Delivery of Premature Infants

Several decades ago, some experts proposed that elimination of the stresses of labor by delivering all preterm babies by cesarean would increase the newborn survival rate. The rationale was that reduced stress on the infant’s head would reduce the possibility of bleeding into the skull. This complication, called intraventricular hemorrhage, is another major cause of death in premature newborns. The best evidence now shows that cesarean delivery does not prevent ventricular hemorrhage. The best currently available evidence does not support performing a cesarean if the only reason for the surgery is a premature infant. Of course, there are times when cesarean is performed for the same reasons as it is in mature babies.

Episiotomy is another procedure that has been advocated as a way of reducing stress on the skull of the immature fetus. Studies are not available to demonstrate whether this is beneficial. The resistance of the perineal muscles, through which the infant passes just as it leaves the vagina and which are cut with an episiotomy, is less than the resistance of the cervix and the vaginal muscles through which the infant has already passed. Despite a lack of definitive evidence, some experts recommend episiotomy for the delivery of preterm infants. Others recommend it only when there is resistance in these muscles, rarely seen except in women having a first baby. This is an area worth further research.

Most important for the premature infants is the presence at the birth of personnel skilled in resuscitation and care of premature infants. Whenever possible, the delivery should take place in a hospital with a neonatal intensive care unit and with constant attendance of physicians, nurse practitioners, and nurses who are knowledgeable in caring for these tiny infants. A staff member, or team of staff members, should be present in the delivery room whenever a premature baby is born, ready to provide expert care from the moment of birth.