Extremely preterm infant viability and periviable counselling — viva

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Examiner-led viva on periviable counselling and management at 23+3 weeks gestation. [8]

Examiner: This infant is at 23+3 weeks. Walk me through your management framework at this gestational age. [8]

Strong answer: At 23+3 weeks, the infant is squarely within the periviable grey zone (22+0 to 24+6 weeks). My framework has two parallel tracks. First, I optimise antenatally: complete the corticosteroid course, administer magnesium sulfate for neuroprotection, arrange tertiary transfer, and mobilise the neonatal team. Second, I conduct a formal antenatal consultation with both parents, presenting honest outcome data and engaging in shared decision-making about active resuscitation versus comfort care. The parents' values are central and decisive at this gestational age. [8] [9]

Examiner: What survival and impairment figures would you quote the parents? [1] [4]

Strong answer: At 23+3 weeks with active treatment, survival is approximately 30 to 50 per cent, based on NICHD Neonatal Research Network data. Among survivors, approximately 40 to 60 per cent will have moderate-to-severe neurodevelopmental impairment, including cerebral palsy (10 to 15 per cent), cognitive impairment with IQ below 70 (40 to 50 per cent), and visual or hearing impairment (5 to 10 per cent). I would present local institutional data where available, because outcomes vary widely between centres. I would emphasise that survival does not equate to intact survival. [1] [4]

Examiner: How do the prognostic factors modify your estimate for this particular infant? [2]

Strong answer: This infant has several favourable factors: she is female, which confers a 5 to 10 per cent survival advantage; she is singleton, which confers a 10 per cent or more advantage over multiples; and she will receive antenatal corticosteroids, which roughly doubles the odds of survival without major morbidity. Using the Tyson model, which combines gestational age, birthweight, sex, singleton status, and antenatal steroids, her estimated fetal weight of 580 g is within the favourable range for 23+3 weeks. These factors together move her prognosis toward the more favourable end of the 23-week spectrum. [2]

Examiner: The parents ask: if she survives, will she be normal? How do you answer honestly? [9]

Strong answer: I explain that many surviving infants go on to have meaningful lives with their families, but that the risk of significant disability is real and substantial. I describe the spectrum of outcomes: some children have no or mild impairment, others have moderate disability such as learning difficulties or mild cerebral palsy, and some have severe disability. I use plain language, avoid the word normal, and instead describe functional outcomes such as walking, talking, feeding, and learning. I frame the conversation around hope and honesty rather than statistics alone, and I invite the parents into a genuine shared decision. [9]

Examiner: The parents choose active treatment. What is your birth plan? [8]

Strong answer: A senior neonatologist, neonatal nurse, and respiratory therapist attend the delivery. We plan delayed cord clamping for 30 to 60 seconds if feasible, immediate thermal protection with a plastic wrap and exothermic mattress to target 36.5 to 37.5 degrees Celsius, and early respiratory support with positive end-expiratory pressure and blended oxygen starting at 21 to 30 per cent titrated to target saturations. Surfactant is given if intubation is required. We establish vascular access and admit to the NICU with ongoing monitoring. The plan is clearly documented and shared with the obstetric and midwifery team. [8]

Examiner: Name a counselling pitfall you would specifically guard against. [1] [9]

Strong answer: I would guard against presenting outcomes as a binary of survival versus death without addressing the quality of survival. Parents must understand that survival at 23 weeks is often accompanied by significant disability. A second pitfall is over-reliance on international averages when local institutional outcomes may differ substantially — the Rysavy study showed that between-hospital variation in treatment and outcomes at this gestational age is extreme. I would use local data wherever possible and be transparent about uncertainty. [1] [9]