Cayman is a wonderful place to have a baby and raise children. Compared to coal-mining Barnsley, where I grew up, the environment is conducive to a healthy pregnancy and a genuinely lovely childhood experience. However, like anywhere, complications do occur and it’s important to consider them from a Cayman perspective. Dr. Sara Watkin, Neonatal and Paediatric Specialist at Integra Healthcare
It’s an Island
We have very good facilities in Cayman, with an excellent neonatal unit for preterm and newborn complications, located within George Town Hospital. However, it’s important to always keep in mind that we are a small Island, more than an hour’s flying time from a major children’s hospital.
A big part of ensuring safety is making choices and taking precautions with our island in mind. Some complications of birth can occur with no warning in an otherwise healthy pregnancy but we are often forewarned too about pregnancies likely to give rise to complications. We are lucky that the two main hospitals for deliveries, Cayman Islands Hospital and CTMH Doctors Hospital, are very close to each other but at the same time, if we know of likely complications, we will often advise on the best location to ensure the greatest likelihood of a safe delivery. For instance, preterm deliveries frequently result in breathing difficulties at birth and a stay in the NICU. If a preterm delivery is likely, we would ideally want that delivery to be in Cayman Islands Hospital where the NICU is located.
Another choice is mode of delivery. While there can be specific reasons why a caesarean section may be a safer choice e.g. when the baby has not turned properly, generally, a normal vaginal delivery is best for the baby and leads to fewer complications. Babies born by elective caesarean section are more likely to have breathing problems, sometimes leading to admission to the neonatal unit for immediate care. Good obstetricians want to support natural birth wherever possible, unless there is a good reason to choose otherwise.
Finally, there is the choice of when to deliver. Mostly that’s nature’s choice, but it is understandable that after nine months of waiting, you want the special day to arrive. The chances of complications rise the earlier the delivery is before your due date. Even at 38 weeks, there is a significantly higher chance of complications than at 40 weeks, which rises further if labour has not started and a caesarean section is performed for no medical reason. Not long after I moved to Cayman, I cared for a baby over a number of weeks, providing complex care for significant respiratory problems, which is obviously costly too, arising after an elective delivery by caesarean section before 39 weeks. Patience, and close monitoring by your obstetrician, is generally the best approach.
I like to split these into three main types:
1. Lack of oxygen (asphyxia) before, during or after birth
2. Complications of immaturity
3. Other complications e.g. genetic problems
1. Lack of oxygen (asphyxia) before, during or after birth
The most serious birth complication is that of asphyxia, which can occur, for example, if there are problems with the placenta or if the umbilical cord gets kinked or wrapped around baby’s neck. It can be life-threatening and even those surviving can have severe brain damage. While thankfully it is rare, it tends to happen in the moment, with no warning. Time is of the essence and good outcomes tend to occur when the right specialist support, including some complex techniques like brain cooling (therapeutic hypothermia), is provided immediately. I was Chief of Service in a world-renowned brain-cooling centre and we would aim to start treatment within minutes of birth. In the UK, it was rare to have a paediatrician present at birth but that’s because in most places there is a neonatal team just minutes down the corridor. Here our facilities are more limited and consequently an experienced neonatal paediatrician is far more frequently present at births.
Lots of good things happen to babies in the final weeks of gestation. In particular, their lungs mature at a fast rate in preparation for independent life in the big wide world. Needless to say, being born too soon interrupts that process, frequently leading to breathing and oxygenation difficulties. Infants born prematurely are also more susceptible to infection and experience feeding difficulties at a time when they need good nutrition for growth and maturation. All of these problems increase in frequency the earlier a baby is born.
It is possible for a baby to survive from about 23 weeks onwards. However, at this very early stage, it will require round the clock intensive care, lots of specialist support and even then, there is a significant chance of long term problems such as learning difficulties. For every week closer to term, the outcome gets better and the complications reduce.
In Cayman, I have supported a number of 23 and 24-week deliveries where it has not been possible to transfer the mother off-Island before the birth. However, the round-the-clock nature of care means that at this stage we try to get them in good shape and then transfer them to a big centre such as Miami or Fort Lauderdale. We are fortunate to have tertiary-standard nursing and medical support at George Town Hospital but the rarity of these babies means we cannot carry enough staff and equipment to tend to all their needs. In London, I had a team of specialist neonatologists and 200+ neonatal nurses on the rota.
Here, we tend to care for babies of 27 weeks or greater gestation. These infants still require lots of specialist support and a fairly long stay in our neonatal unit, as well as periods of ventilation and lots of close monitoring. Our outcomes, considering our small size, really are world class and something to be proud of.
3. Other problems
Sometimes babies have problems that have occurred during pregnancy or even as a result of a genetic issue. Nowadays, the monitoring and tests conducted by obstetricians identify these problems ahead of delivery and that allows the obstetrician and paediatrician to plan any necessary support or interventions ahead of time. Sometimes these babies do need to be delivered by caesarean section and transferred to the neonatal unit. However, the planned nature means you will have this explained to you if it occurs.
There are a number of different conditions but each individual one tends to be very rare. Sometimes they are difficult to spot before birth and thus it is important to ensure your baby has its baby checks and engages in a schedule of well-child checks to help pick up on things.
Sense of Perspective
It’s only natural when reading an article on complications to end up worrying about them. You want things to go well, obviously. It is important to understand that the majority of births here are wonderful experiences, leading to new, happy, healthy lives. Many of the things I have discussed here are not unique to Cayman and can occur anywhere. If you want to know more about any of these things, at any stage, ask a neonatologist or paediatrician. You’ll be thinking about who before birth anyway and most will be glad to meet with you as soon as you are ready to discuss having a baby here.
More About Dr. Watkin
Dr. Sara Watkin MB ChB, MRCP (paeds), FRCPCH, MD is a tertiary neonatal and paediatric specialist, with 25 years’ service as a consultant, including as Chief of Service at University College London Hospital, a world-class tertiary centre for babies from 23 week’s gestation onwards and with complex paediatric and neonatal challenges. She is highly qualified and experienced in supporting children from their earliest preterm and term days right through to early adulthood.