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Shades of Gray: Managing Delivery at the Edge of Viability

Summary and Comment |
April 22, 2014

Shades of Gray: Managing Delivery at the Edge of Viability

  1. Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BC

A joint workshop on obstetric and neonatal practices provides viewpoints and recommendations.

  1. Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BC

The management and counseling of women at risk for delivering fetuses of periviable gestational age (defined as 20 0/7 weeks through 25 6/7 weeks) is multifaceted. Fetal survival rates range from 0% at 20 weeks to >50% at 25 weeks. Preferably, periviable births should occur in tertiary care centers with maternal-fetal medicine and neonatal intensive care services.

A recent workshop involving specialists in maternal-fetal medicine and perinatal pediatrics encompassed several issues regarding periviable delivery. Key recommendations for obstetric interventions by gestational age are as follows:

<22 0/7 weeks

  • Not recommended: Corticosteroids, tocolytics, magnesium sulfate for neuroprotection, antibiotics for group B streptococcus (GBS) prophylaxis, electronic fetal monitoring, cesarean delivery

  • Consider if delivery not imminent: Antibiotics for premature rupture of membranes (PROM)

22 0/7 to 22 6/7 weeks

  • Not recommended: Magnesium sulfate, GBS prophylaxis, electronic fetal monitoring, cesarean delivery

  • Not recommended unless corticosteroids are given concurrently: Tocolytics

  • Consider if anticipating delivery at ≥23 0/7 weeks: Corticosteroids

  • Consider if delivery not imminent: Antibiotics for PROM

≥23 0/7 weeks

  • Recommended: Corticosteroids, magnesium sulfate, antibiotics for PROM if delivery not imminent, GBS prophylaxis, electronic fetal monitoring, cesarean delivery

  • Consider: Tocolytics

Aggressive neonatal resuscitation is not recommended before 22 0/7 weeks (provide only palliative care), not recommended between 22 0/7 and 22 6/7 weeks (unless the fetus is potentially viable), and recommended after 23 0/7 weeks (unless the fetus is nonviable). Family counseling should provide unbiased information, recognize local regulations, allow shared decision-making, and offer compassionate support.

Comment

This interdisciplinary workshop has put forth suggestions (especially in the triage setting) for clinical decision-making during the periviable period, a complex and critical time. For many providers, aggressive obstetric and neonatal intervention as early as 23 0/7 weeks represents a departure from current practice. Along with these procedural recommendations, detailed suggestions are provided for counseling to determine and promote the best interests of each family and to guide the clinician at every step. The suggestion that clinicians be aware of local standards and regulations is important; in particular, these recommendations should not supersede definitions of fetal viability as they relate to policies for pregnancy termination.

Editor Disclosures at Time of Publication

  • Disclosures for Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BC at time of publication Editorial boards Journal of Perinatal and Neonatal Nursing

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