Periviable birth refers to delivery of a very premature infant near the limit of viability defined as 20 0/7 to 25 6/7 weeks’ estimated gestation.[1] In the United States, less than 1% of all births occur before the third trimester, yet these very early births account for a large portion of neonatal and infant deaths.[2] Patients at risk for periviable birth require extensive and timely counseling. Models to predict outcomes and aid in counseling have been developed, but these tools have limitations and their utility is not well studied.[3] OB/GYN hospitalists, who typically serve as first responders and provide a safety net for their units, have an important role in assessing, counseling, and managing this patient population. Opportunities to contribute to patient care range from ensuring the timely mobilization of personnel and/or transfer, maintaining hands-on skills to ensure safe delivery, and leading educational programs to optimize team performance in the complex situation of periviable birth.