1. The limits of viability: A national consensus document
Malcolm Battin*

2. Survival Inborn Babies by Birth Weight
Cambridge – vent cohort (green>1kg)
Cambridge
< 1kg & vent cohorts
UCH London UK

3. Perinatal care at the borderlines of viability: consensus workshop
Grey Zone between 230 and 256 weeks
Parental wishes
Condition at birth & anomalies
Withdraw of intensive care in grey zone is influenced by neurological complications
Med J Aust ;185(9):

4. Perinatal care at the borderlines of viability: consensus workshop
Grey Zone between 230 and 256 weeks
Parental wishes
Condition at birth & anomalies
Withdraw of intensive care in grey zone is influenced by neurological complications
Med J Aust ;185(9):

5. Survival of admitted infants
Author
Date published
Site
Total
Livebirths
22 weeks
23 weeks
De Waal (2012)
Netherlands
345 -
EPIPAGE 1 (2004)
France
Markstad (2005)
Norway
182
26%
Field (2008)
Trent
669
18%
Bolisetty (2004)
NSW & ACT
355
50%
EPIBEL (2005)
Belgium
525 6%
EPICure (1995)
England
811 9%
20%
EPICure (2012)
2034
16%
30%
EXPRESS (2009)
Sweden
501
10%
53%
Itibashi (2009)
Japan
1303
34%
54%

6. ACR 2015 – A Gill commentry

7. Thoughts from the famous …
“To understand God's thoughts we must study [the] statistics, for these are the measure of his purpose.”
Florence Nightingale

8. Survival of 24 Week Infants
Clear difference in the survival of extreme prems between outborn and inborn infants which is reflected in the perception of the staff
Overall perception is that 24 weekers have poor survival rates (more so if born outside a tertiary centre) Note the optimistic outlier from the tertiary centre!
Midwives tend to be the most optimistic
Boland ANZJOG 2016

9. Counselling Survival Relevant local data Population data Vs individual
Births Vs NICU admissions
Appropriate for clinical situation
Population data Vs individual

10. ANZNN survival to discharge (2016)

11. Prediction of individual outcome
Congenital anomalies
Antenatal steroids
Sex
Optimal growth
Multiple gestation
Infection or asphyxia
Condition at birth ?
Apgar scores?

13. Counselling Survival Quality of survival Relevant local data
Births Vs NICU admissions
Appropriate for clinical situation
Population data Vs individual
Quality of survival
Short term morbidity
Long term morbidity

14. ANZNN data: IVH

15. ANZNN 2010-2013 Neurodevelopmental outcomes
<24 24 25 26 27
> = 28
CP (%)
11.2
12.5
8.3
7.0
3.6
4.0
No cognitive delay (%)
70.7
80.4
84.6
86.3
87.8
87.9
No language delay (%)
61.3
64.0
69.4
75.0 77
71.4
No motor delay (%)
71.8
74.2
78.9
85.8
82.8
Severe functional deficit (%)
11.4
7.5
5.6
5.2
3.2
3.5

16. National Guideline Informed by good quality data
Starting point of quality care
Ensure babies transferred appropriately & timely
Equity of access
Facilitate good counselling by experts
Clear plan across multidisciplinary groups
Include parental wishes

17. National Guideline

18. National Guideline

20. Who was involved ?
Paediatric Society & Perinatal Society of New Zealand
RACP (Paediatrics) & RANZCOG
NZCOM & College of Nurses Aotearoa
New Zealand Maternal Fetal Medicine Network
University of Otago Bioethics Centre
Consumer groups - Sands & Neonatal Trust
Feedback from:
New Zealand College of General Practitioners
National Maternity Monitoring Group & PMMRC
TeOra Māori Medical Practitioner Association
Maternity Quality and Safety Consumer Committee
Health and Disability Commissioner

21. Communication Support people Trained interpreter Ensure privacy
Acknowledge cultural & religious beliefs
Experienced O&G, Paediatrics, M/W
Check list and clearly document decisions

22. Shared decision making
Review all information
Consider individual circumstances
GA, estimated weight, multiple gestation, anomalies, infection, maternal factors
< 23/40 active support not recommended
≥ 23+0/40 intervention dependent on individual circumstances

23. Decision Support

24. Comfort / Palliative care
Consistent with family/whanau wishes
Take time and review plan as needed
Pain and symptom management
Avoid unnecessary interventions
Counsel regarding signs of life
Facilitate memory creation
Provide cultural / spiritual support

26. Practice point
Considering active transfer from 22+5 wks allows time for:
antenatal corticosteroids
magnesium sulphate infusion
arrival at tertiary centre prior 23+0 wks
Decision to provide active NICU care can be reviewed if situation or family wishes change

28. Standardized approach
An opportunity to develop formal 23/24 week bundle of care:
Surfactant & ventilation strategies
Skin care
PDA management, fluid balance and TPN
Strategies on prevention of infection and NEC e.g. fungal prophylaxis, probiotics, lactoferrin
Breast milk bank

29. Final points
A comprehensive strategy for care < 24 wks will potentially have benefit > 24 weeks
Opportunity to develop bundle of care
Implementation strategy for document
Need for ongoing education
Approach based on current evidence
Interdisciplinary communication important