Management of Pregnancies at Borderline Viability	Reviewed by Newborn Services Specialists
	October 2007

Antenatal Counselling	Less than 23 weeks	23+0 to 23+6 weeks
24 weeks and more	Survival Rates	Long-term Disability

Antenatal Counselling

Newborn Services provides a counselling service for those parents whose baby is likely to be born extremely preterm or those babies who are likely to need intensive care support (for example, infants with congenital diaphragmatic hernia).
Counselling may be undertaken by a specialist, fellow, registrar, or NS-ANP, depending on the circumstances and gestation of the baby.
Parents will also be provided with a "virtual tour" of NICU and some families will have a guided tour, undertaken by a Nurse Specialist - Family Liaison.
For infants <30 weeks or those babies for whom intensive care (Level 3) support is anticipated:
- Between 8am and 9pm: Call the on-duty or on-call NICU specialist.
- Otherwise, inform the Level 3 registrar or NS-ANP, who will notify the on-call specialist as required.
Please note that referrals should be made by staff who are familiar with the mother's condition and who can provide information that will assist the consultation, such as whether antenatal corticosteriods have been given, the most recent ultrasound scan assessment, and what the obstetric plan is.

Click here to open the guideline on Admission Rates to NICU and the degree of Respiratory Support required.

≤23 weeks 0 days

Standard Practice

Do not refer to National Women’s Health.
No fetal monitoring.
No neonatal attendance at birth.
Obstetric staff will usually provide antenatal counselling regarding outcomes.

23 weeks 0 days to 23 weeks 6 days

Usual Practice	No fetal monitoring and therefore no caesarean section for fetal distress. Consider referral to National Women’s Health. No attendance by neonatal staff.
If parents make a decision for active treatment after informed discussion with neonatal and obstetric specialists	Consider corticosteroids if parents wish for active treatment. Neonatal attendance at birth. If birthweight <500g or gestation appears inappropriate, reconsider treatment plan, especially if the baby is in poor condition.

≥24 weeks 0 days

Standard Practice	Definite referral to National Women’s Health. Antenatal corticosteroids. Fetal monitoring, consider caesarean section for fetal distress. Neonatal attendance at birth. If birthweight <500g or gestation appears inappropriate, reconsider treatment plan, especially if the baby is in poor condition.
At parental discretion	If <26 weeks, parents may - after discussion with a neonatologist - elect for no fetal monitoring, no caesarean section and no neonatal attendance at birth. It is rare not to treat infants born alive at 25 weeks. At 24 weeks, parents may potentially choose non-treatment of their baby. However, most parents will elect for their baby to receive active treatment.

Survival Rates of Extremely Preterm Infants

Survival for preterm infants has been increasing steadily over time. National Women's survival data to 28 days are shown below. These birthweight data are only for liveborn infants at National Women's.

Data collated by Associate Professor Ross Howie and Dr David Knight.

Although birthweight is easy to measure and is an important determinant of survival, gestation is a better predictor of outcome. The gestation-based survival figures for liveborn infants born at National Women's Health are:

The outcomes above include all liveborn infants.

Admission to the neonatal unit results in higher survival rates as this is a more selected group of infants.

For the graphs below, subgroups are shown for gestations 30 weeks and below.

Note that the numbers of infants in some gestational groups (for example, 23 and 24 week infants) or by some analyses (for example, outborn infants) are relatively small.

	Click on the link to the left to look at survival figures for all admissions to NICU for inborn infants at National Women's 1996-2006.
	Click on the link to the left to look at survival figures for all admissions (inborn and outborn) to NICU 1996-2006.
	Click on the link to the left to look at survival figures for outborn infants (infants born in other institutions) admitted to NICU 1996-2006.
	Click on the link to the left to look at overall survival for liveborn infants 24-30 weeks gestation at National Women's Health between 1996 and 2006. Infants born at 23 weeks have been excluded, due to the relatively low numbers of infants.
These data have largely been collected by Dr David Knight as part of ongoing audit for the Annual Report.

Long-Term Outcomes

Disability rates are approximately 20% in extremely low birthweight (<1000g) survivors at any gestation.
- The rate of cerebral palsy is relatively constant at around 10%.
- Severe disability rates are approximately 10%.
- Disability rates are higher in infants below 25 weeks.
- Around 50% of surviving infants at 23 weeks have moderate or severe disability.
- At 24 weeks, approximately 40% of surviving infants have moderate or severe disability.
Disability includes cerebral palsy, developmental delay, visual and hearing impairment.

Management of Pregnancies at Borderline Viability

Antenatal Counselling

≤23 weeks 0 days

Standard Practice

23 weeks 0 days to 23 weeks 6 days

Usual Practice

If parents make a decision for active treatment after informed discussion with neonatal and obstetric specialists

≥24 weeks 0 days

Standard Practice

At parental discretion

Survival Rates of Extremely Preterm Infants

Long-Term Outcomes