Antenatal Counseling Regarding Resuscitation and Intensive Care Before 25 Weeks of Gestation

Abstract

The anticipated birth of an extremely low gestational age (<25 weeks) infant presents many difficult questions, and variations in practice continue to exist. Decisions regarding care of periviable infants should ideally be well informed, ethically sound, consistent within medical teams, and consonant with the parents’ wishes. Each health care institution should consider having policies and procedures for antenatal counseling in these situations. Family counseling may be aided by the use of visual materials, which should take into consideration the intellectual, cultural, and other characteristics of the family members. Although general recommendations can guide practice, each situation is unique; thus, decision-making should be individualized. In most cases, the approach should be shared decision-making with the family, guided by considering both the likelihood of death or morbidity and the parents’ desires for their unborn child. If a decision is made not to resuscitate, providing comfort care, encouraging family bonding, and palliative care support are appropriate.

Outcomes of infants born at 22–27 weeks' gestation in Victoria according to outborn/inborn birth status

“…Differing attitudes and practices with regard to resuscitation and provision of neonatal intensive care for infants born in the ‘grey zone’ may have played a role 11 12 32. When EPT infants are perceived to have poor survival chances and perinatal interventions, including in utero transfer, are withheld, high mortality risk becomes a self-fulfilling prophecy 10.…”

Shared decision making for infants born at the threshold of viability: a prognosis-based guideline

“…62,63 The American Academy of Pediatrics published their report on antenatal counseling regarding resuscitation and intensive care at o 25 weeks, which emphasizes SDM, with guidance on communication with expectant parents. 64 The Share 'balanced' information including both positive and negative aspects, pros and cons, treatable and not treatable conditions and so on Use different strategies to disclose the outcomes according to parents' preferences: Use grade such as majority, most, significant or some, a minority and so on. Use numbers (for example, 6 out of 10 as opposed to 60%) Use a consistent denominator to present the various options, or outcomes or event rates to make the information easier to understand, compare and be less open to misinterpretation (for example, XX out of 10, 100, 1000, depending on what we're talking about) For example: out of 100 babies like yours, 20 will die, 20 will survive but with NDD and 60 will survive with no NDD.…”

“…11,54,64 SDM is most effective for preference-sensitive decisions, when there is uncertain or no clear evidence supporting one treatment over another, where options have different inherent benefits/risks or when patient values are important in optimizing decision making. SDM has been shown to reduce parental grief after end of life decisions, 66 improve patient satisfaction, 67-69 improve individual's knowledge of their options (including the benefits and harms of those options), assist people in reaching choices that are more consistent with their informed values and foster collaboration with their HCP.…”

Antenatal corticosteroids before 24 weeks: is it time?

“…This discourse includes not only expected outcomes of infants at extremely early gestational ages but also detailed options including (or excluding) treatments and therapies that may impact survival and neurodevelopmental outcome. 4 It is established that administration of antenatal corticosteroids to women who are likely to deliver before 34 weeks' gestation is beneficial. In a 2006 Cochrane review of 21 studies, respiratory distress syndrome, intraventricular hemorrhage (IVH), necrotizing enterocolitis and neonatal mortality were all reduced in infants exposed to maternal administration of antenatal corticosteroids.…”

“…It should be noted that neither the AAP clinical report on counseling parents in the periviable period nor the Joint Workshop executive summary had parents on their working groups (although two neonatologists, recognized as experts in neonatal ethics, who have publically shared their personal NICU experience, were part of the Joint Workshop). 4,9 As others have noted, clinical practice guidelines must be 'led by specialty societies but with a new model that integrates other stakeholders, including patients.' 12…”