UNIVERSITY HOSPITALS COVENTRY & WARWICKSHIRE NHS TRUST
WALSGRAVE HOSPITAL - NEWBORN SERVICES
Resuscitation & Management of Extremely Premature Infants
22-26 weeks gestation
This guideline should be used in conjunction with the guideline for
Resuscitation and Stabilisation of the neonate. Discussion with Neonatal
Consultant is expected when time allows.
1. Communication and counselling before delivery

A senior member of the neonatal team should determine history and
clinical information relevant to the current pregnancy. A provisional
management plan should be agreed after discussion with both neonatal
and obstetric teams.

The most senior member of the team available should conduct discussion
with parents at the time. Counselling regarding outcome should be based
on the most up to date national and local information (Appendix A and B).
Where delivery is expected at the threshold of viability (23 weeks) parents
should be clear that the neonatal team will be present at the birth to
assess the babies condition and that resuscitation will be determined by
this assessment. Parents should be assured that if support is withheld or
withdrawn their baby will be given comfort care (wrapped, warmed, and
treated with love and dignity).

The management plan and a summary of the conversation with
parents should be clearly recorded in the notes.
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2. Resuscitation

<23 weeks 0 days
Survival is uncommon. Counselling should ideally be conducted by the
obstetric team. Comfort care (should be given to all babies, including those
who show signs of life. It may be appropriate for a neonatologist to attend the
delivery if there is uncertainty about gestational age.

23 weeks 0 days – 23 weeks 6 days
The delivery should be attended by the neonatal team comprising an
experienced doctor (registrar and consultant if time allows) and neonatal
nurse in order to confirm gestational age. An ANNP will also attend if
available. In the absence of a fatal congenital abnormality it may be
appropriate to resuscitate an infant in the following circumstances;
Appearance suggests maturity greater than 23+6 weeks
AND
Signs of life
Absence of bruising or dysmorphic features/anomalies
Weight >500g (Appendix B)
In this event resuscitation should consist of appropriate respiratory support
without use of cardiac massage or drugs. The decision to transfer to the
neonatal unit for continuing intensive care should be based on the response
to resuscitation, i.e. sustained improvement in heart rate, colour and chest
wall movement. If there is no response, resuscitation should be stopped early
and compassionate care provided.
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
>24 weeks 0 days – 25 weeks 6 days
The delivery should be attended by the neonatal team comprising an
experienced doctor (registrar and consultant if time allows) and neonatal
nurse and/or ANNP. In the absence of a fatal congenital abnormality
resuscitation should be commenced and response assessed.
4. Stabilisation and transfer to NICU

See guideline on resuscitation and stabilisation of the neonate.
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APPENDIX A
Survivors and summary of outcomes at 30 months among infants born 20-26
weeks gestation (EPICure Study Group) 1
20-22 wks
23 wks
24 wks
25 wks
N
2112
622
636
633
Live births (%N)
242 (11)
241 (39)
382 (60)
424 (67)
Admissions
22
131
313
389
Survival to
discharge
2
26
100
186
(% admissions)
(% live births)
(% N)
(9)
(0.8)
(0.09)
(20)
(10.8)
(4.2)
(33.6)
(26.2)
(15.7)
(52.1)
(43.8)
(29.3)
Severe disability
at 30 mth
1
8
24
40
Other disability at
30 mth
0
6
28
44
1 (0.7)
1 (5)
11 (5)
11 (8)
45 (12)
45 (15)
98 (23)
98 (27)
Survived without
overall disability
at 30 mth
% live births
% admissions
APPENDIX B
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Survival to discharge by birth weight among infants born 20-26 weeks
gestation (EPICure Study Group) 2
<500g
500-749g
750-999g
>999g
Admissions
33
497
276
5
Survival to
discharge
2
157
152
3
(% admissions)
(6.1)
(31.6)
(55.1)
(60.0)
References
1
Wood NS, Marlow N, Costeloe K, Gibson AT, Wilkinson AR for the EPICure Study Group.
Neurologic and Developmental Disability after Extremely Preterm Birth. NEJM 2000;343:378-84.
2
Costeloe K, Hennessy E, Gibson AT, Marlow N, Wilkinson AR for the EPICure Study Group. The
EPICure Study: Outcomes to Discharge from Hospital for Infants Born at the Threshold of Viability.
Pediatrics 2000;106:659-671.
Fetuses and Newborn Infants at the Threshold of Viability – A Framework for Practice. BAPM
Memorandum. July 2000. http://www.bapm.org/. Accessed 06/11/04.
Guidelines relating to the birth of extremely immature babies (22-26 weeks gestation). Thames
Regional Perinatal Group March 2000. http://www.bapm.org/. Accessed 06/11/04.
Implemented 11 04