now that there maybe some women where it is a hereditary thing, where there is a sort of familiar link, where there is some questions about the strength of the survey, strength of the tissue in the body and so on, or whether there is some blood clotting problems that can lead to in early delivery. But for most women we still don't understand and perhaps for most women there is not a genetic link. Anastasia Baker: So is there anyway of detecting whether a woman is likely to have a premature birth? Dr. Patrick O'Brien: Well, until recently no there wasn't. From many years obstetricians have performed vaginal examinations regularly throughout the pregnancy and women that they thought where at an increase risk of premature labor. But we now know -- with good research now we know that that's not effective at all. But in the lasts decade, two techniques have come forward, which are particularly promising. One is ultrasound scan. So vaginal scanning where we look at the cervix, the neck of the womb and actually measure, see how long it is, and whether it is tightly closed the way that it should be, and what we now know is that if on scan in the middle of pregnancy, the cervix is a bit short or beginning to open a little bit, then those women are at significantly increased risk of premature labor. Anastasia Baker: So what would you do then? Dr. Patrick O'Brien: Well, that's a big question. We really don't have any -- Anastasia Baker: It goes to bed rest or --? Dr. Patrick O'Brien: Bed rest doesn't make any difference at all. What we tried initially was putting in a stitch, so a stitch in the neck of the womb to try to keep it close and strengthen it, but we now know that, that didn't make any difference that did not improve the outcome actually. We've tried various medicines and hormones and things like that. There are some promising research from the United States recently, which suggest that progesterone hormone for women who are at an at higher risk of preterm labor can have to reduce the chances of an early delivery, but still we don't have any good effective means of stopping, even when we know women are at very high risk. We haven't got good methods of stopping that. Anastasia Baker: Stopping the birth happening. Dr. Patrick O'Brien: That's right. Anastasia Baker: So what you likely to do for the baby when you know they are about to be born prematurely? What's the most important thing that you need to do for the baby and the mother? Dr. Patrick O'Brien: Well, it's a slightly different issue, when somebody actually comes in labor, actually in premature labors, let's say somebody is 28 weeks pregnant and they come in, they are getting contractions when we examine them, we find that the cervix, the neck of the womb is beginning to open. Then there are few things that we must do. The first is to give some injections to the mother, or the type of steroid hormone that actually helps to mature the baby's lungs and also reduces the chances of the baby having breathing problems after his born and problems with brain hemorrhages after his born, and may even reduce the chances of bowel problems as well. So we must give those steroids very quickly. Anastasia Baker: Well, how long have you got? Dr. Patrick O'Brien: Well, ideally they take about 24 hours to work, so we give the first injection straight away and then repeat injection about 12 hours later, and ideally we would like the baby to stay in there for another 24 hours to give those injections -- Anastasia Baker: So everyday helps, everyday. Dr. Patrick O'Brien: Every hour helps even at that stage. Then we do have medicines that can try to stop the labor, either through a drip in the woman's arm or some tablets, they are not fantastic. They can stop labor for perhaps a maximum of 48 hours but even those 48 hours can make a huge difference. If you can get those steroid injections give them time to work or even perhaps if a woman come to a small hospitals where the neonatal unit can't deal with such premature baby, if it gives us time, if those medicines gives us time to transfer the woman to a bigger unit with a better baby care unit, then that can make a huge difference in the baby's birth as well. Anastasia Baker: So how does a woman know that she is about to have a premature birth? How does she know it's that and not a --? Dr. Patrick O'Brien: Well, it sometimes very difficult to be sure, and I have to say in every hospital ever worked in, every single day we have six women coming in, thinking that they are in labor and most of them aren't be. They will be getting pains, they may even be getting contractions, but actually when we examine them and check the cervix -- Anastasia Baker: It's quite easy. Dr. Patrick O'Brien: -- is tightly closed. Exactly. Anastasia Baker: Right. It's only if it's not. Dr. Patrick O'Brien: Exactly. It's only if the cervix is opening that the women is actually in labor. Anastasia Baker: So women who gives birth 24 weeks, what chance is that, what does will that baby need immediately? Dr. Patrick O'Brien: Well, that's very early and that's close to the earliest that a baby can possibly hope to survive and in a very good baby care unit like the one at University College Hospital, the baby will have perhaps of 50% or 60% chance of surviving, but all of the babies that survive about half will have major longterm problems like cerebral palsy or blindness or deafness. This sort of major problems that the babies will have in the early hours and days will be the lungs are very, very immature, so almost certainly the baby will need to be on a ventilator machine to do the breathing for the baby. The baby's brain is very premature or very delicate. So the risk of brain hemorrhages and cerebral palsy is very high indeed. Other problems like the baby's bowel is very immature and sometimes parts of the bowel begin to die and the baby needs operations to remove sections of the bowel. So just about every system in the baby is very immature and these needs to be supported in a very major way. Anastasia Baker: And would be in hospital for quite a long time. Dr. Patrick O'Brien: Week and weeks, or months even. What the baby team will normal say is that, look you should expect your baby to be in hospital at least up to the due date. Now, sometimes if you are lucky the baby will come up before that but that's kind of what you have to plan for and of course a very rocky course especially in the early weeks. Anastasia Baker: So there is no advice or anything you can give a woman to avoid this scenario. No. Dr. Patrick O'Brien: To be quite honest there isn't. It's good advice be healthy in your pregnancy, eat healthily, exercise and all of this, avoid smoking and so on. But at the end of the day we -- in many cases we just don't understand why the premature labor is happening. Anastasia Baker: Are you seeing an increase? Dr. Patrick O'Brien: Not to the extent that I would notice. There is some evidence in the medical literature that premature labors are increasing slowly over the years but I don't know why that's happening and it's not something that's happening quick enough for us to notice individually. Anastasia Baker: Presumably the longterm effects. We are not really sure about because we have not been able to save these very, very small babies in the last 10 or so years. So we don't know really what the longterm effects are going to be. Dr. Patrick O'Brien: Well, that's true, that's true, and certainly there is evidence, growing evidence. For a number of years now, we have been able to save babies at 28 weeks for example. Most babies at 28 weeks will survive. So in the last decade we are getting more and more information and how these babies do as they grow up as they go into childhood and then they are in teens and even later. There does seem to be a slightly higher incidence of milder problems like Attention Deficit Disorder or Dyslexia or these sort of problems, but not a particularly higher incidence of major problems like blindness and cerebral palsy and so on. What about these babies that are surviving from 24 weeks nowadays? Well, I don't know. I mean certainly they have been watched very, very carefully and over the 5, 10, 15 years to come will get more and more information on how these babies do in longterm. Anastasia Baker: And is it a class of social or racial issue in any of these cases for premature labor? Dr. Patrick O'Brien: Well, it is true that the lower the social class and the lower the income, the more manual the labor. It does seem to be true that the greater the risk of premature labor. Now why is that? It's very hard to tease it out. It may be where we know that, that lower social classes smoke more and we definitely know the smoking increases the chances of preterm labor, so maybe that's it. We know that if you are income isn't as good, then you diet isn't as good, you don't eat as healthily maybe that's part of the reason. So it's very hard to tease out exactly what the major issue is here. We also know that when it comes to raise, we know that Afro-Caribbean women are more likely in this country at least to be in a lower social economic class, that's just the way the demographics are. And maybe the reason that the premature labor is more common in Afro-Caribbean women is that, the nutrition isn't as good, more likely to be doing manual labor and so on. It's very hard to tease out the confounding factors as I call. Anastasia Baker: Presumably there are lots of research going on into this whole area. Where is the research specifically being focused at your hospital, for instance? Dr. Patrick O'Brien: In every single aspect of premature labor you could hope to think about is being investigator across the world. In our hospital, we are focusing on the role of infection in preterm labor. We think that at least a quarter of all women who go into labor early that is caused by infection at some sort, and it maybe as the years pass we gain more and more information and we get better identifying infection that perhaps a greater proportion are being caused. There have been big studies looking at these of antibiotics in these women in some types of problem the antibiotic seem to be helpful in others, they don't. There is a huge amount of research. Anastasia Baker: Vitamins? Dr. Patrick O'Brien: Vitamins, no, don't seem to have. Anastasia Baker: But antibiotics might be a possibility? Dr. Patrick O'Brien: About a third of all women who are going to early labor, what happens is that the waters break first, the bag of waters around the baby will start to leak. And when that happens, most women within the next week or so will actually go into labor. There is a huge study a few years back called the Oracle Trial, which is in many country across the world. If you give these women an antibiotic called Erythromycin, a very simply antibiotic available everywhere that it significantly reduces the chances of the baby delivering within a week, if the baby dying, or the baby having major problems with infection. So in this situation now routinely we give antibiotics. On the other hand a woman who comes in, in labor where the waters doesn't broken, antibiotics don't seem to happen in that situation. Anastasia Baker: So you don't waste your time in the near future where premature labor might be a thing of the past? Dr. Patrick O'Brien: Not in the near future, I have to say, I mean the research is huge. The funding for research is huge, the papers have been published week after week, but the progress is really slow, really painstaking. I don't think there is going to be any huge breakthrough suddenly at all, unfortunately. Anastasia Baker: Dr. Patrick O'Brien thank you very much for coming in today. Dr. Patrick O'Brien: Thank you very much!