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

Executive summary:

1. This Framework has been developed by a multidisciplinary working group in the light of evidence of improving outcomes for babies born before 27 completed weeks of gestation, and evolving national and international changes in the approach to their care.
2. Management of labour, birth and the immediate neonatal period should reflect the wishes and values of the mother and her partner, informed and supported by consultation and in partnership with obstetric and neonatal professionals.
3. Whenever possible extreme preterm birth should be managed in a maternity facility co-located with a designated neonatal intensive care unit (NICU).
4. Neonatal stabilisation may be considered for babies born from 22+0 weeks of gestation following assessment of risk and multiprofessional discussion with parents. It is not appropriate to attempt to resuscitate babies born before 22+0 weeks of gestation.
5. Decision making for babies born before 27 weeks of gestation should not be based on gestational age alone, but on assessment of the baby’s prognosis taking into account multiple factors. Decisions should be made with input from obstetric and neonatal teams in the relevant referral centre if transfer is being contemplated.
6. Risk assessment should be performed with the aim of stratifying the risk of a poor outcome into three groups: extremely high risk, high risk, and moderate risk.
7. For fetuses/babies at extremely high risk, palliative (comfort focused) care would be the usual management.
8. For fetuses/babies at high risk of poor outcome, the decision to provide either active (survival focused) management or palliative care should be based primarily on the wishes of the parents.
9. For fetuses/babies at moderate risk, active management should be planned.
10. If life-sustaining treatment for the baby is anticipated, pregnancy and delivery should be managed with the aim of optimising the baby’s condition at birth and subsequently.
11. Conversations with parents should be clearly documented and care taken to ensure that the agreed management plan is communicated between professionals and staff shifts.
12. Decisions and management should be regularly reviewed before and after birth in conjunction with the parents; plans may be reconsidered if the risk for the fetus/baby changes, or if parental wishes change.