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pregnancy, prematurity

Vaginal delivery is safe for premature babies who aren’t breech

Born at 26 weeks, now we are nine!

Finding out your baby is going to be premature is one of the most stressful things for parents-to-be. In addition to all the fears about the effects of prematurity, many parents also worry about the method of delivery. How can a tiny, fragile premature baby manage to make it through the birth canal without injury?

If your baby is head down (what OB/GYNs call a vertex presentation), the answer is, “They will do just fine.”

A new study published in the American Journal of Obstetrics and Gynecology (Reddy et al) by researchers at the National Institute of Child Health Development (NICHD) analyzed data from more than 200,000 deliveries over 6 years from 19 hospitals. What they found was premature babies between 24 and 32 weeks did just as well with a vaginal delivery as with a c-section. Furthermore, when a vaginal delivery was attempted for mothers with a baby who was head down, 84% were successful.

This data is retrospective, meaning the women delivered and then the medical records of the mothers and their babies were looked at after the fact. While the researchers try to control for unforeseen factors that might somehow skew the results (called confounders), it isn’t always possible with retrospective studies. However, the strength of this study lies in the sheer number of deliveries that were evaluated.

The data (c-section is no safer for delivering a premature baby who is head down) from this new study supports similar results that have come from randomized prospective studies. Why spend government money studying something that has already been studied? While randomized prospective studies are the gold standard, the ones addressing this particular issue suffer from very low numbers of women who were enrolled. So while the design of these other studies was good, not having enough study participants weakens the results and hence the need for more information.

Why aim for a vaginal delivery with a premature baby? I mean the situation is stressful enough, why not just “get it over with?”

There are several reasons to avoid a c-section

  • You never, ever want to have surgery if you don’t really need it. Surgery is injury and the risk of death for mom is higher with a c-section, never mind the risk of complications.
  • After a c-section it is harder to get to the NICU and see your baby. Stress makes pain worse (it affects brain chemistry, pouring fuel on the fire that is your pain) and having a baby in the NICU is about the most stressful thing you will ever go through. Being there for your baby is the single most important thing a preemie mom can do, so you don’t want anything to slow you down. I was desperate to get to the NICU after my c-section at 26 weeks and I was soaked in sweat and dying from the pain just getting into the wheelchair 24 hours later. And I consider myself pretty tough (I once spent not only spent the night with a ruptured spleen, but then took the bus, with a ruptured spleen, to get to the doctors). The pain from my ruptured spleen or the pain from having a kidney removed (one of the most painful abdominal surgeries there is) were nothing in comparison with the pain I had after my c-section.
  • Delivering through the vagina may have other benefits. New studies are emerging telling us that babies get some of the good bacteria in their gut by passing through the vaginal canal. Obviously if a c-section is needed for your baby to get to the NICU safely that’s the trump card, but if the c-section isn’t going to improve your baby’s chances then the default has to be first do no harm (i.e. you want you baby to have all the good bacteria that she/he can get).
  • C-section lowers breast-feeding rates. There are a variety of reasons including lack of skin-to-skin contact after delivery, surgical stress on the body, and post delivery pain. Many preemie moms already have to pump because their babies can’t suck and swallow and pumping is a less effective stimulus for breast milk than having a baby on the breast. In addition, delivering prematurely affects milk production for many moms. As breast milk is the absolute best for preemies, you don’t want to introduce any unnecessary variable that’s going to impact your ability.

What if your baby is breech? This study does tell us that delivering a premature breech baby (bottom/feet first) may be safer by c-section. However, it is important not to feel guilty about that. The first task is to get your baby to the NICU as safely as possible, so if a c-section is needed, then it’s needed. If I hadn’t had a c-section I wouldn’t have two 9-year-olds. You have to put it in perspective. Delivering vaginally just wasn’t an option.

But if a premature baby is head down, then delivering vaginally is safe and that should help some parents take one stressor off the table.

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