Extreme prematurity and perinatal management

Abstract

Key content Perinatal management of pregnant women delivering at the threshold of viability has medical and ethical considerations. It should be preceded by the best advice from a multidisciplinary neonatal and obstetric team to fully inform parents and achieve a consensus on the optimal care for the mother and neonate. Obstetric interventions can affect maternal and neonatal outcomes after birth at the threshold of viability. These include administration of steroids, magnesium sulphate and tocolysis, fetal monitoring in labour and mode of delivery. Obstetric complications such as malpresentation are common and can affect delivery choices at extreme preterm gestational ages. This requires obstetricians to plan carefully with parents before labour starts. Learning objectives To understand how obstetric decisions and interventions can affect maternal and neonatal outcomes when women are at risk of delivery at extreme premature gestational ages. To enable trainee obstetricians to better counsel women and their partners about possible complications before and during labour at extreme preterm gestations. Ethical issues Should we monitor the fetal heart during labour, deliver by caesarean section and resuscitate a baby born at extreme prematurity when short‐term and long‐term neonatal outcomes are likely to be poor?

Perinatal management of extreme preterm birth before 27 weeks of gestation: a framework for practice

“…Survival is highest at these extreme preterm gestations in centres with experienced staff and higher patient numbers. A strategy of antenatal transfer below 27 weeks of gestation for birth in a maternity unit with a co-located NICU is recommended 4 33–37…”

“…When it has been agreed that potentially life-sustaining care for the baby is appropriate, active obstetric management is important to ensure the baby is born in the best possible condition. An individualised package of obstetric intervention should be offered in all cases where a commitment to active neonatal care is in place 4 35. The potential for each component intervention to optimise the condition of the individual baby at birth should be considered and not excluded on the basis of gestational age alone.…”