Extremely preterm infant viability and periviable counselling — OSCE

Objectives

1. Conduct a balanced, honest antenatal counselling conversation using plain language. [9]
2. Present survival and neurodevelopmental outcome data for a 23-week gestation infant accurately. [1]
3. Engage in shared decision-making and create space for genuine parental autonomy. [9]
4. Describe both the active intensive care pathway and the comfort care pathway without bias. [10]

Candidate brief

12-minute station. You are the neonatal registrar called to the labour ward at 2 am. A woman at 23+2 weeks gestation (confirmed by first-trimester dating) has ruptured membranes and is contracting regularly. She is 5 cm dilated. The fetus is singleton, estimated weight 560 g. The obstetric team has commenced betamethasone and magnesium sulfate. The parents are frightened, tearful, and have not previously discussed the implications of extreme prematurity. They ask: "Is our baby going to live? What will happen at birth? What should we decide?" [9]

Expected actions

• Acknowledge the parents' fear and create a calm, private, empathetic environment for the conversation. [9]
• Establish the facts: 23+2 weeks is within the grey zone where there is a genuine choice between active treatment and comfort care. [8]
• Present survival data honestly: approximately 30 to 50 per cent survival with active treatment at this gestational age, with the range reflecting variation between centres. [1]
• Present quality-of-survival data: among survivors, approximately 40 to 60 per cent will have moderate-to-severe neurodevelopmental impairment; describe functional outcomes in plain language (walking, talking, learning, feeding). [1]
• Describe the two pathways clearly: active treatment means admission to the NICU, ventilation, surfactant, prolonged hospitalisation, and complications including intraventricular haemorrhage, chronic lung disease, and sepsis; comfort care means the baby is kept warm, held, and cared for with dignity, with bereavement support. [10]
• Emphasise that this is a shared decision and that there is no single right answer; the decision should align with their values and beliefs. [9]
• Offer time for reflection and questions; offer a follow-up conversation with a consultant neonatologist; provide written information. [9]
• Document the conversation and the agreed plan; communicate the plan to the obstetric and midwifery team. [9]

Examiner prompts

• "Is there any chance our baby will be normal?" — Acknowledge the question with empathy; explain the spectrum of outcomes from no or mild disability to severe impairment; avoid the word normal; describe functional outcomes honestly. [9]
• "What would you do if it were your baby?" — Gently decline to answer directly; redirect to the parents' values; explain that the decision is theirs to make with the team's support. [9]
• "Can we have more time to decide?" — Acknowledge that time is limited by labour progress; offer to continue the conversation with a consultant; explain that a provisional plan can be made and revisited. [9]

Marking foci

• Empathic, balanced, and honest communication using plain language throughout [9]
• Accurate presentation of survival and impairment data for a 23-week infant [1]
• Clear, non-judgemental description of both active treatment and comfort care pathways [10]
• Genuine shared decision-making: creating space for parental autonomy and respecting their values [9]
• Practical next steps: documentation, team communication, follow-up [9]