23+0 - 23+6 weeks’ gestation
Survival data from the Epicure 2 study demonstrated that 15% of babies born at this gestation in 2006 survived from the onset of labour to the age of 3 years (63/416). Of those admitted to the neonatal care unit 29% survived (63/217). Of the survivors, approximately 50% survived without moderate or severe disability. More recent comparative data on the cohort that survive to admission to the neonate unit (approx 60-70%) suggests that in this group neonatal survival may be higher in 2013 than 2006 (36% survived to discharge) (Santhakumaran et al. 2017).
Therefore, as the prospect for survival without disability is at present limited, obstetric interventions are not routine in the management of these pregnancies, but should be carefully considered by a consultant obstetrician within the context of the individual pregnancy.
After accurately assessing gestation, a complete history including any predisposing risk factors
for preterm delivery should be obtained. A baseline assessment of maternal temperature, BP and pulse, assessment of uterine activity (palpation) and assessment of fetal viability by doptone or USS should be performed.
If history suggestive of preterm labour and regular uterine activity on abdominal palpation proceed to internal examination by registrar on call.
- Perform a sterile speculum examination
- If cervical dilatation cannot be assessed proceed to digital assessment of cervix length and dilatation.
- If active diagnosis of preterm labour is suspected inform the consultant obstetrician on call, admit and discuss in the context of individual case, taking into account maternal and fetal wellbeing ( including estimated fetal weight if available).
- Early discussion between the neonatal/paediatric consultant and the parents, preferably with the obstetrician present, is recommended. The outcomes and issues should be clearly laid out. Decisions should be made as to whether ‘comfort care only’ or for assessment +/- instigation of neonatal intensive care is planned.
- Discussion should include:
- The possible benefits antenatal corticosteroids (efficacy data is lacking for deliveries < 26 weeks gestation, but potential benefit may be extrapolated that seen in deliveries >26 weeks’ gestation). The influence of any fetal comorbidities and of parental views should be included in the decision to administer antenatal steroids or not.
- The option of fetal monitoring for viability but not intervention during labour by intermittent auscultation versus the equally valid option of no monitoring. Intermittent auscultation may however guide the neonatal team’s resuscitation.
- The role of MgSO4 at this gestational age is unproven. The decision to offer this should be made by the Obstetric consultant.
- In-utero transfer from a center which does not have level 3 neonatal care is a complex decision and requires a risk assessment of both maternal and fetal risks by a consultant obstetrician, but should probably be considered if the parents opt for resuscitation +/- intensive care.
- Caesarean section would not be recommended at this gestational age.
- A clear obstetric and neonatal summary of discussions should be documented in the case record.
Costeloe KL et al. Short term outcomes after extreme premature birth in England: comparison of two birth cohorts in1995 and 2006 (the EPICure studies). BMJ 2012:345:e7976.
Santhakumaran s et al. Survival of very preterm infants admitted to neonatal care in England 2008-2014: time trends and regional variation Arch Dis Child Fetal Neonatal Ed 2017;0:F1-F8.