Managing the birth of extremely premature babies involves complex decisions and requires shared decision making between healthcare professionals and parents, says a new scientific opinion paper published today by the Royal College of Obstetricians and Gynaecologists (RCOG).
The Scientific Impact Paper (SIP) looks at the existing evidence base around obstetric management of extremely preterm infants born spontaneously between 23 and 24 weeks of gestation.
SIPs are produced by the Scientific Advisory Committee at the RCOG and are up to date reviews of emerging or controversial scientific issues of relevance to obstetrics and gynaecology.
Viability may be defined as the quality or state of being able to live independently, grow and develop, states the paper. In the UK, the limit of viability has legally remained at 24 weeks due to the poor survival at gestations below this threshold.
The latest EPICure 2 study showed a marked improvement in survival for extremely premature babies of 12%, from 40% to 52%. However, it also showed that there has not been an associated reduction in morbidity with no change in the proportion of survivors with major short term complications such as brain haemorrhage and chronic lung disease.
The paper discusses neonatal survival and the importance of extreme preterm infants being delivered in an obstetric unit with an appropriate level neonatal unit. It also covers prevention of and delaying preterm birth in women, induction of labour, the different interventions for delivery, fetal monitoring during labour, cord clamping, resuscitation and long term outcomes.
Decision making is very complex in relation to babies born between 23-24 weeks and needs to consider a number of factors, states the opinion paper. These include parental wishes, fetal wellbeing, evaluation of gestational age, birth weight, clinical condition at delivery and progress after delivery.
The paper states that it is essential that there is joint working between the obstetrician, midwife and the neonatologist and shared decision making with the parents. This is reinforced by the GMC’s advice on caring for newborns which advises clinicians to work in partnership with parents when considering decisions about their child’s treatment and sharing information with them.
Furthermore, the paper says that discussions with parents should focus on whether survival is possible at the gestational age, the risks of significant disability and maternal and fertility morbidity. Discussions with parents should also take place in advance of the labour when possible so that they are counselled of the likely outcomes.
Dr Anna David, Reader and Honorary Consultant in Obstetrics and Maternal Fetal Medicine at Institute for Women’s Health, University College London and lead author of the paper said:
“Delivery at the threshold of viability can be extremely difficult for all involved. Medical decision making is very complex and needs to carefully consider a number of factors. It is vital that comprehensive information is exchanged with the parents early so that where possible, they are able to make informed choices before the birth. These discussions need to be undertaken with kindness and sensitivity.
“Given the importance of reducing the morbidity associated with extreme prematurity, it is essential that healthcare professionals discuss with the families the likely outcomes for the baby, possible transfer to an appropriate perinatal unit and mode of delivery.”
Dr Sadaf Ghaem-Maghami, Chair of the RCOG Scientific Advisory Committee, added:
“Gestational age is the primary determinant of almost all perinatal outcomes and at the threshold of viability a few days extra in the womb can increase the survival of a baby dramatically.
“This paper explores the available evidence base in the care of women giving birth to extremely preterm infants while recognising that existing studies do not always include extreme prematurity and more research is needed.”
To read the full paper please click here.
The RCOG produces briefings and Q&As for the public based on topical scientific papers written for clinicians. To read our key messages on this paper please click here.
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About new RCOG Scientific Impact Papers
RCOG Scientific Impact Papers are produced by the Scientific Advisory Committee. They are up to date reviews of emerging or controversial scientific issues of relevance to obstetrics and gynaecology, together with the implications for future practice. These documents have been rebranded to raise awareness of the issues in obstetrics and gynaecology discussed in the documents and to more accurately reflect their content and remit of the Committee.