The American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM) released their third joint consensus statement last month, this one addresses care during the periviability period – between 20 weeks and 25 weeks 6 days gestation. These infants require life saving interventions immediately after birth for survival. Recent research shows that treatment and outcomes have varied across hospitals for these very premature infants. This new consensus statement provides guidelines for treatment and decision making for newborn care in the case of periviable birth to increase consistency in care across the U.S. and improve care providers’ ability to predict outcomes in these cases.
The Obstetric Care Consensus on Periviable Birth recommends:
● Transfer to a hospital with advanced levels of neonatal or maternal care before birth when appropriate and feasible.
● Practitioners consider multiple variables that may affect survival and outcomes for the newborn when counseling parents. This recommendation applies to counseling before and after birth on both short-term and long-term outcomes.
● Counseling for the family from a multidisciplinary team including maternity care providers and neonatologists with follow-up counseling when new information is available about the mother or baby’s condition.
● In counseling patients, providers should talk to parents about their goals, specifically whether they wish to optimize survival or minimize suffering.
● Create a predelivery plan with the family and adjust it as additional information becomes available. A stepped approach should be used for care and interventions that is harmonious with the infant’s condition and the parents’ wishes. The specific situation should direct what interventions are offered and conducted including resuscitation.
● Specific interventions based on the clinical situation and family preferences.
The impacts of interventions on the mother’s health should also be considered, the authors note. Periviable infants are more likely to be born via cesarean using a vertical incision which presents risks for future pregnancies. The statement notes that even cesarean birth using a low transverse incision for periviable birth has a greater risk of uterine rupture in subsequent pregnancies.
This document also addresses “individualized compassionate care” for the infant in cases where the decision is made not to offer resuscitation saying, “A decision not to undertake resuscitation of a liveborn infant should not be seen as a decision to provide no care, but rather a decision to redirect care to comfort measures.” Compassionate care recommendations include minimizing discomfort, keeping the baby warm and allowing the family as much time with their infant as they wish.
The new recommendations are a result of research conducted at 19 neonatal intensive care centers to develop a tool to better predict outcomes for infants born during the previable period. The tool, developed by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network uses birth weight, gestational age, sex, plurality and exposure to antenatal corticosteroids rather than previous methods which relied on gestational age and birth weight alone. The use of additional clinical data should allow for more accurate prediction of outcomes and help care providers and families better determine the appropriate care and interventions in periviable births.
For those doulas with particular interest in periviable birth, the Obstetric Care Consensus statement details the research findings including survival rates, morbidity rates and the variation in care for periviable birth, particularly those occurring before 25 weeks gestation. Detailed recommendations for care providers regarding how to counsel families on their options are also included.
-Adrianne Gordon, CD(DONA), MBA