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If designated facilities or sites served by examiner programs are selected gastritis diet ìóçûêà buy zantac 300mg lowest price, their success depends on getting information about them to gastritis fish oil zantac 150mg lowest price victims and agencies that provide immediate response or refer victims for treatment and evidence collection gastritis kaffee discount zantac 150mg online. At a minimum gastritis symptoms vs ulcer symptoms buy genuine zantac on line, the list of designated exam sites should be provided to all local hospitals, law enforcement agencies, emergency medical services, sexual assault victim advocacy programs, and protective services. Promoting community public awareness about these sites is also important given that victims may first disclose an assault to family members, friends, teachers, faith-based leaders, employers, coworkers, and others. In addition, success will depend on interagency cooperation in explaining facility options to victims and transporting them to designated exam sites (with their permission). Law enforcement representatives and advocates may need guidance on how to recommend an exam location to victims without mandating that they go to a specific site. If a transfer from one health care facility to a designated exam site is necessary, use a protocol that 130 minimizes time delays and loss of evidence and addresses patients’ needs. If transfer is necessary, explore options to ensure that the patient’s comfort is prioritized. However, if a sexually assaulted individual arrives at a health care facility that, for some reason, is not able to provide a medical forensic exam, interagency transfer procedures must be in place to transfer that individual to the nearest designated exam site. Evidence should be preserved when examining, treating, or transferring patients and providers should take care to preserve the chain of custody of such evidence. If there are acute medical or psychological injuries that must be treated immediately, treatment should be provided at the initial receiving facility. It may be helpful to offer patients support and advocacy from advocates at both the receiving facility and exam site. A copy of all records, including any X-rays taken, should be transported with patients to the exam facility. They should be aware, however, of the impact of refusing transfer, as it may negatively affect the quality of care, the usefulness of evidence collection, and, ultimately, any criminal investigation and/or prosecution. They should understand that declining a transfer might also be used to discredit them in court. Providers should carefully discuss with patients the benefits of the transfer, the possible benefits of refusing the transfer and the drawbacks of both options, so that patients can make an informed decision. Equipment and Supplies Recommendations at a glance to ensure proper equipment and supplies are available for exams: • Consider what equipment and supplies are necessary to conduct a medical forensic exam. Examiners should know how to use all equipment and supplies (including medications) properly during the exam. It is important that examiners and other individuals involved in sexual assault cases stay abreast of the latest research on the use of equipment and supplies used in caring for sexual assault patients and/or collecting evidence from them. Consider what equipment and supplies are necessary to conduct a medical forensic exam. Plan to have the following equipment and supplies readily available for the exam, according to jurisdictional 132 policies: • A copy of the most current exam protocol used by the jurisdiction. Suggested items: clean and ideally new replacement clothing, toiletries, food and drink, and a phone or at least easy access to a phone in as private a location as possible. It is also important during the exam process to help patients obtain items they 134 request related to their spiritual healing. It may be useful for facilities to have items on hand that are commonly requested in that jurisdiction. Drying evidence is critical to preventing the growth of mold and bacteria that can destroy an evidentiary sample. With any drying method or device used, ensure minimal contamination of evidence, and maintain the chain of custody. Related supplies might include digital media, batteries and/or charger, a flash, a color bar, and a scale ruler for size reference. Also, testing supplies may be needed that are not included in the evidence collection kit. It can be used to scan for evidence, such as dried or moist 132 All the equipment and supplies discussed will not be needed in every exam. What is appropriate in each case will depend on the circumstances of the assault and medical and forensic attention called for, patients’ needs, and patients’ consent to utilize equipment and supplies. Jurisdictional and/or facility policies will also influence what equipment and supplies are used. If this exam table is not available, health care personnel must be aware of how to assist patients with physical disabilities onto standard exam tables. If it is determined that a patient can only be examined on an exam table with a hydraulic lift, procedures should be in place to get the patient to a site with such a table with as little loss of evidence as possible. Keep in mind that each tribe has its own traditional practices to promote healing, but not all Native people follow traditional spiritual paths. Rather, spiritual values and belief systems among Native people are as widely diverse as they are among the general population. While the exam can be done without a light source, it is a relatively inexpensive piece of equipment that is commonly used 137 during exams. This instrument may be used to assist in visualizing an anal injury, obtaining reliable rectal swabs (if there is a concern about contamination), and identifying and collecting trace evidence. Although some injuries can be detected visually by examiners without the colposcope, the colposcope is an important asset in the identification of microscopic trauma. Photographic equipment, both still and video, can be attached for forensic documentation. In some jurisdictions, examiners are required to prepare a wet mount slide and 139 immediately examine vaginal/cervical secretions for motile and nonmotile sperm. In these cases, an optically staining microscope is used to highlight cellular material and facilitate the search for 140 sperm. In some jurisdictions, the dye is used to assist in highlighting observed genital and perianal injuries. The Examination Process for more discussion on use of equipment and supplies during the exam. Using this type of technology, examiners can eliminate the barriers of geography and consult with offsite medical “experts. Jurisdictions that use such technology should consider ways to protect victim confidentiality. Obtaining equipment and supplies that can increase the quality and quantity of evidence collected can have a significant impact on case outcomes. However, the costs of equipment and training on equipment use can be prohibitive for some jurisdictions and examiner programs. Some ideas to address cost barriers: • Seek used or donated equipment or alternative, less-expensive equipment where it exists. Examiners should be aware of what the light sources they use will detect and their limitations. For example, many examiners find the Wood’s Lamp useful in helping to detect secretions, stains, and fibers on patients. However, one research study questioned its utility as a screening device for the detection of semen. Linakis, “Wood’s Lamp Utility in the Identification of Semen,” Pediatrics, 104(6), 1999. Particularly if a patient has been anorectally penetrated, that patient may be uncomfortable with the use of the anoscope and could possibly even feel revictimized by it. The discomfort this procedure may cause the patient should be weighed against its potential medical or forensic benefits. In jurisdictions that require examiners to do wet-mount evaluations for sperm, an optically staining microscope should be readily available to them at all times. Ideally, due to chain-of-custody issues and the fact that the slide will dry in 5 to 10 minutes, examiners should not have to leave the exam room to evaluate the slide. Sexual Assault Evidence Collection Kit Recommendations at a glance when developing/customizing kits: • Use kits that meet or exceed minimum guidelines for contents. Many jurisdictions have developed their own sexual assault evidence collection kits (for evidence from victims) or have purchased premade kits through commercial vendors. Kits may vary from one another in types of samples collected, collection techniques, materials used for collection, and terms used to describe categories of evidence. Despite variations, however, it is critical that every kit meets or exceeds the following minimum guidelines for 143 contents.

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This Third Edition of the Guidelines is based on the work of the original National Guidelines Task Force; the basic structure and content remain the same gastritis diet ketogenic buy zantac with american express. Certain topics gastritis kas tai per liga discount zantac 300 mg mastercard, messages gastritis in pregnancy purchase zantac without prescription, and age-levels gastritis diet õàíóêà order zantac 300 mg visa, however, have been changed to reflect new information and the reality that today’s young people are facing. In addition, we have added a section on using the Guidelines that provides specific advice, ideas, and resources to help educators implement this important framework into their efforts to provide high-quality sexuality education to young people in their schools and communities. Since they were originally developed 13 years ago, the Guidelines have become one of the most influential publications in the field and a trusted resource for educators, curriculum developers, and school administrators. Given how popular and valuable this publication is, undertaking this revision was at the same time exciting and daunting, and we have many people to thank for the success of the final product. We must also thank all of the members of the original task force for the enormity of the task they took on. There is a phrase in the publishing world that asks “Where were you when the page was blankfi We give special thanks to Amy Levine who spent a great deal of time helping us perfect messages. For this edition of the Guidelines, we assembled a panel of experts in the field to review the concepts, topics, and messages. We owe a tremendous debt of gratitude to Nora Gelperin, Eva Goldfarb, Joan Helmich, Maureen Kelly, Lis Maurer, Elizabeth Schroeder, and Bill Yarber. Their comments and ideas were always insightful, often inspirational, and occasionally humorous. It is our sincere hope that this edition of the Guidelines is a valuable resource for educators and curriculum developers and that it ultimately helps to ensure that all young people receive the comprehensive education about sexuality they need to become sexually healthy adults. Monica Rodriguez Director of Public Information Vice President for Education and Training * Original Members of the National Guidelines Task Force Peggy Brick, M. Planned Parenthood of Greater Northern St Louis, Missouri Public Schools New Jersey Clair Scholz, M. Irvington, New Jersey Public Schools March of Dimes Birth Defects Foundation Robert Selverstone, Ph. Brenda Green Westport, Connecticut Public Schools National School Boards Association Stanley Snegroff, Ed. American School Health Association Sexuality Information and Education Council of the United States Mary Lee Tatum, M. Carol Hunter Geboy Planned Parenthood Federation of Independent Sexuality Education America Consultant Katherine Voegtle, Ph. American Medical Association Centers for Disease Control and Prevention James Williams National Education Association Robert Johnson, M. D Indiana University JoAnne Pereira Sexuality Information and Education Council of the United States * 1991 affiliations, for identification purposes only. Kelly Director of Training and Education Vice President of Education and Training Network for Family Life Education at Planned Parenthood of the Southern Rutgers University Finger Lakes Eva S. Training Director, Center for Health Training Table of Contents Background and Introduction. While parents are – and ought to be – their children’s primary sexuality educators, they often need help and encouragement. Faith-based institutions, community-based organizations, and schools can play an important role. Such programs should be appropriate to the age, developmental level, and cultural background of students and respect the diversity of values and beliefs represented in the community. Comprehensive school-based sexuality education complements and augments the sexuality education children receive from their families, religious and community groups, and health care professionals. The Guidelines, created by a national task force of experts in the fields of adolescent development, health care, and education, provide a framework of the key concepts, topics, and messages that all sexuality education programs would ideally include. At the same time, however, debates were raging about whether young people should instead learn solely about abstinence, if certain controversial topics such as masturbation and abortion could be discussed in classrooms, and at what age other topics should be introduced. A 1989 study found that most sexuality education teachers created their own curricular material, often without guidance from the state or local school district. Centers for Disease Control and Prevention, the American Medical Association, the National School Boards Association, the National Education Association, the March of Dimes Birth Defects Foundation, and Planned Parenthood Federation of America, as well as schoolbased sexuality education teachers, national program developers, and experienced trainers. These experts were charged with the difficult task of creating an ideal model of comprehensive sexuality education by developing a framework of the concepts, topics, skills, and messages young people should learn and determining the age-level at which each should be introduced. In 1991, the task force released the Guidelines for Comprehensive Sexuality Education: Kindergarten12th Grade. The Guidelines represented the first national model for comprehensive sexuality education and helped educators evaluate existing curricula and create new programs. Since they were first published, well over 100,000 copies have been distributed in both hard copy and electronic form. In addition, the Guidelines have been adapted and translated into Spanish for use in Latino communities in the U. This Third Edition is based on the work of the original task force; the basic structure and content remain the same. Certain topics, messages, and age-levels, however, have been changed to reflect new information, ongoing community dialogue about the appropriate content of sexuality education, and the reality that today’s young people are facing. To do this, the task force first determined the life behaviors of a sexually healthy adult which serve as outcome measures of successful sexuality education. They then compiled the information and determined the skills necessary to achieve these life behaviors and organized them into key concepts, topics, subconcepts, and age-appropriate developmental messages. Key Concepts: Key concepts are broad categories of information about sexuality and family living. The Guidelines are organized into six key concepts, each of which encompasses one essential area of learning for young people. Human development is characterized by the interrelationship between physical, emotional, social, and intellectual growth. Healthy sexuality requires the development and use of specific personal and interpersonal skills. Sexuality is a central part of being human, and individuals express their sexuality in a variety of ways. The promotion of sexual health requires specific information and attitudes to avoid unwanted consequences of sexual behavior. Social and cultural environments shape the way individuals learn about and express their sexuality. For each of the broad categories identified as a key concept, the Guidelines note several life behaviors of a sexually healthy adult that reflect actions students will be able to take after having applied the information and skills. For example, life behaviors under Key Concept 3: Personal Skills, include: “Identify and live according to one’s values”; “Take responsibility for one’s own behavior”; and “Practice effective decision-making. Background and Introduction • 15 Life Behaviors of a Sexually Healthy Adult A sexually healthy adult will: • Appreciate one’s own body. For example, Key Concept 2: Relationships, includes the following topics: families, friendship, love, romantic relationships and dating, marriage and lifetime commitments, and raising children. Together, the key concepts and topics create a simple outline for comprehensive sexuality education programs. The Guidelines begin the discussion on each topic by identifying a subconcept that directly relates to the desired life behaviors. The subconcept suggests that students learn that “People’s images of their bodies affect their feelings and behaviors. Developmental Messages: Developmental messages are brief statements that contain the specific information young people need to learn about each topic. For each topic, the Guidelines present developmental messages appropriate for four separate age levels which reflect stages of development. The levels are: Level 1: middle childhood, ages 5 through 8; early elementary school Level 2: preadolescence, ages 9 through 12; later elementary school Level 3: early adolescence, ages 12 through 15; middle school/junior high school Level 4: adolescences, ages 15 through 18; high school For example, within Key Concept 6: Society and Culture, Topic 5 is Diversity. Developmental messages about diversity for Level 1 include: “Individuals differ in the way they think, act, look, and live,” and “Talking about differences helps people understand each other better. This does not mean, however, that educators working with older students should not reintroduce or reinforce earlier messages. All developmental messages should be repeatedly reinforced at different age levels. In addition, in programs or communities where sexuality education does not start until middle school or junior high school (Level 3), it may first be necessary to introduce students to the developmental messages suggested in earlier levels.

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Delivery room management and treatment in the initial postnatal phase Initial treatment and procedures in the delivery room are based on the updated Guidelines of the International Consensus on Cardiopulmonary Resuscitation and Emergency 17 Cardiovascular Care Science with Treatment Recommendations gastritis relief discount zantac 150mg without prescription. Monitoring and goal of treatment Measurements of heart rate antral gastritis definition zantac 150mg on line, preand postductal saturations diet with gastritis buy generic zantac 150mg, and intra-arterial blood pressure are recommended diet for gastritis and duodenitis buy zantac paypal. The key principles are the avoidance of high airway pressures and the establishment of adequate perfusion and oxygenation (based on preductal arterial saturation, SpO2 measurements). Based on expert opinion, the consortium agreed on preductal SpO2 boundaries in the delivery room of 80-95%. In the frst 2 hours after birth, preductal SpO2 levels as low as 70% are acceptable if they are improving without ventilator changes, if organ perfusion is satisfactory, as indicated by a pH > 7. Thus, to avoid hyperoxia, supplemental oxygen should be diminished by reducing the oxygen fraction when preductal saturation exceeds 95%. However, based on expert opinion, in those 176 • Chapter 10 infants who are predicted to have good lung development based on their prenatal assessment. Low peak pressures, preferably <25cm H2O, are recommended to avoid lung damage to the ipsilateral and contralateral lung. In 166 infants Caldwell and Watterberg found that premedication for intubation signifcantly attenuated both the clinical pain score and the increase in blood glucose as 22 marker of acute stress. Moreover, it seems that intubation success rates progressively improve with premedication, although in some cases this is not possible due to a lack 23 of vascular access. Nasoor orogastric tube the consortium recommends immediate placing an oroor nasogastric tube with continuous or intermittent suctioning in order to prevent bowel distension and any additional ipsilateral lung compression. Vascular access As preductal PaO2 measurements refect the delivered oxygen to the brain, the arterial line should preferably be inserted into the right radial artery, also for blood sampling and monitoring of the arterial blood pressure. This is less desirable, however, than a right radial artery line because it refects the postductal situation, but on the other hand, it may give more secure longer term arterial access. It is important, however, to prevent further agitation from recurrent insertion attempts as 25 this may impair postnatal adaptation. Blood pressure control Measures to increase the systemic blood pressure may minimize the right-to-left shunting. However, there is no need to increase blood pressure levels to supranormal values if the preductal saturation remains above 80%. Therefore, the consortium recommends maintaining arterial blood pressure at normal levels for gestational age if preductal saturations remain between 80 and 95%. If tissue perfusion and blood pressure do not improve, inotropic and/ or vasopressor medication should be considered according to local practice. Hydrocortisone may be used in the early phase for the treatment of hypotension after 26 other treatment has failed. Recommendations – After delivery, the infant should be intubated routinely without bag and mask ventilation (grade of recommendation = D). In the frst 2 178 • Chapter 10 hours after birth, preductal SpO2 levels as low as 70% are acceptable provided they are slowly improving and organ perfusion is satisfactory (indicated by a pH >7. In individual cases, however, levels down to 80% may be accepted, providing organs are well perfused, as indicated by a pH >7. Oxygen toxicity can be avoided by decreasing FiO2 on the guidance of the saturation levels described above. Recommendations for initial ventilation settings for pressure-controlled ventilation are summarized below. Chest radiograph To assess the patient’s initial condition, a chest radiograph should be obtained as soon as possible. Recommendations – Conventional mechanical ventilation is the optimal initial ventilation strategy (grade of recommendation = C). Infants should remain sedated during mechanical ventilation until weaning form mechanical ventilation is commenced. A head ultrasound scan should be performed at a time when there is little danger of arousing the newborn. Careful monitoring of the blood pressure is then warranted because more fuid volumes or vasoactive drugs may be needed in view of the potential adverse hemodynamic efect of sedatives, in particular midazolam. Supportive care such as cocooning and swaddling is recommended to prevent stress from too much noise, light and nociceptive stimulation. Hemodynamic management Hemodynamic management should be aimed at achieving appropriate end-organ perfusion determined by heart rate, urine output, and lactate levels. Echocardiography is indicated if there are signs of poor perfusion or if the blood pressure is below the normal level for gestation with a preductal saturation below 80%. This may show whether the poor perfusion is due to hypovolemia or myocardial dysfunction. Recommendations – Infants should be sedated and be monitored using validated analgesia and sedation scoring systems (grade of recommendation = D). Pulmonary hypertension A 2D echocardiography performed within the frst 24 hours after birth remains the best modality to 1) rule out the presence of cardiac anomalies; 2) assess the right heart function; and 3) determine the amount of pulmonary hypertension classifed accord37,38 ingly (less or more than 2/3 systemic blood pressure). Especially in severe cases of pulmonary hypertension, a cardiac ultrasound may help to evaluate right ventricular dysfunction and/or right ventricular overload, which condition can also lead to left 39 ventricular dysfunction. There is no evidence for the usefulness of increasing systemic vascular resistance to treat right-to-left shunting, but a number of centers from the consortium suggest using inotropic or vasopressor agents such as dopamine, dobutamine and (nor)epinephrine 40 to maintain blood pressure at normal levels for gestation. If preductal saturation falls below 85% and/ or if there are signs of poor organ perfusion, treatment of pulmonary hypertension should be initiated. The efects of treatment may be best ad46 dressed by repeated cardiac evaluation. This can lead to insufcient flling of the left ventricle and thereby to poor systemic perfusion. Re-opening of the ductus arteriosus with prostaglandin E1 may protect the right ventricle from excessive overload due to 47 increased afterload. Recommendations – Perform echocardiography within the frst 24 hours after birth to rule out structural cardiac anomalies (grade of recommendation = D). The routine use of a chest tube postoperatively to drain the efusion flling the pleural cavity has been abandoned. This does not preclude its use in individual cases to drain an efusion that is symptomatic, for example due to chylothorax existing before surgery. Minimal access surgery is 56 gaining ground on the open approach (thoracotomy or laparotomy). Minimal access surgery has esthetic advantages and may be performed in patients with a left-sided 56,57 defect and liver down, but carries a signifcantly higher risk of recurrence. To allow for better comparison of patient groups between studies it is recommended to 37 record the diaphragmatic defect size in all surgeries. Parenteral nutrition only is allowed until surgical repair and until postoperative enteral feeding has been achieved. Gastroesophageal refux may be treated both by antirefux medication and 61 by surgical intervention. Diuretics should be given in the case of persisting positive fuid balance without hypovolemia, aiming for 63 diuresis of >1 mL/kg/hour. Although it is eminencebased medicine and many recommendations are level D, we think that a consensus of 184 • Chapter 10 many specialized centers on the use of a standardized treatment protocol will contribute to making more valid comparisons of patient data in ongoing and future multicenter prospective clinical studies. Clinical characteristics and outcomes of patients with right congenital diaphragmatic hernia: A populationbased study. Infuence of location of delivery on outcome in neonates with congenital diaphragmatic hernia. Prenatal interventions for congenital diaphragmatic hernia for improving outcomes. Predictors of the need for extracorporeal membrane oxygenation and survival in congenital diaphragmatic hernia: a center’s 10-year experience. Perinatal management of congenital diaphragmatic hernia: when and how should babies be deliveredfi Part 11: Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation of newborn infants with 100% oxygen or air: a systematic review and meta-analysis. Room air resuscitation of the depressed newborn: a systematic review and meta-analysis. Efect of premedication regimen on infant pain and stress response to endotracheal intubation. Impact of premedication on neonatal intubations by pediatric and neonatal trainees.

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The inherent inacfor repeat cesarean delivery in future pregnancies because curacy of ultrasound-estimated fetal weight introduces of the increased risk of uterine rupture with labor gastritis diet apples order zantac 300 mg with visa. In a degree of uncertainty to gastritis diet òâèòòåð buy zantac 300 mg mastercard the prediction of newborn addition gastritis diet 7 hari buy generic zantac 150mg line, recent data indicate that regardless of incision outcomes erythematous gastritis definition order zantac american express. In addition, how parents weigh and value type, periviable cesarean delivery results in an increased these potential outcomes (ie, death, degree of neurorisk of uterine rupture in a subsequent pregnancy (24). Thus, when a specific estimated probability for with interventions surrounding periviable pregnancy an outcome is offered, it should be stated clearly that management but also with decisions not to intervene. For this is an estimate for a population and not a prediction example, decisions to delay delivery (so-called “expectof a certain outcome for a particular patient in a given ant management”) in the setting of preterm premature institution. In the setting of possible periviable birth, fi What obstetric and pediatric resources should be interventions intended to delay delivery or to improve available in institutions that provide care for perivinewborn outcomes often are undertaken but may affect able birthfi Although some interventions (eg, Periviable infants do not survive without life-sustaining antenatal corticosteroid administration or magnesium interventions immediately after delivery. The circumsulfate for neuroprotection) pose relatively low risk to the stances prompting periviable birth are, in many cases (eg, pregnant woman and offer the prospect of a fetal benefit, preeclampsia with severe features), also likely to require others (eg, emergent cerclage placement or classical cesaradvanced care and resources to improve a woman’s outean delivery) may result in significant short-term and come. Although maternal risks associand advanced maternal care to optimize outcomes for the ated with individual interventions may not vary widely neonate and woman (28). Individual Efforts should be made to transfer women before delivobstetrician–gynecologists and other obstetric providery, if feasible, because antenatal transfer has been associers or institutions may have objections to discussing or ated with improved neonatal outcome when compared providing this option, but in the case of such objections, with transport of a neonate after delivery (31, 32). It there should be a system in place to allow families to similarly stands to reason that transfer of a parturient receive counseling about their options and access to for advanced care before her condition worsens may such care (33). Initiation of interventions to care needed for periviable birth should have policies help improve outcome (eg, administration of antenatal and procedures in place to facilitate timely transport to antibiotics or corticosteroids) does not mandate that all a receiving hospital. Protocols with guidelines for the other interventions (eg, cesarean delivery or newborn initial management and safe transport of the periviable resuscitation) subsequently be undertaken. Further intergestation should include recommendations for such ventions should be considered in the context of clinical treatments as antenatal corticosteroids, magnesium sulcircumstances at that time. Obstetric interventions often considered in pregIn some cases, circumstances may preclude antenatal nancies at risk of periviable delivery include treatments maternal transport because of a rapidly evolving clinical to delay delivery as well as efforts to improve newborn situation or because of maternal instability due to severe outcomes should delivery occur despite such efforts. In such cases, neonatal transport after delivery Treatment options vary depending upon the specific may be needed, and protocols also should be in place circumstances but may include short-term tocolytic to facilitate postpartum consultation and transfer. In order studies that included subjects in the periviable gestational to facilitate informed decision making, this discussion age range typically had small numbers in these groups, should include an unbiased presentation of data related with corresponding limited power to evaluate the effect to the chance of both survival and long-term neurodeof interventions. This discussion also should management in the periviable gestational age range are present the option of nonintervention. In light of the high extrapolated from data available for women who gave likelihood of death and the significant degree of neurodebirth between 26 weeks and 34 weeks of gestation. Clinicians from more advanced gestational ages, and expert opinshould recognize that parental goals of care may be oriion. This guidance, summarized in Table 2 and Table 3, is ented toward optimizing survival or minimizing pain and considered in more detail below. There are a few perspecsuffering and should formulate an antenatal plan of care tives that serve to frame these recommendations: in accordance with these parental goals. Outcomes vary widely across this gestational by local institutional policy and relevant laws, of age range, as do the quantity and quality of available which obstetrician–gynecologists and other obstetric data supporting various proposed interventions. A not separately considered as an intervention because stepwise approach concordant with neonatal cirin most cases its use will be linked to plans regardcumstances and condition and with parental wishes ing cesarean delivery for fetal indications. Care should be reevaluated regularly cesarean delivery for fetal indication is not planned, and potentially redirected based on the evolution of if arrangements have been made for resuscitation the clinical situation. Assessment at birth, for examof a potentially viable liveborn neonate, electronic ple, may include confirmation that comfort measures fetal heart rate monitoring may be considered if it is are most appropriate. Recommendations for Periviable Birth ^ Recommendations Grade of Recommendations Based on anticipated neonatal or maternal complications, antepartum transport to a center with Best practice advanced levels of neonatal or maternal care is recommended when feasible and appropriate. Prenatal and postnatal counseling regarding anticipated short-term and long-term neonatal outcome Best practice should take into consideration anticipated gestational age at delivery, as well as other variables that may alter the likelihood of survival and adverse newborn outcomes (eg, fetal sex, multiple gestation, the presence of suspected major fetal malformations, antenatal corticosteroid administration, birth weight, and response to initial newborn resuscitation). Family counseling should be provided by a multidisciplinary team that includes obstetrician– Best practice gynecologists and other obstetric providers, maternal–fetal medicine specialists, if available, and neonatologists who can address their individual and shared considerations and perspectives. Follow-up counseling should be provided when there is relevant new information about the maternal and fetal status or the newborn’s evolving condition. A predelivery plan, made with the parents, family, or both, should be recognized as a general plan of Best practice approach, which may be modified as the neonate’s condition and response is evaluated by the neonatal providers. A recommendation regarding assessment for resuscitation is not meant to indicate that resuscitation should always either be undertaken or deferred, or that every possible intervention need be offered. A stepwise approach concordant with neonatal circumstances and condition and with parental wishes is appropriate. Care should be reevaluated regularly and potentially redirected based on the evolution of the clinical situation. Recommendations regarding specific interventions, tailored to gestational age and other clinical data, and taking into account individual family preferences and values, are summarized in Table 3. Between 22 weeks and 25 weeks of gestation, there may be factors in addition to gestational age that will affect the potential for survival and the determination of viability. Importantly, some families, concordant with their values and preferences, may choose to forgo such resuscitation and support. Many of the other decisions on this table will be linked to decisions regarding resuscitation and support and should be considered in that context. In this study, antenatal corticosteroid exposure potential risk) or if antenatal interventions will be also decreased incidence of death, intraventricular hemaltered by the intention to perform newborn resusciorrhage, periventricular leukomalacia, and necrotizing tation or to provide comfort care. Antenatal Corticosteroids Corticosteroid administration before anticipated preterm Magnesium Sulfate for Neuroprotection birth is one of the most important antenatal therapies Maternal treatment with magnesium sulfate has been available to improve newborn outcomes (35–38). Specific shown to improve neurologic outcomes when adminisdata on the use of steroids in the periviable period are tered before anticipated early preterm birth. The use of supported by a combination of laboratory data on magnesium sulfate for this indication has been studied in the response of lung tissue and clinical observational five randomized controlled trials, with enrollment started studies (35, 39, 40). At 22 weeks of gestation, no significant differprophylaxis is recommended if periviable delivery of a ence in these outcomes was noted (90. Randomized shown to prolong pregnancy and reduce newborn infeccontrolled trials comparing cesarean delivery with vagitions (42). Alternatively, antibiotic treatment of women nal delivery have not been done in the periviable period. Thus, although data specific to if the need for classical cesarean delivery is anticipated (7, the periviable period are not available, broad-spectrum 53–55). Cesarean delivery before 22 weeks of gestation is antibiotic treatment to prolong pregnancy during expectappropriate only for maternal indications (eg, placenta previa or uterine rupture). In the setting of preterm labor with intact memnavigate the complex decisions needed regarding perivibranes, because of the lack of evidence of benefit and the able delivery and in giving the patient and her family the potential risks, such treatment is not recommended. However, except in the rare case when the patient is not competent to do so, only the pregnant woman Studies suggest that nifedipine and indomethacin tocolycan provide consent for maternal interventions. The sis of women in preterm labor with intact membranes counseling process should concurrently address clinimay delay delivery between 48 hours and 72 hours after cal considerations regarding the pregnant woman, her 26 weeks of gestation, but specific data for pregnancies fetus, and the newborn (if delivered). Because of the complexity and although some studies have found that tocolytics delay ramifications of management decisions in the periviable delivery for a short time, improvements in actual neoperiod, other health care team members (eg, bioethicists, natal outcomes have not been consistently demonstrated social workers, palliative care experts, spiritual care pro(46). Because there is some evidence of brief pregnancy viders, and nurses) may provide important contributions prolongation but no consistent data suggesting improved to the counseling process as well as psychological and newborn outcomes at any gestational age, a specific and emotional support. Ideally, counseling by the obstetric strong recommendation in favor of or against tocolytic and neonatology teams will occur simultaneously or therapy for preterm labor cannot be made. These efforts Cervical Cerclage will help to optimize coordination so as to avoid the proPlacement of an emergency (“rescue”) cerclage when the vision of conflicting information to the patient and her fetal membranes are visible at or past the external cervical family. Observational and randomvide accurate, balanced, and unbiased information and ized controlled studies of emergency cerclage placement guidance. Because obstetrician–gynecologists and other based on physical examination findings of dilation have obstetric providers may have divergent opinions and revealed an association between cerclage placement and practices based on personal beliefs or professional experipregnancy prolongation, as well as increased live births ences, it is preferable that institutions develop consensus and neonatal survival, when compared with those treated guidelines regarding counseling about outcomes and without cerclage (48–51). Effective communication within the health by the Eunice Kennedy Shriver National Institute of Child care team will identify conflicts of conscience that may Health and Human Development, Society for Maternalarise. Advanced knowledge of these issues can allow the Fetal Medicine, American Academy of Pediatrics, and team to develop strategies that recognize differences in American College of Obstetricians and Gynecologists.