FIGO issues recommendations for perinatal care at the limit of viability
FIGO and IJGO have released new guidelines addressing the complex ethical and clinical challenges of perinatal care at the threshold of viability. Highlighting the variability in gestational age thresholds for viability across different countries and healthcare settings, the recommendations emphasise the need for a nuanced, individualised approach to decision-making during the periviability interval — the so-called "gray zone" of prognostic uncertainty.
Key Recommendations
- Focus on the periviability interval: recognise the "gray zone" where the benefits and harms of neonatal intensive care are uncertain. Decisions should be tailored to individual cases rather than relying solely on gestational age.
- Ethical framework: Incorporate principles of beneficence, nonmaleficence, autonomy, and justice. These principles may be interpreted differently based on socioeconomic, cultural, and religious contexts.
- Shared decision-making: promote non paternalistic dialogue between parents and physicians. Physicians should offer, but not mandate, interventions, respecting informed parental choices within medical feasibility.
- Pre-birth decisions: advocate for decisions about neonatal resuscitation to be made before birth rather than based on the newborn’s appearance at birth. This ensures consistency in pre- and postnatal care plans.
- Ethics committees: utilise local ethics committees as moderators in cases of disagreement between parents and physicians. These committees provide counselling but do not have decision-making authority.
- Professional guidelines: use guidelines as a starting point for discussions, recognising that they often lack specificity and cannot capture the nuances of every clinical situation.
- Parental counselling: emphasise the importance of personalised, clear and consistent counselling for parents, ideally conducted before delivery to avoid emotionally driven decisions.
- Initial life support: in emergencies where pre-delivery counselling was not possible, initiate life support to allow time for thorough evaluation and discussion with parents.
- Cultural sensitivity: acknowledge the diverse international perspectives on who should make the final decision in periviability cases, ranging from physician-led decisions in some countries to parent-led decisions in others.
Conclusion
FIGO's recommendations underscore the complexity and ethical challenges of perinatal care at the limit of viability. By promoting early involvement of obstetric and neonatal teams and encouraging a balanced, respectful approach to decision-making, the guidelines aim to support both healthcare providers and parents in navigating these difficult situations. International dialogue and local adaptations of these principles are encouraged to ensure ethically justified, high-quality care for the most vulnerable patients.