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BIRTH SUITE · FOUNDATIONS
When a preterm baby arrives sooner or smaller than planned: who stays at Gosford, how to prepare, the first 10 minutes, and the first hour. Warmth, gentle breathing support and calling for help early.
FIRST, THE BIG PICTURE
Gosford SCN cares for babies from 32 weeks. Below that, the baby needs a NICU. Above it, many babies stay with us, but not all.
| Baby | Where they belong | NETS? |
|---|---|---|
| Under 32 weeks | NICU | Yes - call the consultant, who will call NETS early (ideally before the birth) |
| 32 weeks and over, settling | Gosford SCN | Usually not needed |
| 32 weeks and over, escalating | Decided by the consultant | If rising oxygen or work of breathing on CPAP, needs ventilation, or is otherwise unwell |
| Under 25 weeks | NICU, with a senior at the birth | Consultant and NETS involved from the start |
| 22-23 weeks (periviable) | Whether to resuscitate is decided by the consultant with the family | Yes, if active care is planned |
BEFORE THE BIRTH
Even five minutes of preparation changes how the first hour goes.
Call the consultant as soon as you hear about a preterm labour, not when the baby is born.
Ask the obstetric team whether in-utero transfer is still possible. Transferring the mother is safer than transferring the baby.
Gestation and estimated weight. Steroids given, and when? Magnesium sulfate (under 30 weeks)?
Infection risk: ruptured membranes, maternal fever, GBS status, antibiotics in labour. Any known fetal concerns.
Warm the room and turn on the warmer. The preterm pack is in the bottom drawer of Ruby.
Plastic bag and hat, small masks, T-piece with PEEP, blender set to 30%, sats probe, 2.5 and 3.0 ETTs, surfactant if likely, glucose, UVC kit.
Leader, airway, sats and heart rate, timer and scribe. Brief the team on the plan before the baby arrives.
If time allows, the consultant meets the parents first.
AT BIRTH
The same sequence as any birth (see Attending a Birth), with a few preterm changes.
If the baby is stable, wait at least 30-60 seconds before clamping. Do not milk the cord under 28 weeks.
Under 32 weeks: straight into the plastic bag, add a hat, under the warmer. Aim for 36.5-37.5°C.
Probe on the right wrist. Listen to the heart rate or use ECG leads if sats are slow to pick up.
If breathing: CPAP (PEEP 5-8) via T-piece. If not breathing or HR under 100: mask ventilation with PEEP and the lowest pressure that moves the chest.
Start at 21-30% and titrate to the SpO2 targets. Avoid hyperoxia.
Recheck mask seal and airway first. Then call senior help to intubate.
ON THE SCN
Stabilise while you wait for transfer, or settle the baby for an SCN stay.
Check on arrival in the SCN and repeat until stable. Use a humidified incubator or warmer.
Cold and too-hot babies both do worse.
CPAP is first-line. Get a chest X-ray and blood gas.
Consider surfactant if oxygen need rises above about 30% on CPAP. Gosford uses LISA or INSURE, depending on the consultant.
Check the glucose within the first hour. Preterm babies have low stores.
PIVC and IV 10% glucose at the local starting rate. UVC if access is difficult or retrieval is planned.
Unexplained preterm labour can be a sign of infection.
If there are risk factors or the baby is unwell: blood culture, then IV antibiotics per local guideline.
IF NETS IS COMING
Have this ready before the call. The consultant will usually make it.
| Topic | Have ready |
|---|---|
| Baby | Gestation, weight, time of birth, condition at birth, Apgars |
| Breathing | Support (CPAP or ventilation), pressures, FiO2, latest gas, chest X-ray |
| Circulation | Heart rate, BP, perfusion, access (PIVC or UVC) |
| Other | Temperature, glucose, antibiotics given, surfactant given |
| Antenatal | Steroids, magnesium, infection risks |
| Family | What the parents know, and the mother’s condition |
EXTREME PREMATURITY
At 22-23 weeks, whether to offer active resuscitation depends on the baby’s condition and the parents’ wishes. Under 25 weeks, every birth needs a senior.
Under 25 weeks, a consultant should attend the birth. At 22-23 weeks, the consultant leads the decision about resuscitation with the family, with NETS involved early.
If you are first at a very preterm birth, keep the baby warm and call for help. See Antenatal for counselling.
If the plan is comfort care, keep the baby warm and with their parents.
Support the family and staff afterwards.
THE FAMILY
A preterm birth is frightening and fast. Small things help.
Let parents see and touch the baby before transfer if possible. Take photos for the mother.
Explain who is caring for the baby, where they are going, and when they will next hear from the team. Document the conversation.
GO DEEPER · OPTIONAL
Background reading for exams and teaching - not needed on shift.
| Step | Trial | What it found |
|---|---|---|
| Cord clamping | APTS (NEJM 2017) | Delayed (60 s) vs early clamping under 30 weeks: no difference in the primary outcome; lower mortality in a secondary analysis |
| Cord milking | PREMOD2 | More severe IVH with milking under 28 weeks; delayed clamping preferred |
| Warmth | HeLP | Plastic wrap reduces hypothermia; no effect on mortality |
| Drying | Drying before wrapping | No thermal benefit; wrap without drying |
| Oxygen under 29 weeks | TORPIDO 30/60 | Starting at 60% vs 30%: no difference in death or brain injury |
| Oxygen 32-35 weeks | AIROPLANE | Air vs 30%: no difference in ongoing respiratory support |
| Sustained inflation | SAIL | No benefit at 23-26 weeks and more early deaths; use PEEP and intermittent breaths |
| CPAP at caesarean | PLaNT | Prophylactic CPAP in late preterm babies: feasible; less early support; needs a larger trial |