This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well-documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the publisher.
Women have the right and responsibility to make informed decisions about their care in partnership with their health care providers. To facilitate informed choice, women should be provided with information and support that are evidence based, culturally appropriate, and tailored to their needs. The values, beliefs, and individual needs of each woman and her family should be sought and the final decision about the care and treatment options chosen by the woman should be respected.
As technology and medical interventions have evolved, the lower limits of GA at which newborns are considered viable have shifted. With increased provision of active resuscitative measures to infants born at lower GAs, obstetric interventions remain a key component in ensuring that these very fragile infants have the best chance of intact survival. The borderline of viability is classically defined as the period between 22+0 and 25+6 weeks. Most centres will advocate for active intervention beyond 25+0 weeks, and few will offer active intervention at 22+0 weeks. The period of ambiguity of intervention is greatest prior to and including 24+6 weeks. The lower limit of viability is constantly changing. The role of active obstetric intervention in the outcome of the neonates at borderline viability requires increased discussion and research. This document aims at providing guidance for these difficult cases.
According to Canadian data from level 3 centres, neonates at 23+0 to 24+6 weeks constitute about 2% of admissions to NICUs. In the 2015 annual report of the Canadian Neonatal Network,1 75% and 94% of 23-week and 24-week neonates, respectively, received active management. This was an increase from 2013,2 when 46% and 67% of the 23-week and 24-week neonates, respectively, received active management. In 2015, the Canadian Neonatal Network reported that 53% of 23-week neonates and 75% of 24-week neonates survived to discharge from the level 3 NICU. It is unclear from these data what obstetric circumstances and interventions preceded the delivery and what impact these circumstances may have had on neonatal survival.
Because of this lack of differentiation in outcomes based on care provision prior to delivery, and because we know that these interventions may confer a survival benefit, the outcome of database findings should be interpreted with caution. Indeed, as more obstetric interventions are offered, an increase in survival has been seen in database studies examining outcomes in this population.3 At present, there is a paucity of research on outcomes of infants born after mothers received active obstetric management. The impact of administration of ACS for enhanced lung maturity, MgS04 for neuroprotection, and mode of delivery on survival on the long-term outcomes of the neonate at borderline viability remains unanswered in the current literature, and although the gaps are being filled by ongoing research, guidelines are necessary to help direct clinical care during this time of rapid change.
The intention of this guideline is to help practitioners in counselling families to make an informed decision about obstetric management relating to the planned resuscitation of their child and to allow clinicians to optimize this management to allow for the best maternal and neonatal outcome when active management is offered and full resuscitation is intended. The present survival of an infant born prior to 23+0 weeks is uncommon but is increasing as more interventions are offered.1, 2 It should be noted that the lower limit of 23+0 weeks discussed in this guideline may change as technology and interventions evolve. Ultimately, decisions around management in the periviable stage should be made through discussions between families and their care providers.
The guidance provided in this document should be used in conjunction with that of pediatric and neonatal expert groups. A full multidisciplinary team, including maternal-fetal medicine specialists, obstetricians, neonatologists, perinatal nursing, midwifery, and family practice, should be involved in the counselling of women and families making decisions about their potential extremely preterm birth. The development of local guidelines may facilitate this informed consent process.4