Prematurity outcomes — structured oral station (12 minutes)

Opening prompt — "What are her baby's chances?"

Model response — say it in this order: ^[1]

• "ANZNN 2023 Table 29 reports survival to discharge home of 50.7% for babies born under 24 weeks. That is 71 of 140 babies admitted to a level III NICU. I would name to her that this figure excludes fetal deaths, deaths on the labour ward, level II births and babies never transferred — so the honest number for her fetus in utero is lower."
• "I would ask what she wants to know before I quote a percentage — some parents want every number, some want only to know if their baby will live."
• "I would state the range as a natural frequency: 'Of ten babies like yours at this gestation, about half go home.' And I would name what we can change in the next two hours."
• "I would convene the joint obstetric-neonatal conversation, agree with the neonatal team what we will offer at birth, and document the conversation."^[1]

Probe 1 — "What are the four levers and what are you doing about each?"

• Steroids — first dose now, before transfer; the Cochrane review (Roberts 2017) shows benefit for perinatal death, neonatal death, RDS and IVH; a partial course still helps.
• Magnesium — start now if your protocol permits at 23+4; the Crowther 2017 IPD meta-analysis supports neuroprotection before 30 weeks.
• In-utero transfer — arrange now to the level III centre, in parallel with steroids and magnesium; outborn infants do worse (Fang 2020).
• Active treatment policy — know whether the receiving centre offers active resuscitation at 23+4; Rysavy 2015 showed this explains much of the variation in outcome at the threshold.^[2][3][5][1]

Probe 2 — "She asks about disability. What do you say?"

• "ANZNN 2022 Table 45 reports moderate-to-severe functional impairment at 2 to 3 year follow-up in extremely preterm survivors — about one in five overall, falling from about three in ten at 24 weeks and below to about one in seven at 28 weeks and over."
• "I would name the construct: of the 688 infants in that table with moderate-to-severe impairment, 184 were classified on language delay alone. So 'moderate-to-severe impairment' is broader than 'cerebral palsy' implies."
• "I would say: 'Most babies who go home do not have severe disability. Some have difficulties that show up later — at school age, not at two years. We will follow your baby closely whatever happens at birth.'"^[1]

Probe 3 — "What does the MAGENTA trial tell you?"

• "MAGENTA (Crowther, JAMA 2023) randomised women at 30 to 34 weeks at risk of preterm delivery to magnesium vs placebo, and did not show a significant reduction in death or cerebral palsy."
• "It bounds the magnesium recommendation — the benefit is at earlier gestations, typically before 30 weeks in ANZ practice. Extending routine use to 34 weeks is not supported."^[4]

Probe 4 — "Her partner says: 'I've read on the internet that survival is 80% at this gestation.' How do you respond?"

Scored communication domain. ^[1]

• "I would not contradict him flatly. I would acknowledge his research, then say: 'The number you've found is likely survival for babies already admitted to a tertiary nursery — and probably for a slightly older gestation. Your baby is 23+4 weeks and still inside your partner, so the honest number for you is lower, around one in two of babies admitted to a NICU. Let me explain why the denominator matters.'"
• "I would state the range, name what we can change, name the uncertainty, and commit to revisiting the conversation."^[1]

Probe 5 — "Why is in-utero transfer so important?"

• "Outborn extremely preterm neonates have higher mortality and morbidity than inborn — the Fang cohort (2020) reports this clearly. In-utero transfer is the single largest modifiable determinant of outcome for a woman presenting to a non-tertiary hospital."
• "It is pursued in parallel with steroids and magnesium, not instead of them. Tocolysis, if used, is a means to steroids and transfer, not an end in itself."^[5]