Management of babies born extremely preterm at less than 26 weeks of gestation: a framework for clinical practice at the time of birth
- Andrew R Wilkinson1,
- Jag Ahluwalia1,
- Andy Cole2,
- Doreen Crawford3,
- Janet Fyle4,
- Ann Gordon5,
- James Moorcraft1,
- Tina Pollard6,
- Tony Roberts7
- 1BAPM, London, UK
- 2BLISS, London, UK
- 3RCN, London, UK
- 4RCM, London, UK
- 5RCPCH, London, UK
- 6NNA, London, UK
- 7RCOG, London, UK
- Professor Andrew R Wilkinson, University of Oxford, Department of Paediatrics, Neonatal Unit, Women’s Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK;
- Accepted 9 September 2008
- Published Online First 6 October 2008
Management of the delivery of an extremely preterm baby is one of the most challenging aspects of perinatal medicine. The ethical, social, economic and legal issues have recently been reviewed by the Nuffield Council on Bioethics.1 The professions and advocates for parents were encouraged to consider the pattern of care appropriate for babies born before 26 weeks’ gestation on the basis of the best information currently available. There are limitations to contemporary evidence, particularly in terms of predicting outcome after the shortest of pregnancies. While recognising these limitations, and although every pregnancy is different, some general principles can be described.
This is not a set of instructions, but a framework to highlight the range of evidence and opinion that needs to be considered by staff and parents. Care of the mother, her fetus and the baby will always need to be individualised and should be led by senior staff in all disciplines. The parents’ hopes and expectations need to be explored with honesty and compassion in a realistic way, drawing upon the available evidence. Communication and agreed plans must be documented in full and signed legibly. These plans may need to be revised frequently.
When it appears that a mother will deliver her baby at a very early gestational age, there is important clinical information that needs to be carefully reviewed. Accurate information will greatly assist the dialogue and inform the decisions made. Whenever possible antenatal management decisions should involve both of the parents and the clinical staff who will be responsible before and after the delivery.
The obstetric history and antenatal care must be considered carefully, with particular attention to the ultrasound dating scan(s). The earlier this has been carried out the more accurately the gestational age will be known.2 Other information about fetal growth or abnormalities may be available from the scan(s). The best estimation of gestational age should be agreed with the parents. A record of the discussion must be made and revised according to any changes in condition of the fetus or mother.
Discussion with the parents must include information about the expected outcome based on the best available local and national population data. Care must be taken in interpreting local hospital statistics which, at very low gestational ages, will be based on small numbers even in the largest centres.
The practicalities of starting, withholding and withdrawing intensive care and the positive role of palliative care where appropriate should be described to the parents. This will help to prepare them for the different possible outcomes after delivery.
Parents may find the advice and support of their family, friends and spiritual advisers to be of great value at this time.
Assessment of the local neonatal unit staffing and capabilities must be made. Transfer to another hospital, increasingly likely within a managed clinical network, should be discussed if this is clinically appropriate. Written information that includes this possibility should be given to all parents at the time of booking.
If time allows, the parents should be offered the opportunity to visit the neonatal unit.
Box 1 Factors to be taken into account when discussing management with parents
Antenatal factors influencing fetal outcome
Predicted fetal weight
Presence and severity of pathology
Fetal growth restriction
Fetal acidaemia (as suggested by an abnormal cardiotocograph or umbilical artery Doppler flow velocity waveform (particularly absent or reversed end diastolic frequencies))
Past obstetric history
Previous pregnancy loss
Understanding of process
In utero transfers
Condition of infant at delivery
Spontaneous activity level
Respiratory effort and signs of sustained response to resuscitation
On the basis of the best assessment of gestational age, as well as information about the well-being of the fetus and the wishes of the parents, a clear plan for delivery and care of the baby must be made and documented. This will need to be reviewed regularly (fig 1).
Discussion about the mode of delivery should include an explanation of the maternal morbidity in future pregnancies associated with a classical caesarean section when carried out at very early gestational age. However, this may be necessary for maternal indications.
If active obstetric intervention in the interests of the fetus is not planned, continuous monitoring of the fetal heart rate is not advised. However, the parents should be made aware that their baby may show signs of life for a variable time after birth, and intermittent assessment of the fetus by a Doppler device or auscultation is useful to the professionals responsible at the time of birth.
RESUSCITATION AT BIRTH
Preterm labour often progresses rapidly. In these circumstances, there may be insufficient time to hold a detailed discussion with the parents before the baby is born. A decision about resuscitation may need to be made on the basis of the most recent management plan, if any, and the available clinical information. When lung inflation with a mask is an appropriate initial approach, this should be carried out as described in the Newborn Life Support course handbook.3
A FRAMEWORK FOR CLINICAL PRACTICE
This was developed on the basis of consensus and the most recent evidence available.
(A) Less than 23+0 weeks
If gestational age is certain and less than 23+0 (ie, 22 weeks), it would be considered in the best interests of the baby, and standard practice, for resuscitation not to be carried out. If the parents wish, they should have the opportunity to discuss outcomes with a second senior member of the perinatal team.
In the EPICure study of all babies born in 1995 in the UK and Eire at <26 weeks’ gestational age, only two babies reported on at <23 weeks survived to discharge and one has severe disability (table 1).4
In the EPICure 2 study (2006), survival remains extremely rare at this gestational age, with a high incidence of early major morbidity in the few who are discharged home.7
(B) 23+0–23+6 weeks
If gestational age is certain at 23+0–23+6 (ie, 23 weeks) and the fetal heart is heard during labour, a professional experienced in resuscitation should be available to attend the birth. In the best interests of the baby, a decision not to start resuscitation is an appropriate approach, particularly if the parents have expressed this wish. However, if resuscitation is started with lung inflation using a mask, the response of the heart rate will be critical in deciding whether to continue or to stop and sensitively explain to the parents the futility of further interventions.
The EPICure study (1995) reported in 2000 that, at 23 weeks, 121/241 (50%) of live born babies were admitted for intensive care, of whom 105 (80%) died in hospital.4 Twenty-six babies were discharged home, one died and 14 (54%) have a moderate or severe disability at 6 years of age (table 1).5
Early findings in the EPICure 2 study (2006) show that, at this gestational age, survival has not increased significantly and there has been no change in early major morbidity.7
(C) 24+0–24+6 weeks
If gestational age is certain at 24+0–24+6 weeks, resuscitation should be started unless the parents and clinicians have considered that the baby will be born severely compromised. However, the response of the heart rate to lung inflation using a mask will be critical in deciding whether to proceed to intensive care. If the baby is assessed to be more immature than expected, deciding not to start resuscitation may be considered in the best interest of the baby.
In the 1995 study,4 although 313/382 (78%) of babies born at this gestational age (313) were given intensive care, 198 (66%) died.3 Half of the survivors (52) have a moderate or severe disability at 6 years of age (table 1).6
Early findings in the EPICure 2 study (2006) show that, at this gestational age, survival has increased significantly by 12%. More babies were treated for retinopathy of prematurity, but there is no evidence of any change in other early major morbidity.7
(D) 25 weeks and greater
When gestational age is 25+0 weeks or more, survival is now considerably greater than in 1995. It is appropriate to resuscitate babies at this gestation and, if the response is encouraging, to start intensive care.
In 2006, survival had increased significantly from 54% to 67%, but there is no evidence of any change in early major morbidity.5
(E) Uncertain gestational age
If gestational age is uncertain (ie, no dating ultrasound scan) but thought to be ⩾23+0 weeks, an ultrasound scan by an experienced sonographer should be carried out if time permits. If the fetal heart is heard during labour, a professional experienced in resuscitation and another clinician (neonatal nurse or trainee paediatrician) should be called to attend the birth. A decision should then be made, in the best interests of the baby, as to whether resuscitation should begin with mask ventilation. Once begun, the response of the heart rate to lung inflation will be crucial in judging how long to continue resuscitation. If there is any uncertainty about management, guidance from more senior staff should be sought urgently.
The response of the baby to mask ventilation is critical in deciding whether to start intensive care. If the heart rate increases rapidly and the colour improves, appropriate ventilatory support, including intubation and surfactant therapy, should be given, and the baby transferred to the neonatal unit for further assessment.
There is no evidence to support the use of epinephrine by any route, or chest compressions, during resuscitation at gestational age <26 weeks.8
Management should be decided by doctors and nurses experienced in neonatal intensive care.
WITHHOLDING OR WITHDRAWING RESUSCITATION OR INTENSIVE CARE
When resuscitation or intensive care is withheld or withdrawn, the baby should be given all the care needed for his/her comfort and the parents encouraged by appropriate staff to hold and spend time with their baby, if they wish, in a quiet and private location. Further recommendations can be found in a Royal College of Paediatrics and Child Health monograph on withholding or withdrawing life-sustaining treatment.9
When a baby dies, the parents should be offered bereavement counselling, including advice about post-mortem examination. At an appropriate time, the prognosis for future pregnancies should also be discussed.
BAPM would like to thank those members of the Working Group from other organisations who made such valuable contributions to this report. The Working Group thanks all those who commented on earlier drafts and those who responded during the consultation period, particularly all the members and executive committee of BAPM. The Group is also grateful for the additional comments made by Malcolm Chiswick, Kate Costeloe, Alison Leaf and Edile Murdoch from BAPM and Stephen Robson from RCOG.
Report of a Working Group of the British Association of Perinatal Medicine
Competing interests: None.
Endorsed by the Executive Committee of the Association.