Management of the woman with threatened birth of an infant of extremely low gestational age. Fetus and Newborn Committee, Canadian Paediatric Society, Maternal-Fetal Medicine Committee, Society of Obstetricians and Gynaecologists of Canada.
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OBJECTIVE: To offer guidelines for parents, physicians and other members of the health-care team for management of the probable birth of an infant with a gestational age of 26 completed weeks or less. OPTIONS: Vaginal birth or birth by cesarean section for fetal indications and active treatment or palliative care of the infant at birth. OUTCOMES: Increased risk of complications for the mother from cesarean section at this stage of pregnancy and the difficulty in making a prognosis before or at birth for an infant of this gestational age. EVIDENCE: Published survival rates and risks of impairment or disability for infants of each gestational age; current information provided by directors of follow-up clinics in Canadian university-based pediatric programs. VALUES: The recommended management of the woman and her fetus or infant is based on many underlying considerations, including the best interests of the mother and her infant and the views of fully informed parents. BENEFITS, HARMS AND COSTS: Use of these guidelines will enable health care providers to offer parents of infants of extremely low gestational age therapeutic choices before birth based on full information on likely outcomes, to avoid unnecessary cesarean section and to minimize suffering when treatment of infants is not in their best interests. RECOMMENDATIONS: According to current Canadian outcome data, fetuses with a gestational age of less than 22 completed weeks are not viable and those with an age of 22 weeks rarely viable. Their mothers are not, therefore, candidates for cesarean section, and the newborns should be provided with compassionate care, rather than active treatment. The outcomes for infants with a gestational age of 23 to 24 completed weeks vary greatly. Careful consideration should be given to the limited benefits for the infant and potential harms of cesarean section, as well as to the expected results of resuscitation at birth. Cesarean section, when indicated, and any required neonatal treatment are recommended for infants with gestational ages of 25 and 26 completed weeks; most infants of this age will survive, and most survivors will not be severely disabled. Treatment of all infants with a gestational age of 22 to 26 weeks should be tailored to the infant and family and should involve fully informed parents. VALIDATION: Members of the Fetus and Newborn Committee of the Canadian Paediatric Society (CPS) were involved in the preparation of this article, which was reviewed and modified by the Ethics Committee of the CPS and the Maternal-Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC). A draft was circulated to Canadian university-based perinatal programs and members of the Section on Neonatal-Perinatal Medicine of the CPS. Comments from physicians and bioethicists were incorporated, when possible, into the final version. There are no similar guidelines in North America.