Organisation and delivery of perinatal services

Introduction

Over the past 30 years advances in antenatal and perinatal care have improved outcomes for preterm infants greatly. In the United Kingdom the neonatal mortality rate for very low birth weight infants (birth weight < 1500 g) fell from about 50% in 1975 to less than 20% in 1995. Additionally, the incidence of preterm stillbirth has fallen so that it seems that many more preterm infants are born alive than would have been the case 20-30 years ago.

In intensive care preterm infants undergo mechanical ventilation

With these advances in care comes a higher demand for perinatal services, particularly for intensive care for preterm infants. Services such as neonatal intensive care, however, have a low throughput of patients, use complex and technical equipment, and are expensive. Organising the delivery of these services is not simple.

Levels of care

The level of additional care that preterm infants need varies. Broadly, the level of care is inversely related to the gestational age and birth weight.

• Special care—for example, gastric tube feeding, temperature maintenance, and respiratory monitoring for apnoea

• High dependency care—for example, continuous monitoring, supplemental oxygen, and parenteral nutrition

• Intensive care—for example, mechanical ventilation, exogenous surfactant, and other organ support (such as the use of inotropes).

Most infants born after about 32 weeks of gestation or with a birth weight > 1500 g need special care only while they establish oral feeding and grow to sufficient maturity so that they can be safely discharged. Often the infant's mother is a major carer. Neonatal nurseries may have transitional care facilities to allow mothers to stay with their infants, particularly when they are establishing breast feeding.

Infants in special care are often fed using a nasogastric tube containing maternal expressed breast milk

Less mature (or less well) infants may need high dependency care for days or weeks …