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.

BEFORE DELIVERY

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 …