Pre-mature babies born in the pre-hospital setting: A challenging situation

Age of viabilityThe UK Ambulance Service Clinical Practice Guidelines (2006) recommend that paramedic teams should make every effort to transport a mother where the delivery is imminent between 20 to 37 weeks of gestation as the baby is likely to need specialist care once delivered (Fisher et al. 2006). There are no clear recommendations available from the UK parliament regarding the ‘age of viability’. After consideration of the available evidence a conclusion was reached that while survival rates at 24 weeks and over has improved, this has not been the case below that gestational point (Select Committee on Science and Technology Twelfth Report, 2007).It is also important that paramedic teams remain aware of the guidelines on giving intensive care to extremely premature babies as laid out by the Nuffield Council on Bioethics and this is highlighted in Table 2. These guidelines are also important in situations where an expectant mother in labour may ask the paramedic not to resuscitate the preterm baby (or enquire what to expect once the baby is transferred to hospital) and a quick but focussed discussion may be necessary in such situations.Table 2.Guidelines on giving intensive care to extremely premature babies (adapted from recommendations by the Nuffeld Council on BioethicsAt 25 Weeks and above.Intensive care should be initiated and the baby admitted to a neonatal intensive care unit unless he or she is known to be affected by some severe abnormality incompatible with any significant period of survival.Between 24 weeks, 0 days and 24 weeks 6 days.Normal practice should be that the baby will be offered full intensive care and support from birth and admitted to a neonatal intensive care unit, unless the parents and the clinicians are agreed in the light of the baby's condition it is not in his or her best interest to start intensive care.Between 23 weeks, 0 days and 23 week and 6 days.It is very difficult to predict the future outcome for an individual baby. Precedence should be given to the wishes of the parents. However, where the condition of the baby indicates that he or she will not survive for long, clinicians should not be obliged to proceed with the treatment wholly contrary to their clinical judgement, if they judge that treatment would be futile.Between 22 weeks, 0 days and 22 weeks 6 days.Standard practice should not be to resuscitate the baby, resuscitation should only be attempted and intensive care offered if parents request resuscitation, and reiterate this request, after thorough discussion with a paediatrician about the risks and long-term outcomes and if the clinicians agree that it is in the baby's best interests.Before 22 weeks.Any intervention at this stage is experimental. Attempts to resuscitate should only take place within a clinical research study that has been assessed and approved by a research ethics committee and with informal parental consent.

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