Pierre M, Plu I, Hervé C, Bétrémieux P
Service de réanimation néonatale, hôpital Sud, CHU de Rennes, 16, boulevard de Bulgarie, BP 90 347, 35203 Rennes cedex 2, France.
Arch Pediatr. 2011 Oct;18(10):1044-54. doi: 10.1016/j.arcped.2011.01.031. Epub 2011 Mar 12.
To describe the management of extremely preterm newborns at the threshold of viability before 24 weeks of gestation in the delivery room when the decision has been made not to provide intensive care; to assess the role of palliative care (PC); to report the problems encountered.
A prospective qualitative study was conducted using semi-structured interviews from November 2009 to June 2010 in two level III French maternity hospitals (A and B). In each center, four midwives, two obstetricians, two pediatricians, two anesthetists, and one chief midwife were interviewed.
In maternity hospital A, a protocol was in place that proposed PC derived from developmental care (noise limitation, drying, warming) provided by parents or staff. The problems reported were related to former euthanasia practices rather than new procedures. In maternity hospital B, no palliative care protocol had been set up. Euthanasia was practiced and accepted fatalistically because the only currently existing alternative (letting the infant die) was considered inhumane. Few problems were reported. The reluctance to carry out PC is conceptual and organizational (the ratio of births per midwife in maternity hospital B was twice that of maternity hospital A). Lexical analysis showed preferential use of the words "fetus" and "expulsion" versus "child" and "delivery" in maternity hospital B (p<0.05) when speaking of the delivery of the extremely preterm infant. Our explanatory hypothesis is that the concept of "fetus ex utero" legitimates euthanasia by assimilating it to feticide.
At the time of this study, two very different approaches to the death of extremely preterm, non-resuscitated newborns in the delivery room coexisted in France. Palliative care is obviously possible, after group reflection, if a true motivation to change, a better understanding of the law, and a clear identification of the respective status of the fetus and the newborn exist in the maternity hospital.
描述妊娠24周前未达存活阈值的极早产儿在产房决定不给予重症监护时的管理情况；评估姑息治疗（PC）的作用；报告遇到的问题。
2009年11月至2010年6月，在法国两家三级妇产医院（A和B）进行了一项前瞻性定性研究，采用半结构化访谈。在每个中心，对四名助产士、两名产科医生、两名儿科医生、两名麻醉师和一名助产士长进行了访谈。
在妇产医院A，有一个方案，提议由父母或工作人员提供源自发育照护（限制噪音、擦干、保暖）的姑息治疗。报告的问题与以前的安乐死做法有关，而非新程序。在妇产医院B，未制定姑息治疗方案。安乐死被实施且被宿命地接受，因为当时唯一的替代方案（让婴儿死亡）被认为不人道。报告的问题很少。实施姑息治疗的不情愿是概念性和组织性的（妇产医院B中每名助产士的分娩比例是妇产医院A的两倍）。词汇分析显示，在妇产医院B，在谈及极早产儿分娩时，与“儿童”和“分娩”相比，更倾向使用“胎儿”和“排出”这两个词（p<0.05）。我们的解释性假设是，“子宫外胎儿”的概念通过将其等同于堕胎使安乐死合法化。
在本研究开展时，法国产房对于未复苏的极早产儿死亡存在两种截然不同的处理方式。如果妇产医院存在真正的变革动机、对法律有更好的理解以及对胎儿和新生儿各自的状态有明确的认定，那么经过集体反思后，显然可以实施姑息治疗。
