Before the First Breath: How Teams Prepare for Birth at the Edge of Viability

Few moments in medicine carry as much weight as the birth of an infant at the edge of viability. Babies born between roughly 21 and 24 weeks of gestation arrive with lungs barely ready to breathe, skin so thin that water evaporates through it, and brains vulnerable to the smallest disturbance. A new review published in Pediatric Research by Kelsi Morgan of Northwestern University and colleagues at Baylor College of Medicine synthesizes the rapidly evolving evidence on how clinicians should prepare for and manage these births, from the antenatal consultation through the first minutes of resuscitation. The authors walk through the key decision points, describe what their own center has chosen to do, and, importantly, flag where the evidence remains thin enough that reasonable experts still disagree.

The stakes are enormous and the numbers are sobering. National databases in the United States show that survival among infants born at periviable gestations has improved over time, yet outcomes vary dramatically between hospitals, and the decision to provide active treatment varies with gestational age and even with maternal race and ethnicity, as documented in a 2022 JAMA analysis of live-born neonates between 22 and 25 weeks. International position statements differ as well: some guidelines recommend offering active resuscitation from 22 weeks, others from 23 or 24, and a structured comparison of these documents published in Frontiers in Pediatrics in 2025 found substantial divergence in how professional bodies weigh survival data against the burden of intensive care. That variability means the first critical task, before any delivery room equipment is touched, is a well-informed conversation with the family.

Antenatal counseling has itself become a subject of serious study. Traditional counseling tended to be doctor-driven, presenting survival statistics and disability rates in a standardized way. A growing literature, including work by Haward, Janvier and colleagues, advocates a personalized approach in which clinicians elicit what matters most to each family, whether that is survival at any cost, quality of life, comfort, or religious considerations, and tailor the discussion accordingly. Scoping reviews of prenatal counseling at the limit of viability show that parents often want honest uncertainty rather than false precision, and that they remember these conversations for the rest of their lives. The review’s authors emphasize that counseling should be a process, not a single meeting, ideally begun when threatened periviable delivery first becomes apparent, with obstetricians and neonatologists presenting a coordinated message about what treatment options exist and what the local outcomes actually are.

Once a family and team have agreed on a plan, the obstetric side of preparation begins. Antenatal corticosteroids are among the most powerful interventions available: the landmark Cochrane review showed they reduce neonatal death and respiratory distress across the preterm spectrum, and a large 2011 JAMA study found that among infants born at 22 to 25 weeks, exposure to antenatal steroids was associated with lower mortality and less neurodevelopmental impairment. Professional guidance now supports offering steroids as early as 22 weeks when active treatment is planned. Magnesium sulfate for neuroprotection, standard before anticipated preterm birth at later gestations, has become more controversial at the very earliest gestations; recent analyses reported in 2026 have questioned whether it provides benefit for periviable deliveries, and the review treats this as an evolving question rather than a settled one. Decisions about mode of delivery, cesarean versus vaginal, also weigh maternal risk against uncertain neonatal benefit at these gestations, and the review stresses that these choices should follow the jointly agreed goals of care.

The delivery room itself demands choreography. The concept of the golden hour, articulated by Wyckoff and colleagues, holds that the first sixty minutes after birth of an extremely preterm infant should be planned with the same rigor as trauma resuscitation, because interventions in this window shape outcomes for weeks to come. Cord management is one of the most debated elements. Delayed cord clamping improves circulation and reduces transfusion requirements in preterm infants, but waiting even sixty to ninety seconds can be difficult when a baby at 22 weeks needs immediate help. Umbilical cord milking, pushing placental blood toward the infant in a few seconds, emerged as an attractive alternative, but a 2019 JAMA trial raised concern that milking in the most immature infants was associated with increased death or severe intraventricular hemorrhage, prompting many centers to restrict its use below 28 weeks. The review describes how teams must decide, in advance, which cord strategy to use at each gestational age so that no one is improvising at the bedside.

Respiratory support in the first minutes is equally consequential. The immature lung of a periviable infant has barely any surfactant and alveoli that collapse with each breath, so the initial inflation pressure, the choice of interface, and the fraction of oxygen all matter. Meta-analyses comparing non-invasive support such as continuous positive airway pressure with early intubation have shown that many extremely preterm infants can be stabilized on CPAP, though the smallest infants often ultimately require mechanical ventilation. Interestingly, intubation itself carries risk: a retrospective cohort study found that intubation attempts in the delivery room were associated with an increased risk of severe intraventricular hemorrhage, likely reflecting both the fragility of these infants and the physiological disturbance of the procedure. Video laryngoscopy has changed the calculus, with a 2024 New England Journal of Medicine trial showing higher first-attempt success for urgent newborn intubation compared with direct laryngoscopy, and studies of very small endotracheal tubes, including 2.0 millimeter tubes for infants under 750 grams, have expanded what is technically possible at the smallest sizes.

Oxygen is a drug with a narrow therapeutic window in the newborn. Too little delays stabilization; too much accelerates oxidative injury to the immature retina and lung. Guidelines have long recommended starting resuscitation of preterm infants at lower oxygen concentrations than term infants, typically 21 to 30 percent, with titration guided by pulse oximetry. A 2024 individual participant data network meta-analysis in JAMA Pediatrics examined initial oxygen concentrations for infants born before 32 weeks and found no single starting fraction clearly superior across all outcomes, underscoring that the emphasis should be on rapid titration rather than any magic number. Surfactant, the lipoprotein mixture that keeps alveoli open, can now be delivered less invasively through a thin catheter placed into the trachea while the infant breathes spontaneously, an approach supported by Cochrane evidence and associated in large observational datasets with better outcomes than conventional intubation-and-surfactant strategies in infants under 27 weeks. Caffeine, long used to stimulate breathing and wean ventilation, is increasingly started early, and trials have explored combining caffeine with minimally invasive surfactant administration in the delivery room itself.

Thermoregulation is the quiet determinant that can undo everything else. Hypothermia on admission to the neonatal intensive care unit is strongly associated with death and adverse outcomes in very preterm infants, as a 2025 systematic review confirmed, and every degree matters. Practical measures are unglamorous but effective: raising the delivery room temperature, wrapping the infant in polyethylene plastic immediately without drying, using exothermic mattresses and warmed hats, and pre-warming the transport incubator. A randomized trial showed that simply increasing delivery room temperature improved admission temperatures in premature infants. For infants born at 21 to 23 weeks, skin care becomes a resuscitation issue in its own right, because the epidermis is functionally permeable; teams use humidity, gentle handling, and careful adhesive avoidance to prevent both fluid loss and skin injury during the transition to the NICU.

Preparation extends to the equipment and personnel that will receive the baby. The review describes the value of pre-brief huddles in which the obstetric and neonatal teams confirm the gestational age, the family’s goals, the planned cord management, the anticipated airway strategy, and the medications and lines that may be needed. Umbilical venous and arterial catheters, the lifelines for fluids, medications and monitoring in the smallest infants, are increasingly placed with point-of-care ultrasound guidance to confirm position. For infants who do not respond to initial efforts, the evidence on extended resuscitation is sobering but not nihilistic: systematic reviews suggest that some infants receiving prolonged delivery room cardiopulmonary resuscitation survive with intact neurodevelopment, though the proportion is small and duration of resuscitation correlates with worse outcomes, making the pre-agreed family plan essential to guide when to stop.

What emerges from the review is a picture of a field in motion. Survival at 22 weeks, once considered extraordinary, is now reported with increasing frequency from centers that offer active treatment, and an emerging consensus, as Lantos and others have observed, is gradually forming around treating the tiniest babies more often. Yet the authors are candid about the gaps: few randomized trials enroll infants this small, much of the evidence is observational and subject to center effects, and the questions families care most about, long-term quality of life, remain hard to predict from birth characteristics. Their central message is that the best outcomes begin long before the first breath, with coordinated antenatal counseling, honest shared decision-making, steroids and obstetric optimization when appropriate, and a delivery room team that has rehearsed every step, because at the edge of viability, the chores done before you start are often what determine how the story unfolds.

Subject of Research: Antenatal care, delivery room management and initial resuscitation of infants born at periviable gestational ages

Article Title: Periviable antenatal care, labor and delivery, and initial resuscitation: Some chores to get done before you start

Article References: Morgan, K., Cavazos, R., Sundgren, N., & Parmekar, S. (2026). Periviable antenatal care, labor and delivery, and initial resuscitation: Some chores to get done before you start. Pediatric Research. https://doi.org/10.1038/s41390-026-05498-z

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05498-z

Keywords: periviable birth, extreme prematurity, neonatal resuscitation, antenatal corticosteroids, delayed cord clamping, umbilical cord milking, surfactant therapy, thermoregulation, antenatal counseling, video laryngoscopy, neonatal intensive care, magnesium sulfate