Seminars in Fetal & Neonatal Medicine (2008) 13, 440e447

ava i lab le a t www.sc iencedi rec t .com

journa l homepage : www.e l sev i er . com/ loca te /s iny

The ethics of delivery-room resuscitation

Steven Byrne a,*, Edgardo Szyld b, John Kattwinkel c

a James Cook University Hospital, Middlesbrough, UKb Hospital Diego Paroissien, Buenos Aires, Argentinac University of Virginia, Charlottesville, USA

KEY WORDSEthics;Extreme prematurity;Neonatal mortality;Neonatal resuscitationethics;Resuscitation;Viability

* Corresponding author. Neonatal UHospital, Marton Road, Middlesbrou1642 282 724; fax: þ44 1642 854 874.

E-mail address: Steve.byrne@stee

1744-165X/$ - see front matter ª 200doi:10.1016/j.siny.2008.04.014

Summary Perinatal care continues to improve and the number of extremely preterm babiesdelivered increases. What is the outcome for those babies? Under what circumstances shouldwe not initiate resuscitation or under what circumstances should we discontinue support? Howaccurate and predictive are the data we have and how can these be improved? Who shouldmake the decisions and how should they be made? Should we follow different guidelines indifferent settings? The following narrative will examine some of these questions but cannot an-swer them all.ª 2008 Elsevier Ltd. All rights reserved.

Introduction

The treatment recommendations from the latest Interna-tional Liaison Committee on Resuscitation (ILCOR)neonatal resuscitation guidelines1 include the followingstatement:

A consistent and coordinated approach to individualcases by obstetric and neonatal teams and parents is animportant goal. Not starting resuscitation and discontin-uation of life-sustaining treatment during or after re-suscitation are ethically equivalent, and cliniciansshould not be hesitant to withdraw support whenfunctional survival is highly unlikely. The followingguidelines must be interpreted according to currentregional outcomes and societal principles:

nit, James Cook Universitygh TS4 3BW, UK. Tel.: þ44

s.nhs.uk (S. Byrne).

8 Elsevier Ltd. All rights reserved

� When gestation, birthweight or congenital anomaliesare associated with almost certain early death and anunacceptably high morbidity is likely among the raresurvivors, resuscitation is not indicated. Examplesfrom the published literature include:� extreme prematurity (gestational age <23 weeks or

birthweight <400 g)� anomalies such as anencephaly and confirmed tri-

somy 13 or 18.� In conditions associated with a high rate of survival and

acceptable morbidity, resuscitation is nearly alwaysindicated.� In conditions associated with uncertain prognosis, when

there is borderline survival and a relatively high rate ofmorbidity, and when the burden to the child is high, theparents’ views on starting resuscitation should besupported.

If there are no signs of life after 10 minutes ofcontinuous and adequate resuscitative efforts, it maybe justifiable to stop resuscitation.

.

The ethics of delivery-room resuscitation 441

Most neonatologists would agree that resuscitation ofextremely premature babies of <23 weeks gestationand/or <400 g birthweight (provided there is no growthrestriction) is not generally indicated, on the groundsof futility2; others might push the weight threshold to<500 g.3 There is reasonable agreement that, in general,it would be appropriate to resuscitate babies at �25weeks and/or >600e650 g.2,3 But what is the evidencefor these views and what do we know about babies whoare in the ‘grey zone’ of 23e24 weeks and 6 days and/or >400e500 g but <600e650 g? Also, what evidence isthere to support the final statement for stopping resusci-tation after �10 minutes in babies who continue to showno signs of life despite optimum resuscitative efforts?

� If there are no signs of life after 10 minutes of continuousand adequate resuscitative efforts, it may be justifiableto stop resuscitation.

Most neonatologists would agree that resuscitation ofextremely premature babies of <23 weeks gestation and/or<400 g birthweight (provided there is no growth restriction)is not generally indicated, on the grounds of futility2;others might push the weight threshold to <500 g.3 Thereis reasonable agreement that, in general, it would beappropriate to resuscitate babies at �25 weeks and/or>600e650 g.2,3 But what is the evidence for these viewsand what do we know about babies who are in the ‘greyzone’ of 23e24 weeks and 6 days and/or >400e500 g but<600e650 g? Also, what evidence is there to support thefinal statement for stopping resuscitation after �10minutes in babies who continue to show no signs of life de-spite optimum resuscitative efforts?

Problems with the evidence

Restricted to retrospective case series

Research in the area of resuscitation has generally beenlimited by the impracticalities associated with obtaining trueinformed parental consent before the intervention and bya concern that the aetiology, extent and implications of theevents leading to the need for resuscitation are often unknownat the time of intervention. However, there are precedents ofcontrolled neonatal resuscitation trials performed withoutconsent (e.g. resuscitation with and without supplementaloxygen,4 intrapartum suctioning or non-suctioning of theairway in meconium-stained newborns).5,6 Although severalof these were conducted in developing countries, where thecriteria for informed consent may be less stringent than inmore developed countries, some were not. Also, some resusci-tation research has involved seeking consent retrospectively(e.g. after resuscitations had been videorecorde).7 Retrospec-tive consent involves informing the patient or guardian of thepatient’s tentative inclusion in the research with the option towithdraw without any reduction in the quality of care. Legisla-tive approval of various forms of this research has been recog-nized in the US,8,9 Australia10 and the UK, and has receivedinternational recognition.12 In view of the current low qualityof evidence on which many resuscitation practices are based,

it is hoped that significantly more resuscitation research proto-cols of this nature will be approved in the future.

Self-fulfilling prophecy

It is very likely that the mode of delivery and the aggres-siveness of attempted resuscitation will have been limited inthose babies thought to have little hope of intact survival.The aggressiveness of resuscitation efforts varies not onlybetween developing and developed countries, but alsoamong developed countries and in different regions of thesame country.2,13 For example, in the Netherlands, babies of<25 weeks gestation are generally not resuscitated and earlysurvivors generally not transferred.14 In the UK it is unusualfor this group of babies to be delivered by caesarean sectiondue to concerns about the effect on maternal health,15

despite there being some evidence that caesarean sectionis associated with an improved chance of survival, parti-cularly for those babies with in-utero growth restriction.16

In one population-based study from Sweden, institution ofa proactive management strategy of extremely-low-birthweight (ELBW) babies in the delivery room more thandoubled the survival rate, without increasing morbidity.17

Also it is reported that the data presented to parents tohelp them make an informed decision about their extremelypreterm baby often overestimates the risks of both deathand long-term disability, thus increasing the likelihood ofwithholding resuscitative efforts.18 Finally, resuscitation issometimes withheld because of a fear that it might resultin a severely disabled surviving baby. This situation e of anunknown negative long-term effect from an action with anapparent immediate benefit e was referred to by the lateWilliam Silverman as ‘collateral damage’.19

Inconsistency of reporting

Interpretation of the available evidence can be very difficult.Mortality statistics are reported by gestational age in somereports and by birthweight in others. The mortality figuresreported might represent the whole spectrum, ranging fromall those alive at the onset of labour to only those alive whenadmitted to a Neonatal Intensive Care Unit (NICU), the latterbeing a highly selected group of babies far more likely toexperience long-term survival. Data for long-term disabilityis even more difficult to compare due to differences in howthis is ascertained, at what age the infants are evaluated,and the rate of loss to long term follow up.20

Inaccuracies of gestational age estimationand unreliability of birthweight accuratelyreflecting fetal maturity

Unless the pregnancy occurs by technology-assistedconception, gestational age must be estimated by variousassessments of fetal growth at different stages of pregnancy.The 95% confidence limits of such estimates has been judged torange from �4e5 days in the first trimester, to �6e14 days inthe second trimester, to �3 weeks in the third trimester.21 Asall gestational-age data for populations reported in publica-tions of mortality and morbidity were drawn from estimatesmade at varying times during gestation, it is inevitable that

Table 1 Levels of evidence used in the analysis of identi-fied studies for the ILCOR guidelines1

Level ofevidence

Definitions

Level 1 Randomized clinical trials or meta-analyses ofmultiple clinical trials with substantialtreatment effects

Level 2 Randomized clinical trials with smaller or lesssignificant treatment effects

Level 3 Prospective, controlled, non-randomized,cohort studies

Level 4 Historic, non-randomized, cohort or case-controlstudies

Level 5 Case series: Patients compiled in serial fashion,lacking a control group

Level 6 Animal studies or mechanical model studiesLevel 7 Extrapolations from existing data collected for

other purposes, theoretical analysesLevel 8 Rational conjecture (common sense); common

practices accepted before evidence-basedguidelines

442 S. Byrne et al.

these dates must be unreliable (e.g. at least�1 or more weeksfrom the numbers reported). Therefore, although gestationsare routinely referred to in clinical usage with a precision ofdays (e.g. ‘23 weeksand 6days’), the reality is that a particularpregnancy and the published tables consulted for referenceare far less accurate than such jargon implies. For example,a gestation estimated to be 23 weeks and 0 days might inactuality be significantly less than 22 weeks, or greater than24 weeks. Data reported by birthweight, of course, will gener-ally be very reliable as the weight can be measured quiteaccurately following birth. However, antenatal estimates offetal weight have been shown to be quite inaccurate (95%confidence intervals exceeding�14% in all studies reported),22

thus making it clinically difficult to make reliable antenatalpredictions of mortality and morbidity from comparison withpublished charts based on birthweight. Also, birthweight datado not reflect the wide spectrum of maturity that will exist inany stratum of birthweight range.23,24

The evidence

Articles collected in the literature search were limited tofull studies published in peer-reviewed journals (noabstracts) for human subjects only. The studies were thenreviewed to determine whether they were of good, fair orpoor quality, and their level of evidence (see Table 1 below):

Tables 2 and 3 give an overview of the published survivaldata for babies born at 22e24 weeks and <500e999 g. Themost significant studies included in the tables are consideredbriefly below.

Tommaska et al.25: level of evidence(LOE) 4, good qualityA well-executed prospective study in Finland compared twoepochs (1996e1997 and 1999e2000), with ascertainment of alldeliveries and good follow-up rates up to age <3 years. Theevidence is fairly recent,antenatal steroidusewas66e74%anddata are presented by both gestational age and birthweight.The data show survival that is comparable to the Norwegianand UK data26,27 and a little better than for EPICure,28 whichwas 5 years earlier. The data for babies who were live born issimilar to that reported for the US.29 However, the high inci-dence of death and severe morbidity is still of concern.

Markestad et al.26: LOE 4, good qualityAnother well-designed and well-implemented study with goodascertainment of all deliveries in Norway at 22e27 weeks and 6days from January 1999 to December 2000 (24 months). Again,the data are recent enough to make these data useful inantenatal counselling, as they include all deliveries and arepresented by both gestational age and birthweight. The highincidence of death or severe morbidity is still of concern.

Wilson-Costello et al.29: LOE 5, fair qualityA fairly recent study but based entirely on birthweightrather than gestational age and excluding babies <500 g.The follow-up rate of 90% in the later cohort is acceptable.There was an increased risk of survival with impairmentfrom the earlier cohort [odds ratio (OR) 2.3, 95% confidenceintervals (CI) 1.7e3.3]. Overall, the study suggests thatmortality has improved and that there is an increased

number of intact survivors, but a greater relative increasein the number of impaired survivors.

Lucey et al.30: LOE 4, good qualityA useful study, as it contains some of the most recent datapublished on these very small 401e500 g babies, and describesa large number of deliveries from the Vermont Oxford Network(VON). Only inborn liveborns were included but survivors weremore likely if the baby was small for gestational age: thesebabies were in general 2 weeks more mature than the others.There was some evidence of improved survival followingantenatal steroids and delivery by caesarean section. Ingeneral, mortality was high (83% of liveborn) and there areas yet no long-term data on neurodevelopmental outcome.

Draper et al.27: LOE 4, good qualityAn update of a previous article but containing sex- andrace-specific tables derived from a large UK database.These help to predict survival related to both gestationalage and birthweight and provide mean and 90th and 10thcentile figures from 250þ g and from 22þ weeks. Thesedata can be very useful for antenatal counselling as they in-clude all babies alive at the onset of labour, which is thetime at when such counselling most often happens. Below500 g and 23 weeks, mortality is 98% (CI 95 to 99%): manyof these babies will be stillborn. It is also apparent thatat each extreme preterm gestation, those babies who aresmall for gestational age are at a considerable disadvantage(this has been confirmed by other studies13,31).

Lemons et al.32: LOE 4, fair qualityProspective data collection from the well-respected NICHDResearch Network. Figures reported are similar to otherstudies for liveborn babies and a little better than EPICure(see below) but where there was doubt about gestationalage from last menstrual period and ultrasound (>2-weekdifference) the lower figure was always taken: this willoverestimate survival to some extent. It has been suggested

Table 2 Summary of survival data by gestational age. Figures are percentages with 95% confidence intervals where available.Dates are study dates

Study (ref. no.) Gestational weeks Babies included

22 23 24

Tommiska et al. 1999e2000 Finland25 0 11 31 All deliveriesTommiska et al. 1999e2000 Finland25 0 24 47 LivebornMarkestad et al. 1999e2000 Norway26 0 16 (7e26) 44 (33e55) All deliveriesDraper et al. 1998e200127 7 (4e11) 15 (11e20) 29 (25e34) Alive at onset of labour, excludes

lethal malformationsStoelhorst et al. 1996e199753 NA NA 42 Admitted to NICUDoyle et al. (Royal Womens Hospital)

1994e1997 Australia54NA 38 (21e58) 59 (41e75) Excludes death in labour and

lethal malformationsDonoghue and the Australia/NZ

Neonatal Network 1994e19975517 (6e36) 32 (25e40) 59 (54e64) Admitted to NICU only, and

exludes lethal malformationsVictoria, Australia 1994e199756 3 (0e10) 25 (17e36) 46 (37e55) All live birthsEPICure 1995 UK28 Aa 1 11 26 Born aliveEPICure 1995 UK28 Ba 9 (0e21) 20 (13e27) 34 (28e39) Admitted to NICUEl-Metwally et al. 1993e1997 USA57 1.8 34 49 All deliveries (? Lethal

malformations)a Study divided into two groups: A, born alive; B, admitted to NICU.

The ethics of delivery-room resuscitation 443

by Evans and Levene33 that ‘to minimize the potential foroverestimating survival around the limits of viability,studies should endeavour to report the outcome of allpregnancies for each week of gestation’.

Costeloe et al. (the EPICure study)28:LOE 4, good qualityStill one of the largest reported population-based studies withgood-quality data collection and a full picture of the outcomeof all deliveries, although the data are now 12 years old andtherefore not fully representative of current obstetric andneonatal practice (EPICure 2 has recently finished recruiting

Table 3 Summary of survival data by birthweight. Figures areDates are study dates

Study (ref. no.) Birthweight (in grams

<500 g 500e749

Tommaska et al. 1999e2000 Finland25 9 33Tommaska et al. 1999e2000 Finland25 25 52Markestad et al. 1999e2000 Norway26 10 (3e17) 42 (35e4Lucey et al. 1996e2000 USA30 17 e

Draper et al. 1998e2001 UK27 3 (2e6) 32 (28e3

Wilson-Costello et al. 1990e1998 USA29 NA 48EPICure 1995 UK28 6.1 33 (27e3Hack and Fanaroff 1993e1995 USA58 NA 38Darlow et al. 1998e1999 on behalf of the

Australian and New Zealand NeonatalNetwork (ANZNN)59

1 37*

Shankaran et al. 1993e1997 USA60 NA 36

Finer et al. 1994e1996 USA35 16.7 59.5

Lemons et al. 1995e1996 USA32 NA 53.9

in the UK and its results are eagerly awaited). Further datalooking at neurodevelopmental outcome in this group havebeen published.34

Finer et al.35: LOE 5, fair to poor qualityA large cohort of babies (especially ELBW) who neededcardiopulmonary resuscitation (CPR) in the delivery room.Unfortunately, the term ‘CPR’ is not clarified and it is difficultto know how well the resuscitation was carried out. Was theairway and breathing under good control? It is apparent thatmany babies received adrenaline (epinephrine) withouthaving started external cardiac massage. This might explain,

percentages with 95% confidence intervals where available.

) Comments

g 750e999 g

67 All deliveries84 Liveborn

8) 78 (73e83) All deliveriese Liveborn, no outborn, survived

to discharge7) 76 (73e79) Alive at onset of labour. Excludes

lethal malformations85 Admitted to NICU, no major malformations

6) 55 (48e62) Admitted to NICU onlyNA Livebirths, ?malformations at 20 monthse NICU admissions, excludes lethal

malformations. *Figure for 500e999 g

64 Liveborn, admitted to NICU, home orage 120 days

86.3 All liveborn excluding lethal malformations,survival to discharge

86.3 All liveborn excluding malformations,survival to discharge

444 S. Byrne et al.

in large part, the apparently good outcomes in theseextremely preterm babies that ‘needed’ CPR.

Retrospective data

Several retrospective studies have demonstrated that a pro-active strategy of resuscitation in ELBW babies increasestheir survival rate.17,36 However, in some cases e mainly inthe developing world, where adequate resources might notbe available e subsequent care for those resuscitated babiesis inadequate, which increases the risk of morbidity consid-erably. One example of this is the overwhelming rate of ret-inopathy of prematurity in Argentina during the last decade,presumably due to insufficient monitoring of oxygen deliveryin this group.37

Parental involvement in decision making(especially in the grey area)

Many different groups, such as ILCOR,1 BAPM,10 and theAmerican Academy of Pediatrics (AAP),38 have emphasizedthe importance of parental involvement in making difficultethical decisions, especially when there is a low likelihoodof survival and a high rate of morbidity among survivors(such as babies of 23 to 24 weeks and 6 days gestation).The standard for treatment of newborns had always beenthe best interest of the child and it was the parents whowere the proxy to make these decisions. However, in 2005,a historic ruling, the Texas Supreme Court (Miller vs. HCA,Inc) found in favour of the hospital after a neonatal fellowhad resuscitated a 23-week 1-day-gestation baby againstparental wishes. The child subsequently survived, but withsevere developmental delay and mental retardation, blind-ness, cerebral palsy (spastic quadriplegia) and seizures.The decision overturned the earlier case, in which the familyhad been awarded just over $60 million in damages as thecourt felt that the hospital had been negligent in resuscitat-ing the baby against parental wishes. In the appeal case theneonatal fellow testified that: ‘this is a baby that is notnecessarily going to have problems later on. There are babiesthat survive at this gestational age e with this birthweight ethat go on and do well’. Paris et al.39 commented:

Table 4 Outcome of babies with Apgar score of 0 at 10 minute

Author (ref. no.) Studyyears

Number % death(no.)

Disabili

Patel and Beeby47

Australia1992e2002 29 69 (20) 89% sev

modera

Haddad et al.48 USA 1986e1999 32 94 (30) 100% se

Casalez et al.49 UK 1986e1994 4 75 (3) 100% se

Jain et al.50 USA 1982e1986 58 98 (57) 100% se

This is a ruling of enormous sweeping scope, albeit ina narrowly circumscribed situation. It applies, as the courtwould have it, only to children and ‘only when there is notimetoconsult theparents, or seekcourt intervention if theparents withhold consent before death is likely to result’.

Although Paris et al. believe that this ruling could be seenas contradicting the good practice guidelines of the AAP, theRoyal College of Paediatrics and Child Health (in the UK)40

and the consensus of ILCOR,1 which recommends that insuch situations ‘the parents’ views on starting resuscitationshould be supported’, it is consistent with details of the AAP’sworking document41 of the recommendations, which state:

Given the uncertainty of gestational age and birthweightpredictions, be cautious about making unalterabledecisions about resuscitative efforts before the baby isborn. When counseling parents, advise them thatdecisions made about neonatal management beforebirth may need to be modified in the delivery room,depending on the condition of the baby at birth and thepostnatal gestational age assessment.

This recommendation is supported by the following state-ment made by the Texas Supreme Court in the case mentionedabove: ‘.any decisions concerning treatment for the Millers’child would not be fully informed decisions until birth’.42 It isimportant to note that the court’s ruling did not mandate thatthe physician must attempt resuscitation in all cases, but didleave the final decision in his or her hands, depending on an as-sessment made at the critical moment. In making this deci-sion, hopefully physicians will follow the ILCOR and otherguidelines and weigh very heavily the parents’ prior requestswhen deciding to resuscitate or not at that moment.

How good are we at taking the parents’ view into accountor, even more importantly, at following the parents’ wisheswhen they have made an informed decision? Sadly, the answerto this question appears to be not as good as we think we are,depending on whether the decision is to resuscitate or to notresuscitate. There are differences both within and betweencountries. In two studies where the same survey was admin-istered to neonatologists in different countries, 75% of Swedishneonatologists versus 24% of US neonatologists respondedthat, if there were an uncertain prognosis, they wouldresuscitate an ELBW infant in the delivery room despite

s of age

ty in survivors Comments

ere, 11%te, total Z 9

In total, death or severe disabilityoccurred in 97% of babies.Apgar 0 at 10 minutes

vere, total Z 2 Term babies had 100% risk of death orsevere handicap. Only series with pretermbabies: 70% of babies were preterm(100% mortality if birthweight <1800 g).Apgar scores 0 at 1 and 5 minutes

vere, total Z 1 100% risk of death or severe disability inthe group with Apgar of 0 at 10 minutes

vere, total Z 1 100% risk of mortality or severe disabilityif Apgar 0 at 10 minutes

Practice points

� Whenever possible, it is important that parents areinvolved in making decisions for babies born at thelimits of viability and that those counselling themaccurately convey to the parents the most recentpublished mortality and morbidity data, modified

The ethics of delivery-room resuscitation 445

a parental request to withhold treatment. Conversely, 33% ofneonatologists in the US compared to 19% in Sweden, werewilling to provide what they considered to be futile treatmentif the parents so requested.2,43 Although written guidelines forresuscitation of ELBW infants have become quite consistent,44

differences between countries in the implementation of theseguidelines and in involvement of the parents in the decision-making can be highly significant.45,46

Research agenda

� It is important that neonatal mortality and morbid-ity data are updated continuously to improve therelevancy to current care practices and thus theaccuracy of antenatal counselling. Data shouldpreferably be population based and be reportedby both birthweight and gestational age.� Data for long-term follow-up that are comparable

and as complete as possible are needed urgently.This entails excellent follow-up arrangementsand the standardization of tests performed tolook for neurodevelopmental impairment.� Evaluating the efficacies of resuscitation strategies,

such as the use of various drugs (e.g. epinephrine,bicarbonate) will be improved with the design ofprospective trials that rely on obtaining consentretrospectively, but this will require a change inthe ethos of many institutional research boards.

to reflect local figures.� Perinatal healthcare professionals should be aware

of national and local guidelines regarding thesupport of parental wishes for or against interven-tion at the limits of viability, and be prepared tosupport their informed decisions appropriately.� Regardless of discussions that might have taken

place antenatally, there may still be critical life-and-death decisions to make after the baby’s birth,and the techniques of resuscitating a very pretermbaby requires seasoned expertise. Therefore, werecommend having an experienced neonatologistpresent at the birth of an ELBW whenever possible.� The best mortality and morbidity data include

results from all deliveries from a geographic popu-lation, not just those from babies admitted toa NICU. Both gestational-age-specific and birth-weight-specific data are associated with inherentinaccuracies, which make precise antenatal prog-nosis difficult in individual cases.� There is some evidence that babies who are small

for gestational age might do worse at extremepreterm gestations but it is difficult to excludethe effect of differences in obstetric care.� If babies have received continuous effective resus-

citation for 10 minutes and the baby shows nosigns of life then the likely outcome is death orsevere disability.

Discontinuation of resuscitation

What is the evidence behind the ILCOR treatment recom-mendation that ‘if there are no signs of life after 10minutes of continuous and adequate resuscitative efforts,it may be justifiable to stop resuscitation’? First, it must bestated from the outset that the evidence available is mostlyfor term babies and the total number of babies from whichthe recommendation was made is only 123. However, thereis good concordance between studies with regards to thepoor outcome in this group (Table 4).

The data in Table 4 are either study results or derivedfrom subgroups within the reports. For both term andpreterm babies it is clear that if the Apgar score is 0 at10 minutes following birth (so presumably there were nosigns of life), then nearly all of the studies supported thatthe outcome will be likely death (89% of all babies studiedat term) or handicap (>90% of which will be severe).47e50 Inthose babies <1800 g, the mortality was 100% (but in onesmall series of babies only). Only the data of Fineret al.35 suggest a somewhat more optimistic outlook forthe ELBW baby requiring CPR in the delivery room (theconcerns regarding the data in this study are set outabove). Also, the data in this study did not include Apgarscores at 10 minutes. The ILCOR guideline stipulates thatbefore discontinuation of resuscitation efforts, thesebabies should have received 10 minutes of continuous andadequate ventilation and there are concerns that some-times this does not occur as ventilation might beinadequate.51

Many neonatologists have reported that when there isquestion about resuscitation at the extremes of viability,they would prefer to ‘see what the infant looks like’ afterbirth before making a decision.3 The reasons for this mightbe to confirm the presumed maturity of the baby and/or tojudge the degree of presumed asphyxia exhibited at thetime of birth. Although, as noted earlier, there is ample ev-idence that obstetrical dating is notoriously imprecise,there are no studies examining whether the judgement ofa neonatologist present at birth can substantially improvethe accuracy of either the gestation or the prognosis.However, one retrospective study of 102 such infants foundthat neither an Apgar score nor a heart rate at 1 or 5 min-utes were sensitive or predictive of outcome. Another re-port showed that the appearance of the baby at 5minutes was predictive52 and a third study reported thatan Apgar score of <4 at 1 minute gave an odds ratio of3.73 (95% CI 3.01e4.62) favouring death in these patients.49

The jury seems still to be out on this practice of leaving thefinal decision in the hands of the neonatologist present atbirth, but it continues to be widely observed in manycountries.

446 S. Byrne et al.

Conflict of interest

None of the authors has any conflict to declare.

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