Preterm birth

also known as premature birth, is the birth of a baby at fewer than 37 weeks gestational age, as opposed to full-term delivery at approximately 40 weeks.^[1] Extreme preterm^[2] is less than 28 weeks, very early preterm birth is between 28 and 32 weeks, early preterm birth occurs between 32 and 34 weeks, late preterm birth is between 34 and 36 weeks’ gestation.^[8] These babies are also known as premature babies or colloquially preemies (American English)^[9] or premmies (Australian English).^[10] Symptoms of preterm labor include uterine contractions which occur more often than every ten minutes and/or the leaking of fluid from the vagina before 37 weeks.^[11][12] Premature infants are at greater risk for cerebral palsy, delays in development, hearing problems and problems with their vision.^[1] The earlier a baby is born, the greater these risks will be.^[1]

The cause of spontaneous preterm birth is often not known.^[2] Risk factors include diabetes, high blood pressure, multiple gestation (being pregnant with more than one baby), being either obese or underweight, vaginal infections, air pollution exposure, tobacco smoking, and psychological stress.^[2][3][13] For a healthy pregnancy, medical induction of labor or cesarean section are not recommended before 39 weeks unless required for other medical reasons.^[2] There may be certain medical reasons for early delivery such as preeclampsia.^[14]

Preterm birth may be prevented in those at risk if the hormone progesterone is taken during pregnancy.^[5] Evidence does not support the usefulness of bed rest.^[5][15] It is estimated that at least 75% of preterm infants would survive with appropriate treatment, and the survival rate is highest among the infants born the latest in gestation.^[2] In women who might deliver between 24 and 37 weeks, corticosteroid treatment may improve outcomes.^[6][16] A number of medications, including nifedipine, may delay delivery so that a mother can be moved to where more medical care is available and the corticosteroids have a greater chance to work.^[17] Once the baby is born, care includes keeping the baby warm through skin-to-skin contact or incubation, supporting breastfeeding and/or formula feeding, treating infections, and supporting breathing.^[2] Preterm babies sometimes require intubation.^[2]

Preterm birth is the most common cause of death among infants worldwide.^[1] About 15 million babies are preterm each year (5% to 18% of all deliveries).^[2] Late preterm birth accounts for 75% of all preterm births.^[18] This rate is inconsistent across countries. In the United Kingdom 7.9% of babies are born pre-term and in the United States 12.3% of all births are before 37 weeks gestation.^[19][20] Approximately 0.5% of births are extremely early periviable births (20–25 weeks of gestation), and these account for most of the deaths.^[21] In many countries, rates of premature births have increased between the 1990s and 2010s.^[2] Complications from preterm births resulted in 0.81 million deaths in 2015, down from 1.57 million in 1990.^[7][22] The chance of survival at 22 weeks is about 6%, while at 23 weeks it is 26%, 24 weeks 55% and 25 weeks about 72%.^{[23][needs update]} The chances of survival without any long-term difficulties are lower.^[24]

Signs and symptoms

Signs and symptoms of preterm labor include four or more uterine contractions in one hour. In contrast to false labour, true labor is accompanied by cervical dilation and effacement. Also, vaginal bleeding in the third trimester, heavy pressure in the pelvis, or abdominal or back pain could be indicators that a preterm birth is about to occur. A watery discharge from the vagina may indicate premature rupture of the membranes that surround the baby. While the rupture of the membranes may not be followed by labor, usually delivery is indicated as infection (chorioamnionitis) is a serious threat to both fetus and mother. In some cases, the cervix dilates prematurely without pain or perceived contractions, so that the mother may not have warning signs until very late in the birthing process.

Causes

The main categories of causes of preterm birth are preterm labor induction and spontaneous preterm labor.

Risk factors

The exact cause of spontaneous preterm birth is difficult to determine and it may be caused by many different factors at the same time as labor is a complex process.^[25][26] The research available is limited with regard to the cervix and therefore is limited in discerning what is or is not normal.^[12] Four different pathways have been identified that can result in preterm birth and have considerable evidence: precocious fetal endocrine activation, uterine overdistension (placental abruption), decidual bleeding, and intrauterine inflammation or infection.^[27]

Identifying women at high risk of giving birth early would enable the health services to provide specialized care for these women and their babies, for example a hospital with a special care baby unit such as a neonatal intensive care unit (NICU). In some instances, it may be possible to delay the birth. Risk scoring systems have been suggested as an approach to identify those at higher risk, however, there is no strong research in this area so it is unclear whether the use of risk scoring systems for identifying mothers would prolong pregnancy and reduce the numbers of preterm births or not