The complete resource for NICU families from admission to discharge and beyond

CONGRATULATIONS!!! You made it to 32 weeks!!! Maybe your membranes have been ruptured for several weeks and you’ve been sitting in the hospital hoping and praying you don’t get an infection. Or maybe you’ve got identical twins that are sharing a placenta, or your doctors have told you there is something else wrong with the way your baby was formed that will require a surgeries and other treatments after birth. You’ve gotten the steroid shots to help your baby’s lungs develop (that’s not all they do!), and you’ve put your entire life on hold to follow doctor’s orders for strict bedrest in the hospital.

Or maybe your doctor told you that swelling in your ankles was pre-eclampsia. Your blood pressures are high, and you don’t feel very good! You don’t understand it, because you’ve always been healthy and your friends told you that the 3rd trimester was a euphoric time. But you’re in the hospital on intravenous medications that make you feel really strange and your doctors have told you that, for the health of both you and your baby, you have to be delivered ---- NOW.

So, regardless of how you got here, you have delivered your baby at 32 – 34+ weeks. Your baby is in the NICU and you can’t be with him/her and you don’t really understand what is happening. Some people have come to tell you that your baby will need to be here for many weeks, but you’re sure that you know someone whose baby came home with her after delivering at 34 weeks. Will somebody please just talk straight to you???!!!!????

The truth is that most babies born in hospitals at >32 weeks survive and are healthy when they go home (assuming they have no other problems than prematurity). But that doesn’t mean they can go home right away. You can expect your son/daughter to need to be in the NICU until close to your due date; that’s the day when Nature said your baby would be developed enough to live outside the womb. And now that s/he is here, we will do our best to help him/her develop at the same rate s/he would have developed had your pregnancy continued. We can’t do much to speed up development, and sometimes we don’t do as good a job as Mother Nature, and it takes a little longer. And, of course, if your baby has problems – either before or after birth – that timeline could be much longer.

The first few hours after birth

A lot of people were in the delivery room, and there was a lot of activity by your baby’s bedside. Your baby probably started out breathing on his/her own, but over the first few minutes you noticed that his/her chest started caving in with each breath and it sounded like s/he was crying a little bit with every breath. That noise is called “grunting” and it’s an indication that your baby is struggling to breathe. The doctors at your baby’s bedside probably placed a mask over his/her nose and are now blowing air into his/her lungs to help inflate them and relieve the respiratory distress. You only briefly got to see him/her – and maybe got to take pictures – before your new son or daughter was taken to the NICU. Your birthing support person went with your baby – and now it seems like a very long time since s/he’s come back.

In the NICU, the medical team is working to stabilize your baby and help him/her begin making the transition from life inside the womb to outside. Some type of breathing support is likely, from just a small nasal cannula like you may have had during labor all the way to a breathing tube inserted into his/her airway. Even if your obstetrician did a test that predicted your baby’s “lungs were mature,” it’s not uncommon for your baby to still require help breathing. Remember that Nature planned for another 1 ½ - 2 months before your baby was born, and not one organ system in your baby is fully developed! Those steroid shots that you had before birth helped a lot – and your baby would be worse off without them – but they cannot make up for 6 – 8 weeks of in utero development. Your baby will also be receiving some external heat – either from an overhead radiant warmer or already be in an incubator – and will have an intravenous line placed for fluids, nutrition, and medication.

Depending on why your baby was born prematurely, additional studies and/or therapies may be implemented. If the respiratory distress worsens, your baby may receive surfactant through a tube inserted and then removed from his/her airway. If your preterm delivery was unexpected, your baby’s blood will be drawn to look for infection, and antibiotics will be started until the test results are back (typically 2-3 days). If you knew prenatally that your baby had a congenital abnormality, further tests and examinations will be performed – maybe by other subspecialists such as pediatric surgeons or pediatric cardiologists – now that your baby is out in the world for us to examine directly!

You have been brought into the NICU to see your baby as you were moved into your post-partum room. Lots of people are telling you all sorts of things that don’t make a lot of sense and that you can’t remember. And they’re all telling you to starting pumping your breasts, but you don’t have any milk! And you don’t feel very good…..

The end of the first week

If your baby ended up on the breathing machine, this most likely has been removed and now there’s only the device on his/her nose/face that is blowing air into his/her lungs. That IV catheters may have been replaced with a different kind of catheter called a PICC line or a PCVC (see FAQ’s for further information), or the doctors may be trying to “get by” with just a peripheral IV line for the next several days. But it’s already been changed out every day and you hate to see your baby stuck so many times…. This is where intravenous nutrition and medications are being delivered, but your doctors are hopeful that your baby won’t need them for too much longer. You were probably asked about breastfeeding and, if you said yes, you have been pumping regularly. Finally you’re starting to get enough milk that you can collect it. Your baby is likely receiving small amounts of your breastmilk – or another specialized feeding substance – through a tube into his/her tummy. S/he may actually be taking some amounts from a bottle or nuzzling at your breast but, as volumes increase, s/he will tire out and won’t be able to take the full amount by him/herself. Your baby has lost weight this first week, but your doctors say that’s a good thing, and s/he may actually be starting to gain small amounts. Things seem to be pretty good, and you start to relax a bit.

Second week of life (DOL 8 – 14)

By the second week of life, your baby may be off of positive pressure ventilation (CPAP) and may only have a nasal cannula in place – or may be breathing entirely independently! S/he may have been started on caffeine for apnea of prematurity – but, hopefully, this medication will be stopped before s/he goes home. You are holding him/her every time you visit, and even starting to help take temperatures, bathe, and even feed him/her!

Feeds should be increasing in volume into your baby’s tummy and less into his/her veins. Probably, there’s a feeding tube in his/her nose that goes into the stomach, and s/he may actually be taking less volumes by bottle than last week. But that’s normal, so don’t be concerned! S/he should be gaining weight daily now, and may actually be back to birthweight by now. Your baby probably remains under some heat source – either an incubator or a radiant warmer.

Approaching one month in the NICU

If things have gone well, your baby is very close to going home!!!! S/he is now feeding entirely into his/her tummy, may no longer need any sort of help breathing, and the caffeine may have been stopped. S/he may still be having drops in heart rate (“bradys”) and or oxygen levels (“desats”) – especially when feeding, but they’re getting less frequent. You may be helping with lots of the baby care, s/he is gaining weight gain steadily. (Don’t forget to chronicle your baby’s journey, and chart his/her growth, in My NICU.) Your baby is probably feeding on a cocktail of breastmilk with additives to provide the nutrients normally provided by the placenta during the 3rd trimester. (If you’re having some trouble keeping your supply of breastmilk up, see “Breastfeeding” for helpful tips. ) If you’re not breastfeeding, your baby is receiving a formula specially formulated for premature infants that provides the necessary calories, protein, and minerals for good growth. S/he may have moved to another spot in the NICU, sometimes called the “convalescent” nursery or “special care” nursery.

At this point, you may learn that your baby is having an eye examination! Babies born below 32 weeks, and sometimes later based on birthweight, may be at risk for developing premature eye disease, called retinopathy of prematurity (ROP). This is a condition that, if untreated, can cause blindness in premature infants. The American Academy of Pediatrics, along pediatric ophthalmologists, has published recommendations for eye examinations in premature infants to look for ROP and treat, if necessary . ROP is treatable, and your baby may undergo one or more eye examinations by a pediatric ophthalmologist to look for the early signs.

Now is when it gets really hard. Why can’t you take your baby home? All s/he really needs to do is eat better, and, if only the nurses would try more often, your baby would get it. Your NICU team understands you are impatient. Everyone wants your baby to get home the moment s/he is ready – not one moment later, but not one moment sooner, either. (See “When Can I Take My Baby Home?) A baby without complications will be ready for discharge home when s/he can do all the things a term baby can do. These skills come through brain development, not by practice. Nature says it takes 266 days from conception for a baby to fully develop – that’s how your due date was determined. For babies born prematurely, our hope is that development occurs at the same rate as if the pregnancy had continued. We can slow it down, but we can’t do too much to speed it up. Some babies are ready for discharge as early as 36 – 37 weeks PMA, but we can’t predict which ones. Keep your due date in mind as your target for discharge, and keep an open dialogue with your neonatologists about discharge plans.