increasing medical care by more frequent visits and more education has not been shown to reduce preterm birth rates. use of nutritional supplements such as omega-3 polyunsaturated fatty acids is based on the observation that populations who have a high intake of such agents are at low risk for preterm birth, presumably as these agents inhibit production of proinflammatory cytokines. a randomized trial showed a significant decline in preterm birth rates, and further studies are in the making. antibiotics while antibiotics can get rid of bacterial vaginosis in pregnancy, this does not appear to change the risk of preterm birth. it has been suggested that chronic chorioamnionitis is not sufficiently treated by antibiotics alone (and therefore they cannot ameliorate the need for preterm delivery in this condition). progestogens progestogens—often given in the form of vaginal progesterone or hydroxyprogesterone caproate—relax the uterine musculature, maintain cervical length, and possess anti-inflammatory properties; all of which invoke physiological and anatomical changes considered to be beneficial in reducing preterm birth. two meta-analyses demonstrated a reduction in the risk of preterm birth in women with recurrent preterm birth by 40–55%. progestogen supplementation also reduces the frequency of preterm birth in pregnancies where there is a short cervix. a short cervix is one that is less than 25mm, as detected during a transvaginal cervical length assessment in the midtrimester. however, progestogens are not effective in all populations, as a study involving twin gestations failed to see any benefit. despite extensive research related to progestogen effectiveness, uncertainties remain concerning types of progesterone and routes of administration. cervical cerclage in preparation for childbirth, the woman's cervix shortens. preterm cervical shortening is linked to preterm birth and can be detected by ultrasonography. cervical cerclage is a surgical intervention that places a suture around the cervix to prevent its shortening and widening. numerous studies have been performed to assess the value of cervical cerclage and the procedure appears helpful primarily for women with a short cervix and a history of preterm birth. instead of a prophylactic cerclage, women at risk can be monitored during pregnancy by sonography, and when shortening of the cervix is observed, the cerclage can be performed. treatment preterm birth at 32 weeks 4 days, with a weight of 2,000 g attached to medical equipment tertiary interventions are aimed at women who are about to go into preterm labor, or rupture the membranes or bleed preterm. the use of the fibronectin test and ultrasonography improves the diagnostic accuracy and reduces false-positive diagnosis. while treatments to arrest early labor where there is progressive cervical dilatation and effacement will not be effective to gain sufficient time to allow the fetus to grow and mature further, it may defer delivery sufficiently to allow the mother to be brought to a specialized center that is equipped and staffed to handle preterm deliveries. in a hospital setting women are hydrated via intravenous infusion (as dehydration can lead to premature uterine contractions). if a baby has cardiac arrest at birth and is less than 22 to 24 weeks’ gestational age attempts at resuscitation are not generally indicated. steroids severely premature infants may have underdeveloped lungs because they are not yet producing their own surfactant. this can lead directly to respiratory distress syndrome, also called hyaline membrane disease, in the neonate. to try to reduce the risk of this outcome, pregnant mothers with threatened premature delivery prior to 34 weeks are often administered at least one course of glucocorticoids, an antenatal steroid that crosses the placental barrier and stimulates the production of surfactant in the lungs of the baby. steroid use up to 37 weeks is also recommended by the american congress of obstetricians and gynecologists. typical glucocorticoids that would be administered in this context are betamethasone or dexamethasone, often when the pregnancy has reached viability at 23 weeks. in cases where premature birth is imminent, a second "rescue" course of steroids may be administered 12 to 24 hours before the anticipated birth. there are still some concerns about the efficacy and side effects of a second course of steroids, but the consequences of rds are so severe that a second course is often viewed as worth the risk. a 2015 cochrane review (updated in 2022) supports the use of repeat dose(s) of prenatal corticosteroids for women still at risk of preterm birth seven days or more after an initial course. a cochrane review from 2020 recommends the use of a single course of antenatal corticosteroids to accelerate fetal lung maturation in women at risk of preterm birth. treatment with antenatal corticosteroids reduces the risk of perinatal death, neonatal death and respiratory distress syndrome and probably reduces the risk of ivh. concerns about adverse effects of prenatal corticosteroids include increased risk for maternal infection, difficulty with diabetic control, and possible long-term effects on neurodevelopmental outcomes for the infants. there is ongoing discussion about when steroids should be given (i.e. only antenatally or postnatally too) and for how long (i.e. single course or repeated administration). despite these unknowns, there is a consensus that the benefits of a single course of prenatal glucocorticosteroids vastly outweigh the potential risks. antibiotics the routine administration of antibiotics to all women with threatened preterm labor reduces the risk of the baby to get infected with group b streptococcus and has been shown to reduce related mortality rates. when membranes rupture prematurely, obstetrical management looks for development of labor and signs of infection. prophylactic antibiotic administration has been shown to prolong pregnancy and reduced neonatal morbidity with rupture of membranes at less than 34 weeks. because of concern about necrotizing enterocolitis, amoxicillin or erythromycin has been recommended, but not amoxicillin + clavulanic acid (co-amoxiclav). tocolysis a number of medications may be useful to delay delivery including: nonsteroidal anti-inflammatory drugs, calcium channel blockers, beta mimetics, and atosiban. tocolysis rarely delays delivery beyond 24–48 hours. this delay, however, may be sufficient to allow the pregnant woman to be transferred to a center specialized for management of preterm deliveries and give administered corticosteroids to reduce neonatal organ immaturity. meta-analyses indicate that calcium-channel blockers and an oxytocin antagonist can delay delivery by 2–7 days, and β2-agonist drugs delay by 48 hours but carry more side effects. magnesium sulfate does not appear to be useful to prevent preterm birth. its use before delivery, however, does appear to decrease the risk of cerebral palsy. mode of delivery the routine use of caesarean section for early delivery of infants expected to have very low birth weight is controversial, and a decision concerning the route and time of delivery probably needs to be made on a case-by-case basis. neonatal care incubator for preterm baby in developed countries premature infants are usually cared for in a neonatal intensive care unit (nicu). the physicians who specialize in the care of very sick or premature babies are known as neonatologists. in the nicu, premature babies are kept under radiant warmers or in incubators (also called isolettes), which are bassinets enclosed in plastic with climate control equipment designed to keep them warm and limit their exposure to germs. modern neonatal intensive care involves sophisticated measurement of temperature, respiration, cardiac function, oxygenation, and brain activity. after delivery, plastic wraps or warm mattresses are useful to keep the infant warm on their way to the nicu. treatments may include fluids and nutrition through intravenous catheters, oxygen supplementation, mechanical ventilation support, and medications. in developing countries where advanced equipment and even electricity may not be available or reliable, simple measures such as kangaroo care (skin to skin warming), encouraging breastfeeding, and basic infection control measures can significantly reduce preterm morbidity and mortality. kangaroo mother care (kmc) can decrease the risk of neonatal sepsis, hypothermia, hypoglycemia and increase exclusive breastfeeding. bili lights may also be used to treat newborn jaundice (hyperbilirubinemia). water can be carefully provided to prevent dehydration but not so much to increase risks of side effects. breathing support in terms of respiratory support, there may be little or no difference in the risk of death or chronic lung disease between high flow nasal cannulae (hfnc) and continuous positive airway pressure (cpap) or nasal intermittent positive pressure ventilation (nppv). for extremely preterm babies (born before 28 weeks' gestation), targeting a higher versus a lower oxygen saturation range makes little or no difference overall to the risk of death or major disability. babies born before 32 weeks have been shown to have a lower risk of death from bronchopulmonary dysplasia if they have cpap immediately after being born, compared to receiving either supportive care or assisted ventilation. there is insufficient evidence for or against placing preterm stable twins in the same cot or incubator (co-bedding). nutrition meeting the appropriate nutritional needs of preterm infants is important for long-term health. optimal care may require a balance of meeting nutritional needs and preventing complications related to feeding. the ideal growth rate is not known, however, preterm infants usually require a higher energy intake compared to babies who are born at term. the recommended amount of milk is often prescribed based on approximated nutritional requirements of a similar aged fetus who is not compromised. an immature gastrointestinal tract (gi tract), medical conditions (or co-morbidities), risk of aspirating milk, and necrotizing enterocolitis may lead to difficulties in meeting this high nutritional demand and many preterm infants have nutritional deficits that may result in growth restrictions. in addition, very small preterm infants cannot coordinate sucking, swallowing, and breathing. tolerating a full enteral feeding (the prescribed volume of milk or formula) is a priority in neonatal care as this reduces the risks associated with venous catheters including infection, and may reduce the length of time the infant requires specialized care in the hospital. different strategies can be used to optimize feeding for preterm infants. the type of milk/formula and fortifiers, route of administration (by mouth, tube feeding, venous catheter), timing of feeding, quantity of milk, continuous or intermittent feeding, and managing gastric residuals are all considered by the neonatal care team when optimizing care. the evidence in the form of high quality randomized trials is generally fairly weak in this area, and for this reason different neonatal intensive care units may have different practices and this results in a fairly large variation in practice. the care of preterm infants also varies in different countries and depends on resources that are available. human breast milk and formula the american academy of pediatrics recommended feeding preterm infants human milk, finding "significant short- and long-term beneficial effects," including lower rates of necrotizing enterocolitis (nec). in the absence of evidence from randomised controlled trials about the effects of feeding preterm infants with formula compared with mother's own breast milk, data collected from other types of studies suggest that mother's own breast milk is likely to have advantages over formula in terms of the baby's growth and development. a recent (2019) large review of evidence suggests that feeding preterm infants with formula rather than donor breast milk is associated with faster rates of growth, but with a near‐doubling of the risk of developing nec. fortified human breast milk and preterm/term formula breast milk or formula alone may not be sufficient to meet the nutritional needs of some preterm infants. fortification of breast milk or formula by adding extra nutrients is an approach often taken for feeding preterm infants, with the goal of meeting the high nutritional demand. high quality randomized controlled trials are needed in this field to determine the effectiveness of fortification. it is unclear if fortification of breast milk improves outcomes in preterm babies, though it may speed growth. supplementing human milk with extra protein may increase short-term growth but the longer-term effects on body composition, growth and brain development are uncertain. higher protein formula (between 3 and 4 grams of protein per kilo of body weight) may be more effective than low protein formula (less than 3 grams per kilo per day) for weight gain in formula-fed low-birth-weight infants. there is insufficient evidence about the effect on preterm babies' growth of supplementing human milk with carbohydrate, fat, and branched-chain amino acids. conversely, there is some indication that preterm babies who cannot breastfeed may do better if they are fed only with diluted formula compared to full strength formula but the clinical trial evidence remains uncertain. individualizing the nutrients and quantities used to fortify