Optimizing Shared Decision Making for Neonatal Resuscitation at Periviability

The delivery of a fetus at the threshold of viability presents clinicians and families with profound medical and ethical dilemmas, particularly regarding whether to initiate neonatal resuscitation. Although professional societies advocate for shared decision making in this context, the practical implementation of this model is challenged by unpredictable outcomes, regional or institutional variability, and human biases. This manuscript explores the theoretical foundations, contemporary evidence, and best practices for shared decision making in the setting of periviability. Supported by research from palliative and critical care medicine, this manuscript then considers how to elicit patient values within shared decision-making conversations, emphasizing preparation, interdisciplinary collaboration, and scenario-based discussion over listing risk-benefit statistics. Tools to support shared decision making, such as the neonatal outcomes calculator and visual decision aids, are discussed with caution for their appropriate application. Lastly, the article covers shared decision making when resuscitation is offered in settings where available interventions fall outside established standards of care. Ultimately, this review aims to support obstetrician-gynecologists in providing goal-concordant, ethically appropriate care at the threshold of viability by equipping them with communication strategies that respect patient autonomy while maintaining professional integrity in the complex and emotionally charged setting of periviability.