Periviable Birth

Abstract

This is an executive summary of a workshop on the management and counseling issues of women anticipated to deliver at a periviable gestation (broadly defined as 20 0/7 through 25 6/7 weeks of gestation), and the treatment options for the newborn. Upon review of the available literature, the workshop panel noted that the rates of neonatal survival and neurodevelopmental disabilities among the survivors vary greatly across the periviable gestations and are significantly influenced by the obstetric and neonatal management practices (eg, antenatal steroid, tocolytic agents, and antibiotic administration; cesarean birth; and local protocols for perinatal care, neonatal resuscitation, and intensive care support). These are, in turn, influenced by the variations in local and regional definitions of limits of viability. Because of the complexities in making difficult management decisions, obstetric and neonatal teams should confer prior to meeting with the family, when feasible. Family counseling should be coordinated with the goal of creating mutual trust, respect, and understanding and should incorporate evidence-based counseling methods. Since clinical circumstances can change rapidly with increasing gestational age, counseling should include discussion of the benefits and risks of various maternal and neonatal interventions at the time of counseling. There should be a plan for follow-up counseling as clinical circumstances evolve. The panel proposed a research agenda and recommended developing educational curricula on the care and counseling of families facing the birth of a periviable infant.

Between-Hospital Variation in Treatment and Outcomes in Extremely Preterm Infants

“…1,2 Clinicians recognize that in some cases, the infant is too immature for treatment to be effective, whereas in other cases, treatment is clearly indicated. Yet, in many cases, it is unclear whether treatment is in the infant’s best interest.…”

“…2,7–12 Active intervention for infants born before 22 weeks of gestation is generally not recommended, whereas the approach for infants born at or after 22 weeks of gestation varies. In the United States, both the American Academy of Pediatrics (AAP) and the American Congress of Obstetricians and Gynecologists (ACOG) recommend that clinicians and families make individualized decisions about treating extremely preterm infants on the basis of parental preference and the most recent data available regarding survival and morbidity.…”

“…2 To investigate this possibility and its implications, we analyzed data collected for infants who were born at hospitals included in the NICHD Neonatal Research Network (NRN) to identify variation in hospital rates of active treatment and the relationship between active treatment and outcomes at 18 to 22 months of corrected age.…”

Short interpregnancy interval increases the risk of preterm premature rupture of membranes and early delivery

“…As our definitions for periviability and viability are evolving, delivery in this time frame involves complex decision making for patients and providers [10,11]. The inherent morbidity and mortality to the periviable neonate are apparent [12,13]; however, the implications to maternal reproductive health, particularly related to classical cesarean delivery (CD), are important considerations and require thoughtful deliberation.…”

Timing of umbilical cord clamping among infants born at 22 through 27 weeks’ gestation

“…Not all institutions, practitioners or parents would be comfortable with this level of intervention among neonates born at 22 and 23 weeks' gestations, especially when long-term outcomes among infants born at limits of viability are difficult to predict. 43 …”