Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • State of the Art
  • Published:

State-of-the-Art

Periviable birth: executive summary of a Joint Workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists

Journal of Perinatology volume 34, pages 333–342 (2014)Cite this article

Subjects

Abstract

This is an executive summary of a workshop on the management and counseling issues of women anticipated to deliver at a periviable gestation (broadly defined as 20 0/7 through 25 6/7 weeks of gestation), and the treatment options for the newborn. Upon review of the available literature, the workshop panel noted that the rates of neonatal survival and neurodevelopmental disabilities among the survivors vary greatly across the periviable gestations and are significantly influenced by the obstetric and neonatal management practices (for example, antenatal steroid, tocolytic agents and antibiotic administration; cesarean birth; and local protocols for perinatal care, neonatal resuscitation and intensive care support). These are, in turn, influenced by the variations in local and regional definitions of limits of viability. Because of the complexities in making difficult management decisions, obstetric and neonatal teams should confer prior to meeting with the family, when feasible. Family counseling should be coordinated with the goal of creating mutual trust, respect and understanding, and should incorporate evidence-based counseling methods. Since clinical circumstances can change rapidly with increasing gestational age, counseling should include discussion of the benefits and risks of various maternal and neonatal interventions at the time of counseling. There should be a plan for follow-up counseling as clinical circumstances evolve. The panel proposed a research agenda and recommended developing educational curricula on the care and counseling of families facing the birth of a periviable infant.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

References

  1. Campbell DE, Fleischman AR . Limits of viability: dilemmas, decisions, and decision makers. Am J Perinatol 2001; 18: 117–128.

    Article  CAS  PubMed  Google Scholar 

  2. Perinatal care at the threshold of viability. ACOG Practice Bulletin No. 38. American College of Obstetricians and Gynecologists. Obstet Gynecol 2002; 100: 617–624.

    Google Scholar 

  3. MacDonald H American Academy of Pediatrics. Committee on Fetus and Newborn. Perinatal care at the threshold of viability. Pediatrics 2002; 110: 1024–1027.

    Article  PubMed  Google Scholar 

  4. Batton DG, Committee on Fetus and Newborn. Clinical report—antenatal counseling regarding resuscitation at an extremely low gestational age. Pediatrics 2009; 124: 422–427.

    Article  PubMed  Google Scholar 

  5. Pignotti MS . The definition of human viability: a historical perspective. Acta Paediatr 2010; 99: 33–36.

    CAS  PubMed  Google Scholar 

  6. Khan RA, Burgoyne L, O’Connell MP, Dempsey EM . Resuscitation at the limits of viability—an Irish perspective. Acta Paediatr 2009; 98: 1456–1460.

    Article  CAS  PubMed  Google Scholar 

  7. Kollée LA, Cuttini M, Delmas D, Papiernik E, den Ouden AL, Agostino R et al. MOSAIC Research group. Obstetric interventions for babies born before 28 weeks of gestation in Europe: results of the MOSAIC study. BJOG 2009; 116: 1481–1491.

    Article  PubMed  Google Scholar 

  8. Zecca E, de Luca D, Costa S, Marras M, de Turris P, Romagnoli C . Delivery room strategies and outcomes in preterm infants with gestational age 24–28 weeks. J Matern Fetal Neonatal Med 2006; 19: 569–574.

    Article  PubMed  Google Scholar 

  9. Louis JM, Ehrenberg HM, Collin MF, Mercer BM . Perinatal intervention and neonatal outcomes near the limit of viability. Am J Obstet Gynecol 2004; 191: 1398–1402.

    Article  PubMed  Google Scholar 

  10. Verlato G, Gobber D, Drago D, Chiandetti L, Drigo P ; Working Group of Intensive Care in the Delivery Room of Extremely Premature Newborns. Guidelines for resuscitation in the delivery room of extremely preterm infants. J Child Neurol 2004; 19: 31–34.

    Article  PubMed  Google Scholar 

  11. Sanders MR, Donohue PK, Oberdorf MA, Rosenkrantz TS, Allen MC . Perceptions of the limit of viability: neonatologists’ attitudes toward extremely preterm infants. J Perinatol 1995; 15: 494–502.

    CAS  PubMed  Google Scholar 

  12. Allen MC, Donohue PK, Dusman AE . The limit of viability—neonatal outcome of infants born at 22 to 25 weeks’ gestation. N Engl J Med 1993; 329: 1597–1601.

    Article  CAS  PubMed  Google Scholar 

  13. Andrews B, Lagatta J, Chu A, Plesha-Troyke S, Schreiber M, Lantos J et al. The nonimpact of gestational age on neurodevelopmental outcome for ventilated survivors born at 23–28 weeks of gestation. Acta Paediatr 2012; 101: 574–578.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Lau C, Ambalavanan N, Chakraborty H, Wingate MS, Carlo WA . Extremely low birth weight and infant mortality rates in the United States. Pediatrics 2013; 151: 855–860.

    Article  Google Scholar 

  15. Stoll BJ, Hansen NI, Bell EF, Shankaran S, Laptook AR, Walsh MC et al. Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics 2010; 126: 443–456.

    Article  PubMed  Google Scholar 

  16. De Jesus LC, Pappas A, Shankaran S, Kendrick D, Das A, Higgins RD et al. Risk factors for post-neonatal intensive care unit discharge mortality among extremely low birth weight infants. J Pediatr 2012; 161: 70–74 e1–2.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Salihu HM, Emusu D, Aliyu ZY, Kirby RS, Alexander GR . Survival of ‘pre-viable’ infants in the United States. Wien Klin Wochenschr 2005; 117: 324–332.

    Article  PubMed  Google Scholar 

  18. Hoekstra RE, Ferrara TB, Couser RJ, Payne NR, Connett JE . Survival and long-term neurodevelopmental outcome of extremely premature infants born at 23–26 weeks’ gestational age at a tertiary center. Pediatrics 2004; 113: e1–e6.

    Article  PubMed  Google Scholar 

  19. Kamath BD, Box TL, Simpson M, Hernández JA . Infants born at the threshold of viability in relation to neonatal mortality: Colorado, 1991 to 2003. J Perinatol 2008; 28: 354–360.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Iams JD, Mercer BM ; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. What we have learned about antenatal prediction of neonatal morbidity and mortality. Semin Perinatol 2003; 27: 247–252.

    Article  PubMed  Google Scholar 

  21. Donohue PK, Boss RD, Shepard J, Graham E, Allen MC . Intervention at the border of viability: perspective over a decade. Arch Pediatr Adolesc Med 2009; 163: 902–906.

    Article  PubMed  Google Scholar 

  22. Morse SB, Wu SS, Ma C, Ariet M, Resnick M, Roth J . Racial and gender differences in the viability of extremely low birth weight infants: a population-based study. Pediatrics 2006; 117: e106–e112.

    Article  PubMed  Google Scholar 

  23. Mohamed MA, Nada A, Aly H . Day-by-day postnatal survival in very low birth weight infants. Pediatrics 2010; 126: e360–e366.

    Article  PubMed  Google Scholar 

  24. Petrova A, Mehta R, Anwar M, Hiatt M, Hegyi T . Impact of race and ethnicity on the outcome of preterm infants below 32 weeks gestation. J Perinatol 2003; 23: 404–408.

    Article  PubMed  Google Scholar 

  25. Tyson JE, Parikh NA, Langer J, Green C, Higgins RD, National Institute of Child Health and Human Development Neonatal Research Network. Intensive care for extreme prematurity—moving beyond gestational age. N Engl J Med 2008; 358: 1672–1681.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Batton B, Burnett C, Verhulst S, Batton D . Extremely preterm infant mortality rates and cesarean deliveries in the United States. Obstet Gynecol 2011; 118: 43–48.

    Article  PubMed  Google Scholar 

  27. Mehler K, Grimme J, Abele J, Huenseler C, Roth B, Kribs A . Outcome of extremely low gestational age newborns after introduction of a revised protocol to assist preterm infants in their transition to extrauterine life. Acta Paediatr 2012; 101: 1232–1239.

    Article  PubMed  Google Scholar 

  28. Kyser KL, Morriss FH Jr, Bell EF, Klein JM, Dagle JM . Improving survival of extremely preterm infants born between 22 and 25 weeks of gestation. Obstet Gynecol 2012; 119: 795–800.

    Article  PubMed  Google Scholar 

  29. Lee HC, Green C, Hintz SR, Tyson JE, Parikh NA, Langer J et al. Prediction of death for extremely premature infants in a population-based cohort. Pediatrics 2010; 126: e644–e650.

    Article  PubMed  Google Scholar 

  30. Smith PB, Ambalavanan N, Li L, Cotten CM, Laughon M, Walsh MC et al. Approach to infants born at 22 to 24 weeks’ gestation: relationship to outcomes of more-mature infants. Pediatrics 2012; 129: e1508–e1516.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Wood NS, Marlow N, Costeloe K, Gibson AT, Wilkinson AR . EPICure Study Group Neurologic and developmental disability after extremely preterm birth. N Engl J Med 2000; 343: 378–384.

    Article  CAS  PubMed  Google Scholar 

  32. Marlow N, Wolke D, Bracewell MA, Samara M EPICure Study Group. Neurologic and developmental disability at six years of age after extremely preterm birth. N Engl J Med 2005; 352: 9–19.

    Article  CAS  PubMed  Google Scholar 

  33. Moore GP, Lemyre B, Barrowman N, Daboval T . Neurodevelopmental outcomes at 4 to 8 years of children born at 22 to 25 weeks’ gestational age. a meta-analysis. JAMA Pediatr 2013; 167: 967–974.

    Article  PubMed  Google Scholar 

  34. Doyle LW, Crowther CA, Middleton P, Marret S, Rouse D . Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus. The Cochrane Database of Systematic Reviews 2009 Issue 1. Art. No CD004661 doi:10.1002/14651858.CD004661.pub3.

  35. Althuisius SM, Dekker GA, Hummel P, van Geijn HP, Cervical Incompetence Prevention Randomized Cerclage Trial. Cervical incompetence prevention randomized cerclage trial: emergency cerclage with bed rest versus bed rest alone. Am J Obstet Gynecol 2003; 189: 907–910.

    Article  PubMed  Google Scholar 

  36. Daskalakis G, Papantoniou N, Mesogitis S, Antsaklis A . Management of cervical insufficiency and bulging fetal membranes. Obstet Gynecol 2006; 107: 221–226.

    Article  PubMed  Google Scholar 

  37. Debby A, Sadan O, Glezerman M, Golan A . Favorable outcome following emergency second trimester cerclage. Int J Gynaecol Obstet 2007; 96: 16–19.

    Article  CAS  PubMed  Google Scholar 

  38. Stupin JH, David M, Siedentopf JP, Dudenhausen JW . Emergency cerclage versus bed rest for amniotic sac prolapse before 27 gestational weeks. A retrospective, comparative study of 161 women. Eur J Obstet Gynecol Reprod Biol 2008; 139: 32–37.

    Article  PubMed  Google Scholar 

  39. Gonzales LW, Ballard PL, Ertsey R, Williams MC . Glucocorticoids and thyroid hormones stimulate biochemical and morphological differentiation of human fetal lung in organ culture. J Clin Endocrinol Metab 1986; 62: 678–691.

    Article  CAS  PubMed  Google Scholar 

  40. Carlo WA, McDonald SA, Fanaroff AA, Vohr BR, Stoll BJ, Ehrenkranz RA et al. Association of antenatal corticosteroids with mortality and neurodevelopmental outcomes among infants born at 22 to 25 weeks’ gestation. JAMA 2011; 306: 2348–2358.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Mori R, Kusuda S, Fujimura M, Neonatal Research Network Japan. Antenatal corticosteroids promote survival of extremely preterm infants born at 22 to 23 weeks of gestation. J Pediatr 2011; 159 (110–14): e1.

    Google Scholar 

  42. Chawla S, Natarajan G, Rane S, Thomas R, Cortez J, Lua J . Outcomes of extremely low birth weight infants with varying doses and intervals of antenatal steroid exposure. J Perinat Med 2010; 38: 419–423.

    Article  PubMed  Google Scholar 

  43. Chawla S, Bapat R, Pappas A, Bara R, Zidan M, Natarajan G . Neurodevelopmental outcome of extremely premature infants exposed to incomplete, no or complete antenatal steroids. J Matern Fetal Neonatal Med 2013; 26: 1542–1547.

    Article  PubMed  Google Scholar 

  44. Costantine MM, Weiner SJ Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Effects of antenatal exposure to magnesium sulfate on neuroprotection and mortality in preterm infants: a meta-analysis. Obstet Gynecol 2009; 114: 354–364.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Alfirevic Z, Milan SJ, Livio S . Caesarean section versus vaginal delivery for preterm birth in singletons. The Cochrane Database of Systematic Reviews 2013 Issue 9. Art CD000078. doi:10.1002/14651858.cd000078.pub3.

  46. Lee HC, Gould JB . Survival rates and mode of delivery for vertex preterm neonates according to small- or appropriate-for-gestational-age status. Pediatrics 2006; 118: e1836–e1844.

    Article  PubMed  Google Scholar 

  47. Costeloe KL, Hennessy EM, Haider S, Stacey F, Marlow N, Draper ES . Short term outcomes after extreme preterm birth in England: comparison of two birth cohorts in 1995 and 2006 (the EPICure studies). BMJ 2012; 345: e7976.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Wylie BJ, Davidson LL, Batra M, Reed SD . Method of delivery and neonatal outcome in very low-birthweight vertex-presenting fetuses. Am J Obstet Gynecol 2008; 198 (640): e1–e7.

    Google Scholar 

  49. Reddy UM, Zhang J, Sun L, Chen Z, Raju TN, Laughon SK . Neonatal mortality by attempted route of delivery in early preterm birth. Am J Obstet Gynecol 2012; 207 (117): e1–e8.

    Google Scholar 

  50. Chervenak FA, McCullough LB, Levene MI . An ethically justified, clinically comprehensive approach to peri-viability: gynaecological, obstetric, perinatal and neonatal dimensions. J Obstet Gynaecol 2007; 27: 3–7.

    Article  CAS  PubMed  Google Scholar 

  51. Perlman JM, Wyllie J, Kattwinkel J, Atkins DL, Chameides L, Goldsmith JP et al. Part 11: neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2010; 122: S516–S538.

    Article  PubMed  Google Scholar 

  52. Wyckoff MH, Salhab WA, Heyne RJ, Kendrick DE, Stoll BJ, Laptook AR, National Institute of Child Health and Human Development Neonatal Research Network. Outcome of extremely low birth weight infants who received delivery room cardiopulmonary resuscitation. J Pediatr 2012; 160 (239–44): e2.

    Google Scholar 

  53. Laptook AR, Salhab W, Bhaskar B Neonatal Research Network. Admission temperature of low birth weight infants: predictors and associated morbidities. Pediatrics 2007; 119: e643–e649.

    Article  PubMed  Google Scholar 

  54. World Health Organization, Maternal and Newborn Health/Safe Motherhood. Thermal Protection of the Newborn: a Practical Guide . World Health Organization: Geneva, Switzerland, 1997.

  55. Been JV, Degraeuwe PL, Kramer BW, Zimmermann LJ . Antenatal steroids and neonatal outcome after chorioamnionitis: a meta-analysis. BJOG 2011; 118: 113–122.

    Article  CAS  PubMed  Google Scholar 

  56. Eriksson L, Haglund B, Ewald U, Odlind V, Kieler H . Short and long-term effects of antenatal corticosteroids assessed in a cohort of 7827 children born preterm. Acta Obstet Gynecol Scand 2009; 88: 933–938.

    Article  CAS  PubMed  Google Scholar 

  57. Abbasi S, Oxford C, Gerdes J, Sehdev H, Ludmir J . Antenatal corticosteroids prior to 24 weeks’ gestation and neonatal outcome of extremely low birth weight infants. Am J Perinatol 2010; 27: 61–66.

    Article  PubMed  Google Scholar 

  58. Fowlie PW, Davis PG, McGuire W . Prophylactic intravenous indomethacin for preventing mortality and morbidity in preterm infants. The Cochrane Database of Systematic Reviews 2010 Issue 7. Art No. CD000174. doi:10.1002/14651858.CD000174.pub2.

  59. Schmidt B, Davis P, Moddemann D, Ohlsson A, Roberts RS, Saigal S et al. Long-term effects of indomethacin prophylaxis in extremely-low-birth-weight infants. N Engl J Med 2001; 344: 1966–1972.

    Article  CAS  PubMed  Google Scholar 

  60. Janvier A, Lorenz JM, Lantos JD . Antenatal counselling for parents facing an extremely preterm birth: limitations of the medical evidence. Acta Paediatr 2012; 101: 800–804.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA,

    T N K Raju

  2. The Society for Maternal-Fetal Medicine and Case Western Reserve University–MetroHealth Medical Center, Cleveland, OH, USA,

    B M Mercer

  3. The American Academy of Pediatrics and University of Florida, Gainesville, FL, USA,

    D J Burchfield

  4. The American College of Obstetricians and Gynecologists, Washington, DC, USA,

    G F Joseph

Authors
  1. T N K Raju
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. B M Mercer
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. D J Burchfield
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. G F Joseph
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to B M Mercer.

Ethics declarations

Competing interests

The authors declare no conflict of interest.

Additional information

This is an executive summary of a Society for Maternal-Fetal Medicine, Eunice Kennedy Shriver National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists and American Academy of Pediatricians Workshop that was held 12–13 February 2013 in San Francisco, CA, USA. This article is being published concurrently in the May 2014 issue (vol. 123, no. 5) of Obstetrics & Gynecology and the May 2014 issue (vol. 210, no. 5) of the American Journal of Obstetrics and Gynecology.

DISCLAIMER

The information and guidance herein reflect consensus regarding clinical and scientific advances as of the Workshop, is subject to change, and should not be construed as dictating an exclusive course of treatment or procedure. The information and guidance provided does not necessarily represent the official views of the National Institutes of Health, Society for Maternal-Fetal Medicine, National Institute of Child Health and Human Development, the American College of Obstetricians and Gynecologists, or the American Academy of Pediatricians, or the views of each individual participant in the Workshop. For a list of organizers, invited speakers, and discussants who participated in the workshop, see the Appendix online at http://links.lww.com/AOG/A483.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Raju, T., Mercer, B., Burchfield, D. et al. Periviable birth: executive summary of a Joint Workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists. J Perinatol 34, 333–342 (2014). https://doi.org/10.1038/jp.2014.70

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/jp.2014.70

This article is cited by

Search

Advanced search

Quick links