The ethics of neonatal resuscitation at the margins of viability: informed consent and outcomes.

OBJECTIVES

To determine the adequacy of records of parental counseling in mothers with threatened preterm delivery before 27 weeks gestation, whether interventions performed at birth were consistent with recorded antenatal decisions and whether extent of resuscitation affected the occurrence of serious short-term morbidity.

STUDY DESIGN

Antenatal consultation records and records of resuscitation and short-term outcomes were analyzed of 65 mothers with threatened delivery at 21 weeks to 26 weeks and 6 days gestation, and their 61 infants who delivered before 27 weeks.

RESULTS

Discussions about survival rates and the frequency of handicap were more likely to be recorded before 25 weeks gestation than after; the adequacy of the records varied among individuals. A decision not to resuscitate was present in 6 of the 13 consultations performed before 23 weeks gestation, and in none of the 52 at 23 weeks or above. A decision to resuscitate only if the infant's condition at birth was good was found in 7 consultations, 6 of which were at less than 24 weeks gestation. All infants born at 23 weeks and above were resuscitated, including the infants with conditional resuscitation decisions. Three of the 6 infants receiving heart massage were discharged alive without major short-term morbidity (severe intracranial hemorrhage, periventricular leukomalacia, or threshold retinopathy). All 8 infants of less than 25 weeks gestation with a heart rate at 3 minutes that was still less than 100 beats/min, in spite of active resuscitation, either died or had major short-term morbidity.

CONCLUSIONS

Records of antenatal consultations were often lacking important information. Variations in physician documentation practices are substantial and affect the care offered to infants at the threshold of viability. Even extensive resuscitation can be followed by intact survival if the resuscitation required is brief.