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Perinatal management of extreme preterm birth before 27 weeks of gestation: a framework for practice
  1. Helen Mactier1,
  2. Sarah Elizabeth Bates2,
  3. Tracey Johnston3,
  4. Caroline Lee-Davey4,
  5. Neil Marlow5,
  6. Kate Mulley6,
  7. Lucy K Smith7,
  8. Meekai To8,
  9. Dominic Wilkinson9
  10. BAPM Working Group
    1. 1 Neonatology, Princess Royal Maternity, Glasgow, UK
    2. 2 Women and Children’s, Great Western Hospitals NHS Foundation Trust, Swindon, UK
    3. 3 Department of Fetal and Maternal Medicine, Birmingham Women and Children’s NHS Foundation Trust, Birmingham, UK
    4. 4 Bliss, London, UK
    5. 5 Institute for Women’s Health, University College London, London, UK
    6. 6 Sands, London, UK
    7. 7 Health Sciences, University of Leicester, Leicester, UK
    8. 8 King’s College Hospital NHS Trust, London, UK
    9. 9 Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
    1. Correspondence to Dr Helen Mactier, Neonatology, Princess Royal Maternity, Glasgow G31 2ER, UK; Helen.Mactier{at}glasgow.ac.uk

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    Executive summary

    • 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.

    • 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.

    • Whenever possible, extreme preterm birth should be managed in a maternity facility co-located with a designated neonatal intensive care unit.

    • 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.

    • 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.

    • 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.

    • For fetuses/babies at extremely high risk, palliative (comfort focused) care would be the usual management.

    • 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.

    • For fetuses/babies at moderate risk, active management should be planned.

    • 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.

    • Conversations with parents should be clearly documented and care taken …

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    Footnotes

    • Twitter @HMactier, @SarahBates18, @carolinemdavey, @NeonatalEthics

    • Collaborators British Association of Perinatal Medicine Working Group: Erica Everett, Tara Selman. British Association of Perinatal Medicine in conjunction with the Royal College of Obstetricians and Gynaecologists, the Royal College of Paediatrics and Child Health, the British Maternal and Fetal Medicine Society, MBRRACE-UK, Bliss and Sands.

    • Contributors All of the authors attended at least one Working Group meeting and contributed to the writing and editing of the Framework for Practice. HM: chaired the Working Group and wrote the first and all subsequent drafts of the article. Approved the final version. SEB: contributed significantly to the drafting of the article and appendices and subsequent edits, and approved the final manuscript. TJ: contributed to the drafting of the article and subsequent edits, and approved the final manuscript. CL-D: contributed to the drafting of the article and appendices and approved the final manuscript. NM: contributed significantly to the drafting of the article and appendices and subsequent edits, compiled the figures and approved the final manuscript. KM: contributed to the drafting of the article and appendices and subsequent edits, and approved the final manuscript. LKS: contributed to the drafting of the article and appendices and subsequent edits, compiled the tables and approved the final manuscript. MT: contributed to the drafting of the article and subsequent edits, and approved the final manuscript. DW: contributed significantly to the drafting of the article and appendices and subsequent edits, compiled the figures and approved the final manuscript.

    • Funding BAPM supported preparation of this document by funding travelling expenses for Working Group members.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; internally peer reviewed.

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