Antenatal care in uncomplicated pregnancies

European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth.

Objective To determine whether improvements in school age outcomes had occurred between two cohorts of births at 22–25 weeks of gestation to women residents in England in 1995 and 2006. Design Longitudinal national cohort studies. Setting School-based or home-based assessments at 11 years of age. Participants EPICure2 cohort of births at 22–26 weeks of gestation in England during 2006: a sample of 200 of 1031 survivors were evaluated; outcomes for 112 children born at 22–25 weeks of gestation were compared with those of 176 born in England during 1995 from the EPICure cohort. Classroom controls for each group acted as a reference population. Main outcome measures Standardised measures of cognition and academic attainment were combined with parent report of other impairments to estimate overall neurodevelopmental status. Results At 11 years in EPICure2, 18% had severe and 20% moderate impairments. Comparing births at 22–25 weeks in EPICure2 (n=112), 26% had severe and 21% moderate impairment compared with 18% and 32%, respectively, in EPICure. After adjustment, the OR of moderate or severe neurodevelopmental impairment in 2006 compared with 1995 was 0.76 (95% CI 0.45 to 1.31, p=0.32). IQ scores were similar in 1995 (mean 82.7, SD 18.4) and 2006 (81.4, SD 19.2), adjusted difference in mean z-scores 0.2 SD (95% CI −0.2 to 0.6), as were attainment test scores. The use of multiple imputation did not alter these findings. Conclusion Improvements in care and survival between 1995 and 2006 are not paralleled by improved cognitive or educational outcomes or a reduced rate of neurodevelopmental impairment.

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No change in neurodevelopment at 11 years after extremely preterm birth.

Abstract Since the early 1980’s, with the clinical advent of in vitro fertilization resulting in so-called “test tube babies,” a wide array of ethical considerations and concerns regarding artificial womb technology (AWT) have been described. Recent breakthroughs in the development of extracorporeal neonatal life support by means of AWT have reinitiated ethical interest about this topic with a sense of urgency. Most of the recent ethical literature on the topic, however, pertains not to the more imminent scenario of a physiologically improved method of neonatal care through AWT, but instead to the remote scenario of “complete ectogenesis” that imagines human gestation occurring entirely outside of the womb. This scoping review of the ethical literature on AWT spans from more abstract concerns about complete ectogenesis to more immediate concerns about the soon-to-be-expected clinical life support of what we term the fetal neonate or fetonate. Within an organizing framework of different stages of human gestational development, from conception to the viable premature infant, we discuss both already identified and newly emerging ethical considerations and concerns regarding AWT and the care of the fetonate.

https://www.tandfonline.com/doi/pdf/10.1080/15265161.2022.2048738?needAccess=true

Ethics Considerations Regarding Artificial Womb Technology for the Fetonate

The response to the coronavirus outbreak and how the disease and its societal consequences pose risks to already vulnerable groups such those who are socioeconomically disadvantaged and ethnic minority groups. Researchers and community groups analysed how the COVID-19 crisis has exacerbated persisting vulnerabilities, socio-economic and structural disadvantage and discrimination faced by many communities of social disadvantage and ethnic diversity, and discussed future strategies on how best to engage and involve local groups in research to improve outcomes for childbearing women experiencing mental illness and those living in areas of social disadvantage and ethnic diversity. Discussions centred around: access, engagement and quality of care; racism, discrimination and trust; the need for engagement with community stakeholders; and the impact of wider social and economic inequalities. Addressing biomedical factors alone is not sufficient, and integrative and holistic long-term public health strategies that address societal and structural racism and overall disadvantage in society are urgently needed to improve health disparities and can only be implemented in partnership with local communities.

/pdf/addressing-inequities-in-maternal-health-among-women-living-4fmsfb500u.pdf

Addressing inequities in maternal health among women living in communities of social disadvantage and ethnic diversity.

1. This Framework has been developed by a multidisciplinary working group in the light
of evidence of improving outcomes for babies born before 27 completed weeks of
gestation, and evolving national and international changes in the approach to their
care. 2. Management of labour, birth and the immediate neonatal period should reflect
the wishes and values of the mother and her partner, informed and supported by
consultation and in partnership with obstetric and neonatal professionals. 3. Whenever possible, extreme preterm birth should be managed in a maternity facility
co-located with a designated neonatal intensive care unit. 4. Neonatal stabilisation may be considered for babies born from 22+0 weeks of
gestation following assessment of risk and multiprofessional discussion with parents.
It is not appropriate to attempt to resuscitate babies born before 22+0 weeks of
gestation.
5. Decision-making for babies born before 27 weeks of gestation should not be based
on gestational age alone, but on assessment of the baby’s prognosis taking into
account multiple factors. Decisions should be made with input from obstetric and
neonatal teams in the relevant referral centre if transfer is being contemplated. 6. Risk assessment should be performed with the aim of stratifying the risk of a poor
outcome into three groups: extremely high risk, high risk and moderate risk. 7. For fetuses/babies at extremely high risk, palliative (comfort focused) care would be
the usual management. 8. For fetuses/babies at high risk of poor outcome, the decision to provide either active
(survival focused) management or palliative care should be based primarily on the
wishes of the parents. 9. For fetuses/babies at moderate risk, active management should be planned. 10. If life-sustaining treatment for the baby is anticipated, pregnancy and delivery
should be managed with the aim of optimising the baby’s condition at birth and
subsequently. 11. Conversations with parents should be clearly documented and care taken to ensure
that the agreed management plan is communicated between professionals and staff
shifts. 12. Decisions and management should be regularly reviewed before and after birth in
conjunction with the parents; plans may be reconsidered if the risk for the fetus/baby
changes or if parental wishes change.

https://fn.bmj.com/content/fetalneonatal/105/3/232.full.pdf

Perinatal management of extreme preterm birth before 27 weeks of gestation: a framework for practice.

Background Decisions about treatments for extremely preterm infants (EPIs) born in the ‘grey zone’ of viability can be ethically complex. This 2020 survey aimed to determine views of UK neonatal staff about thresholds for treatment of EPIs given a recently revised national Framework for Practice from the British Association of Perinatal Medicine. Methods The online survey requested participants indicate the lowest gestation at which they would be willing to offer active treatment and the highest gestation at which they would withhold active treatment of an EPI at parental request (their lower and upper thresholds). Relative risks were used to compare respondents’ views based on profession and neonatal unit designation. Further questions explored respondents’ conceptual understanding of viability. Results 336 respondents included 167 consultants, 127 registrars/fellows and 42 advanced neonatal nurse practitioners (ANNPs). Respondents reported a median grey zone for neonatal resuscitation between 22+1 and 24+0 weeks’ gestation. Registrars/fellows were more likely to select a lower threshold at 22+0 weeks compared with consultants (Relative Risk (RR)=1.37 (95% CI 1.07 to 1.74)) and ANNPs (RR=2.68 (95% CI 1.42 to 5.06)). Those working in neonatal intensive care units compared with other units were also more likely to offer active treatment at 22+0 weeks (RR=1.86 (95% CI 1.18 to 2.94)). Most participants understood a fetus/newborn to be ‘viable’ if it was possible to survive, regardless of disability, with medical interventions accessible to the treating team. Conclusion Compared with previous studies, we found a shift in the reported lower threshold for resuscitation in the UK, with greater acceptance of active treatment for infants

https://fn.bmj.com/content/fetalneonatal/early/2021/04/28/archdischild-2020-321273.full.pdf

Viability and thresholds for treatment of extremely preterm infants: survey of UK neonatal professionals

Perinatal management of extreme preterm birth before 27 weeks of gestation A Framework for Practice Report of a Working Group

Background: The British Association of Perinatal Medicine (BAPM) published a revised framework
for perinatal management of extremely preterm infants (EPIs) in 2019. We aimed to assess UK neonatal professionals’ interpretation of elements of this framework, as well as the consistency of their estimates of outcome for EPIs. Methods: An online survey gave participants five cases involving anticipated extremely preterm
birth with different favourable and unfavourable risk factors. Respondents were asked to assign a risk category and management option using the BAPM framework and to estimate the chance of survival if the baby received active resuscitation, and the chance of severe disability if they survived. Results: Respondents were consistent in interpretation of risk categories. The majority would follow
parental wishes about management. Management decisions did not always correspond with risk assessment, with less inclination to recommend palliative (comfort) care. There were wide estimates of survival or severe disability (5-90%) with consultants providing lower estimates of severe disability
then other groups. Conclusion: UK neonatal professionals deferred to parental wishes in the cases presented, indicating
an emphasis on shared decision making. However, they did not necessarily use the risk stratification approach for management decisions. Variation in estimates of outcome raises questions about the accuracy of informed decision-making and suggests support is needed for UK clinicians to incorporate risk factors into individualised counselling. There may be value in validating existing online risk calculators for UK infants, or in developing a UK specific risk model.

https://fn.bmj.com/content/fetalneonatal/early/2021/08/18/archdischild-2021-322147.full.pdf

Individualised decision making: interpretation of risk for extremely preterm infants-a survey of UK neonatal professionals.

Perinatal Excellence to Reduce Injury in Premature Birth (PERIPrem) is an 11-element perinatal care bundle designed to improve outcomes for preterm babies, in line with the National Health Service (NHS) Long Term plan. Designed in collaboration with 12 NHS Trusts (secondary care hospitals), South West and West of England Academic Health Science Networks, South West Neonatal Operational Delivery Network, parent partners and clinical experts, implementation was via bespoke quality improvement (QI) methodology. Before project initiation, there was regional variation in uptake of elements, evidenced by baseline audit. Optimisation of the preterm infant is complex; eligibility for treatments is dependent on gestation and local policies. Preterm infants experience variability in care dependent on the place of birth, and there remains an implementation gap for several effective, evidence-based treatments. The PERIPrem ambition is to reduce severe brain injury and death caused by prematurity by at least 50% through the delivery of a perinatal care bundle. The PERIPrem approach resulted in improved element implementation by 26% (from 3% to 29%) between 2019 and 2021, with dyads significantly more likely to receive the full bundle in 2021 compared with 2019 (probability=0.96 (95% CI 0.87 to 0.99), p<0.001). When examining the impact on psychological safety and team-working of PERIPrem, linear mixed models indicated an improvement in team function (p=0.021), situation monitoring (p=0.029) and communication within teams (p=0.002). Central to success was the development of a committed multiorganisational collaborative that continues to drive perinatal improvement using a common language and streamlining processes. In addition to saving the lives of the most vulnerable babies, PERIPrem aims to improve the chances of disability-free lives and is successfully nurturing high-functioning perinatal teams with enhanced QI skills.

https://bmjopenquality.bmj.com/content/bmjqir/11/3/e001904.full.pdf

S Bates

Papers

Perinatal management of extreme preterm birth before 27 weeks of gestation: a framework for practice.

Viability and thresholds for treatment of extremely preterm infants: survey of UK neonatal professionals

Perinatal management of extreme preterm birth before 27 weeks of gestation A Framework for Practice Report of a Working Group

Individualised decision making: interpretation of risk for extremely preterm infants-a survey of UK neonatal professionals.

Perinatal excellence to reduce injury in preterm birth (PERIPrem) through quality improvement