Question regarding very premature birth

[OhWhatAPalaver]

My sister is currently 23+5 and in hospital with heavy bleeding and waters leaking significantly. My question is, what are the drs meant to do if she goes in to labour in the next couple of days? Ie. Before 24 weeks? Are they supposed to try and help the baby survive or would they treat it as a 'late miscarriage'? Seems a bit odd to me that they haven't already transferred her to a specialist early pregnancy unit. Should she be demanding this? Apparently the drs and midwives are being very cagey about it....

I have no solid information but just wanted to say how sorry I am your sister I going through this. My understanding is that at 24 weeks they will offer interventions to try and save a baby born that early, or if they're over a certain weight. Is she staying in hospital? Have they given her steroids just in case?

Thanks for the replies. Yeah, she's on full bed rest, no steroids yet though. No idea why they haven't given her any. They seem to be avoiding doing anything at the moment, it's very frustrating. She's been in for two weeks now and is very upset and stressed. I think she would feel better if she were in a different hospital as she's not best impressed with the one she's currently in.
From the scans baby seems fine, they don't really know why this is happening, although she does have a heart shaped uterus and had been very sick throughout pregnancy.
I have no idea what I would want in such a situation. It's such a difficult position to be in. She just doesn't seem to be getting as much support as expected from the hospital staff, they seem to just be in 'see what happens' mode.

Hi am a neonatal doctor. We resuscitate anything from 23+0. What happens is we go to delivery and assess the baby when it comes out. We see how it is, and do basic airway measures. If it looks viable and there are signs of life we continue. If it's going nowhere we wrap baby up and give to mum. These babies are sick though and even when they make it to the unit there is a very rocky road ahead. If she had threatened labour she should have steroids, they make a very big difference. If she is really threatening to deliver she should be in a hospital with a level three neonatal unit. Whilst transferring your sister seems risky, i can promise you that as long as she isn't in full blown labour it is much safer than transporting a twenty three weeker ex utero.

Different hospitals though do have slightly different protocols, so things might be a bit different. It is a really difficult situation. Epicure do a leaflet about the risks of preterm birth and gives all the numbers and stats....some parents find this helpful- you can find it on the web. I hope baby stays put for your sister... Every day counts! Good luck.

Love to you and your sister
I had a big bleed at 23+6, and then another 6 times throughout my pregnancy, but she hung on in and I delivered a healthy baby girl at 38 weeks. X

It's very scary but hopefully the baby will stay inside for longer, it can happen! I'd be asking the consultant about moving her to a specialist unit - are you near London or a big city with a specialist unit!?

We're in Manchester so she should be at St Mary's really. She's not threatening labour as such but such a lot of waters have gone I feel they should probably be giving steroids. It feels like they're waiting for 24 weeks to do anything :/

My twins were born at 30 weeks but I first went in to labour at 27 and then 29 weeks. So whilst I have no experience of extreme prematurity, I have a lot of experience of what happens in these situations!

When I was first admitted at 27 weeks and following a foetal fibronectin test (to ascertain if premature delivery was likely) I was put onto an Atosiban drip which aims to stop labour. I was also administered steroid injections to help mature the babies' lungs. At that point my chosen hospital would not have been able to take the babies if they had been born as their neonatal unit only takes babies born at a later gestation. Luckily the other local hospital had neonatal cots so we were put on standby to transfer out if labour continued. As the neonatal doctor above says, it's much better to transfer in utero than wait for baby to be born.

I managed to hold off labour until 30 weeks through a combination of Atosiban drips, careful monitoring and a lot of rest.

It will be a very scary time for your sister but at this stage, I would advise she requests to speak to a consultant and asks the following:

1. Can a foetal fibronectin test be taken if not already done?
2. When will steroid injections be administered?
3. At what point will a transfer out be agreed upon?

I was lucky in that my hospital were absolutely amazing so I am so sorry that she is not in the same position. Unfortunately, she needs to kick up a bit of a fuss and demand that a consultant gives her more information.

We were on a unit with a baby born at 23+4 who spent a very long time in hospital after birth. I bumped into her and her mum in town yesterday and she is now a smiley little girl who is about to celebrate her first birthday!

I hope all is well, please don't hesitate to PM me if you have any questions.

Thanks for the positive posts as well, really hoping baby will stay put for as long as possible!
Looks like she may have an infection now as well. I really hope the hospital get a move on with the steroids and get her somewhere properly equipped soon!

Thanks for the lovely positive post b1rd! What's a foetal fibronectin test btw?

My sister started labour at 29 weeks with contractions. She was given medication to try and slow the labour down. She was transferred to a hospital two hours away as there were no neonatal icu beds in the first hospital.
She carried on going into labour every night with medication becoming less effective to stop things. It was really difficult for us to see as a family but as a pp said every day in counts for the baby.
Things settled down enough for her to be discharged at 31 weeks she went home and went into labour the following day.
My nephew was born in the original hospital at 31+5. He stayed in for two months and is absolutely fine now and is a thriving teenager!
It was a really awful experience though for everyone so to you and yours op

Has she asked for a transfer to the other hospital? We did this when our son was in SCBU and they wanted to admit me to have him in the maternity ward for a few days while he was monitored. I asked to transfer to the local midwife led unit which had individual rooms and it wasn't a problem. If she'd feel happier in the other hospital, maybe she could ask if a transfer is possible?

I just remember it as being such a scary and uncertain time. Hearing positive stories would have been really helpful for me so I hope your sister can take some comfort from knowing that things aren't always as negative as they might now seem!

A FFN test is a swab which examines cervical or vaginal secretions for foetal fibronectin. If it tests positive, there is a good chance that preterm labour is imminent.

It's a bit of an imperfect science as it's actually better for determining if you won't go into labour early (by the absence of fibronectin). If you do test positive there is no way of telling when you will go into labour but in my experience, it helped frame the path of care until I delivered.

It's a very expensive test though and I understand that some hospitals are reluctant to do it. I think it would be worth having the conversation with the consultant though to understand their policy on it.

Hi, I'm an obstetric doctor.

Fetal fibronectin isn't licensed for use in the presence of significant bleeding, or when the waters have broken. Therefore is not appropriate here. It is also no longer recommended by NICE for use prior to 30/40.

You can check which level neonatal unit you are in online, or ask. Sometimes units which you might not expect are actually level 3.

We do not know the full facts here. If the waters went at 22/40 and the baby hasn't grown since, for instance, the outcome can be very different to if this is a bleed which has settled. Also, 27 weeks is very different to 23.

The best advice is always to speak to the consultant in charge with a list of questions. If you do not feel adequately listened to, get to PALS asap.

Also, to contradict the poster above, fibronectin is significantly cheaper than a 48 hour hospital stay for threatened preterm labour. If negative, it allows discharge, and therefore is cost effective and widely used. However, it is no longer recommended for use before 30 weeks (2016 guidance), this is because anyone with significant symptoms at this gestation should receive steroids as the test has a false negative rate.

That's very interesting r.e. fibronectin semblance, I was given quite different information but of course defer to your knowledge over mine! It makes a lot of sense that the test is cheaper than a hospital stay of course.

Please don't get me wrong, I understand that 27 weeks is very different to 23 weeks and was in no way trying to compare the two. I also agree that this is just a snapshot of the situation and in no way indicative of everything that will be at play.

I suppose the gist of my posts was to encourage a full and frank conversation with the consultant as it seems the OP's sister is not being given much information at all. My suggested questions were to help try and kick start that conversation.

And by different information r.e. FFN, I mean regarding cost.

I did not know it could not be used with heavy bleeding or when the waters are gone. I realise my point was badly phrased as it was a suggestion to ask if it was appropriate be taken in this instance, if not already done so.

I have a beautiful, healthy, thriving 1yo who was born at 23+2. The doctors and nurses were amazing and there is so, so much they can do for the very little ones. Our time in hospital was stressful but we were all very well taken care of. Sending positive vibes to your sister.

Thank you all so much. I've just heard that they are giving steroids now and trying to find an appropriate hospital to transfer her to as well so things are getting moving!!

My sister gave birth to fraternal twins at 23 and 26 weeks they were able to stop the birth after the first baby delivered and give the second baby additional weeks to grow in utero this was possible because fraternal twins are in different amniotic sacs.

My sister had sever pre-eclampsia so was already in hospital for that.

Both twins survived (though it was a rough road) and are now big strong 9 year olds.

I can't give you any clinical advice, but I did want to say that babies under 24 weeks can survive so go with your instincts and push to understand what treatment options are available to give your family the best possible outcome.

Fingers crossed for all of you!

Thanks everyone, she's being transferred this afternoon but unfortunately not to st Mary's, they have no space so she's having to go further afield. At least she'll be somewhere appropriate though!

That's good news!! Good luck and keep us posted I'm looking forward to a really positive outcome

Quick update, she is at the new hospital now and the midwives and drs are a million times better than where she was before, which is really great. She's had to make some difficult decisions though. Also she has been told that because the baby is transverse there is a risk of the cord coming out before baby and putting the baby at risk of losing oxygen during birth. However, they won't do a c-section as it's too risky for my sister. So many risks to take in to account!