BAPM have published a new Framework for Practice on the Perinatal Management of Extreme Preterm Birth Before 27 Weeks of Gestation.
The purpose of this Framework for Practice is to assist decision-making relating to perinatal care and preterm delivery at 26 weeks and 6 days of gestation or less in the United Kingdom.
When the last BAPM guidance was published in 2008, it indicated that only two out of ten babies born at 23 weeks (more than four months before their due date) and receiving treatment in neonatal intensive care would survive. Since then, advances in neonatal and obstetric care have improved survival rates for the most premature babies. Today, four out of 10 babies born at 23 weeks and receiving treatment in UK neonatal units are expected to survive.
The framework presents evidence from the UK and internationally and recommends a risk-based approach (graded from extremely high risk to moderate) to clinical decision making for babies born between 22 and 27 weeks of gestation.
It says that while overall outcomes are improving, the prognosis remains guarded for extremely premature babies. According to evidence presented in the framework, seven out of 10 babies born alive at 22 weeks die despite intensive medical treatment. Babies born at the upper end of the extremely premature period have much better outcomes – eight out of 10 babies born alive at 26 weeks now survive.
The framework also notes that for the most premature babies the evidence base is relatively limited, and the outlook depends on many factors. Some premature infants are at extremely high risk of dying even with the best medical care.
Dr Helen Mactier, President of the British Association of Perinatal Medicine and Consultant Neonatologist at the Princess Royal Maternity in Glasgow chaired the BAPM working group which considered evidence and current practice. She said the updated guidance “aligns recommended clinical practice with the most up-to-date science, ensuring that advice to parents is consultative, consistent and evidence-based”.
“We’ve got better at keeping extremely premature babies alive and we know clinicians are increasingly willing to consider survival-focused care for the most extremely premature babies. We have a responsibility to offer the best possible care to the baby and consistent advice and guidance to worried parents. Sometimes this will mean that the mother should be moved before birth to a maternity care centre alongside a neonatal intensive care unit,” said Dr Mactier.
Dominic Wilkinson, Professor of Medical Ethics at the University of Oxford and Consultant Neonatologist at John Radcliffe Hospital, Oxford said, “decisions around the care of tiny infants are some of the most difficult that parents or doctors ever have to face”.
“It is possible, in 2019, to save babies who could not previously have survived. That is fantastic news. But the very high risks mean that it is not always the right thing to do to provide intensive medical treatment. Sometimes the best and wisest path is to take a palliative approach to the baby’s care, focused on the baby’s comfort and avoiding invasive medical treatment.”
“These complex decisions can’t be reduced to simple rules. They need support from specialists in new-born care and obstetrics. Decisions need to reflect the evidence as well as a baby’s individual circumstances and, crucially, the views of parents,” said Professor Wilkinson.
Mr Edward Morris, Vice President for Clinical Quality and President Elect of the Royal College of Obstetricians and Gynaecologists (RCOG), said:
“We are pleased to have collaborated on the development of this comprehensive and multidisciplinary framework for improving the care of babies born before 27 weeks gestation. This framework is aligned with national and international changes to care and recommends a risk-based approach as well as joint decision making between parents and healthcare professionals.
“The RCOG is committed to tackling premature birth - our recently launched three-year programme of work with Tommys will involve the creation of a digital tool to personalise and improve maternity care for women. This will support the Government’s objectives to reduce stillbirth and premature birth across the country.”
The framework was developed in collaboration with Bliss, BMFMS, MBRRACE-UK, the NNA, RCOG, RCPCH and Sands.