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

Published:April 10, 2014DOI:
      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 infant. 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 (eg, 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.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Campbell D.E.
        • Fleischman A.R.
        Limits of viability: dilemmas, decisions, and decision makers.
        Am J Perinatol. 2001; 18: 117-128
        • American College of Obstetricians and Gynecologists
        Perinatal care at the threshold of viability. ACOG Practice bulletin no. 38.
        Obstet Gynecol. 2002; 100: 617-624
        • MacDonald H.
        • American Academy of Pediatrics. Committee on Fetus and Newborn
        Perinatal care at the threshold of viability.
        Pediatrics. 2002; 110: 1024-1027
        • Batton D.G.
        • Committee on Fetus and Newborn
        Clinical report: antenatal counseling regarding resuscitation at an extremely low gestational age.
        Pediatrics. 2009; 124: 422-427
        • Pignotti M.S.
        The definition of human viability: a historical perspective.
        Acta Paediatr. 2010; 99: 33-36
        • Khan R.A.
        • Burgoyne L.
        • O'Connell M.P.
        • Dempsey E.M.
        Resuscitation at the limits of viability: an Irish perspective.
        Acta Paediatr. 2009; 98: 1456-1460
        • Kollée L.A.
        • Cuttini M.
        • Delmas D.
        • et al.
        Obstetric interventions for babies born before 28 weeks of gestation in Europe: results of the MOSAIC study.
        BJOG. 2009; 116: 1481-1491
        • 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
        • Louis J.M.
        • Ehrenberg H.M.
        • Collin M.F.
        • Mercer B.M.
        Perinatal intervention and neonatal outcomes near the limit of viability.
        Am J Obstet Gynecol. 2004; 191: 1398-1402
        • 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
        • Sanders M.R.
        • Donohue P.K.
        • Oberdorf M.A.
        • Rosenkrantz T.S.
        • Allen M.C.
        Perceptions of the limit of viability: neonatologists' attitudes toward extremely preterm infants.
        J Perinatol. 1995; 15: 494-502
        • Allen M.C.
        • Donohue P.K.
        • Dusman A.E.
        The limit of viability: neonatal outcome of infants born at 22 to 25 weeks' gestation.
        N Engl J Med. 1993; 329: 1597-1601
        • Andrews B.
        • Lagatta J.
        • Chu A.
        • 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
        • Lau C.
        • Ambalavanan N.
        • Chakraborty H.
        • Wingate M.S.
        • Carlo W.A.
        Extremely low birth weight and infant mortality rates in the United States.
        Pediatrics. 2013; 151: 855-860
        • Stoll B.J.
        • Hansen N.I.
        • Bell E.F.
        • et al.
        Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network.
        Pediatrics. 2010; 126: 443-456
        • De Jesus L.C.
        • Pappas A.
        • Shankaran S.
        • et al.
        Risk factors for post-neonatal intensive care unit discharge mortality among extremely low birth weight infants.
        J Pediatr. 2012; 161 (e1-2): 70-74
        • Salihu H.M.
        • Emusu D.
        • Aliyu Z.Y.
        • Kirby R.S.
        • Alexander G.R.
        Survival of “pre-viable” infants in the United States.
        Wien Klin Wochenschr. 2005; 117: 324-332
        • Hoekstra R.E.
        • Ferrara T.B.
        • Couser R.J.
        • Payne N.R.
        • Connett J.E.
        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
        • Kamath B.D.
        • Box T.L.
        • Simpson M.
        • Hernández J.A.
        Infants born at the threshold of viability in relation to neonatal mortality: Colorado, 1991 to 2003.
        J Perinatol. 2008; 28: 354-360
        • Iams J.D.
        • Mercer B.M.
        • 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
        • Donohue P.K.
        • Boss R.D.
        • Shepard J.
        • Graham E.
        • Allen M.C.
        Intervention at the border of viability: perspective over a decade.
        Arch Pediatr Adolesc Med. 2009; 163: 902-906
        • Morse S.B.
        • Wu S.S.
        • 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
        • Mohamed M.A.
        • Nada A.
        • Aly H.
        Day-by-day postnatal survival in very low birth weight infants.
        Pediatrics. 2010; 126: e360-e366
        • 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
        • Tyson J.E.
        • Parikh N.A.
        • Langer J.
        • Green C.
        • Higgins R.D.
        • 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
        • 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
        • 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
        • Kyser K.L.
        • Morriss Jr., F.H.
        • Bell E.F.
        • Klein J.M.
        • Dagle J.M.
        Improving survival of extremely preterm infants born between 22 and 25 weeks of gestation.
        Obstet Gynecol. 2012; 119: 795-800
        • Lee H.C.
        • Green C.
        • Hintz S.R.
        • et al.
        Prediction of death for extremely premature infants in a population-based cohort.
        Pediatrics. 2010; 126: e644-e650
        • Smith P.B.
        • Ambalavanan N.
        • Li L.
        • et al.
        Approach to infants born at 22 to 24 weeks' gestation: relationship to outcomes of more-mature infants.
        Pediatrics. 2012; 129: e1508-e1516
        • Wood N.S.
        • Marlow N.
        • Costeloe K.
        • Gibson A.T.
        • Wilkinson A.R.
        Neurologic and developmental disability after extremely preterm birth; EPICure study group.
        N Engl J Med. 2000; 343: 378-384
        • Marlow N.
        • Wolke D.
        • Bracewell M.A.
        • 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
        • Moore G.P.
        • 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
        • Doyle L.W.
        • Crowther C.A.
        • Middleton P.
        • Marret S.
        • Rouse D.
        Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus.
        Cochrane Database Syst Rev. 2009; 1: CD004661
        • Althuisius S.M.
        • Dekker G.A.
        • Hummel P.
        • van Geijn H.P.
        • 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
        • Daskalakis G.
        • Papantoniou N.
        • Mesogitis S.
        • Antsaklis A.
        Management of cervical insufficiency and bulging fetal membranes.
        Obstet Gynecol. 2006; 107: 221-226
        • Debby A.
        • Sadan O.
        • Glezerman M.
        • Golan A.
        Favorable outcome following emergency second trimester cerclage.
        Int J Gynaecol Obstet. 2007; 96: 16-19
        • Stupin J.H.
        • David M.
        • Siedentopf J.P.
        • Dudenhausen J.W.
        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
        • Gonzales L.W.
        • Ballard P.L.
        • Ertsey R.
        • Williams M.C.
        Glucocorticoids and thyroid hormones stimulate biochemical and morphological differentiation of human fetal lung in organ culture.
        J Clin Endocrinol Metab. 1986; 62: 678-691
        • Carlo W.A.
        • McDonald S.A.
        • Fanaroff A.A.
        • 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
        • 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: 110-114.e1
        • 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
        • 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
        • Costantine M.M.
        • Weiner S.J.
        • 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
        • Alfirevic Z.
        • Milan S.J.
        • Livio S.
        Caesarean section versus vaginal delivery for preterm birth in singletons.
        Cochrane Database Syst Rev. 2013; 9: CD000078
        • Lee H.C.
        • Gould J.B.
        Survival rates and mode of delivery for vertex preterm neonates according to small- or appropriate-for-gestational-age status.
        Pediatrics. 2006; 118: e1836-e1844
        • Costeloe K.L.
        • Hennessy E.M.
        • Haider S.
        • Stacey F.
        • Marlow N.
        • Draper E.S.
        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
        • Wylie B.J.
        • Davidson L.L.
        • Batra M.
        • Reed S.D.
        Method of delivery and neonatal outcome in very low-birthweight vertex-presenting fetuses.
        Am J Obstet Gynecol. 2008; 198: 640.e1-640.e7
        • Reddy U.M.
        • Zhang J.
        • Sun L.
        • Chen Z.
        • Raju T.N.
        • Laughon S.K.
        Neonatal mortality by attempted route of delivery in early preterm birth.
        Am J Obstet Gynecol. 2012; 207: 117.e1-117.e8
        • Chervenak F.A.
        • McCullough L.B.
        • Levene M.I.
        An ethically justified, clinically comprehensive approach to peri-viability: gynaecological, obstetric, perinatal and neonatal dimensions.
        J Obstet Gynaecol. 2007; 27: 3-7
        • Perlman J.M.
        • Wyllie J.
        • Kattwinkel J.
        • 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
        • Wyckoff M.H.
        • Salhab W.A.
        • Heyne R.J.
        • Kendrick D.E.
        • Stoll B.J.
        • Laptook A.R.
        • 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: 239-244.e2
        • Laptook A.R.
        • Salhab W.
        • Bhaskar B.
        • Neonatal Research Network
        Admission temperature of low birth weight infants: predictors and associated morbidities.
        Pediatrics. 2007; 119: e643-e649
        • World Health Organization
        Maternal and newborn health/safe motherhood. thermal protection of the newborn: a practical guide.
        World Health Organization, Geneva (Switzerland)1997
        • Been J.V.
        • Degraeuwe P.L.
        • Kramer B.W.
        • Zimmermann L.J.
        Antenatal steroids and neonatal outcome after chorioamnionitis: a meta-analysis.
        BJOG. 2011; 118: 113-122
        • Eriksson L.
        • Haglund B.
        • Ewald U.
        • Odlind V.
        • Kieler H.
        Short and long-term effects of antenatal corticosteroids assessed in a cohort of 7,827 children born preterm.
        Acta Obstet Gynecol Scand. 2009; 88: 933-938
        • 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
        • Fowlie P.W.
        • Davis P.G.
        • McGuire W.
        Prophylactic intravenous indomethacin for preventing mortality and morbidity in preterm infants.
        Cochrane Database Syst Rev. 2010; 7: CD000174
        • Schmidt B.
        • Davis P.
        • Moddemann D.
        • et al.
        Long-term effects of indomethacin prophylaxis in extremely-low-birth-weight infants.
        N Engl J Med. 2001; 344: 1966-1972
        • Janvier A.
        • Lorenz J.M.
        • Lantos J.D.
        Antenatal counselling for parents facing an extremely preterm birth: limitations of the medical evidence.
        Acta Paediatr. 2012; 101: 800-804