Infants Of Less Than 26 Weeks Gestation - Guideline For Resuscitation And Institution Of Intensive Care In

Publication: 01/08/2007  --
Last review: 13/07/2018  
Next review: 13/07/2021  
Clinical Guideline
CURRENT 
ID: 1366 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for resuscitation and institution of intensive care in infants of less than 26 weeks gestation

  1. Background
  2. Factors influencing decision making
  3. Multidisciplinary Involvement
  4. The Guideline
  5. Key Points to Consider
  6. Consultation   

1.0 Background

This guideline is provided for the Leeds Teaching Hospital Trust. It reflects the BAPM Framework for clinical practice at the time of birth (October 2008) and the conclusions of Nuffield Council on Bioethics report (November 2006) ‘critical care decisions in fetal and neonatal medicine’, ethical issues. Good practice reflects the need to support the baby, their family and our staff (BAPM 2014) and accords with UK framework for limitation of treatment (RCPCH 2015).

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2.0 Factors influencing decision making

Parents views, the fetal prognosis and other relevant factors known to the multidisciplinary team must be synthesised in the decision making. It is our responsibility to do the best possible for the newborn infant and to act in the baby’s best interest. Equity and justice should be taken into account. We also need to be aware of the resource implications of our decisions.

Fundamental to any decision:

  • good information
  • open and honest discussion with parents
  • the baby's best interest

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3.0 Multidisciplinary Involvement:

Decisions and discussions should be multidisciplinary and include a registrar or consultant neonatal paediatrician. The importance of an accurate estimation of gestation is clear. It is essential to review the gestation and if there is any discrepancy between estimates discuss with colleagues in midwifery and obstetrics.
All decisions are made with the mother and usually both parents/carer, after full discussion with the multidisciplinary team. Discussion and decision should be recorded in the maternal notes, clear documentation of those present/involved is required.

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4.0 The Guideline

The following guideline relates only to initial decision making regarding resuscitation and the institution of intensive care. Naturally, it remains imperative to continue to review the place of neonatal intensive care in the infant’s best interest over the period of NICU.

The response of the baby to mask ventilation is critical in deciding whether to commence intensive care. If the heart rate remains below 100/minute despite adequate chest wall rise and increasing inspired oxygen to 100%, then this indicates a poor response. There is no evidence to support the use of adrenaline by any route, or chest compressions, during resuscitation at gestational age <26 weeks.

The guideline refers to completed weeks of gestation. Thus, 24 weeks gestation means 24+0 to 24+6. Weeks of gestation are not rounded up or rounded down.

25 weeks of gestation and above – resuscitation should be given and  intensive care administered unless an infant has a severe congenital anomaly or other agreed contraindication.

 

24 weeks of gestation – normally infants will be offered intensive care.
Resuscitation and intensive care will not be given when parents and clinicians have a prior agreement that in light of the baby’s condition it is not in the baby’s best interest.

 

23 weeks of gestation – the wishes of the parents regarding resuscitation
and intensive care are most important and are obtained after counselling by an
experienced neonatal paediatrician.

If treatment would be futile, that is there is no realistic chance of benefit, the clinicians are not legally obliged to proceed with treatment. In attempting resuscitation, the response of the baby to mask ventilation is critical in deciding whether to commence intensive care. If there has not been an opportunity to discuss with the parents then resuscitation may be given.

 

22 weeks of gestation – our standard practice is not to offer resuscitation due to the major concerns about survival and disability rates. It is essential that the information given to the family is wholly consistent with this view.  

On occasions, it may be appropriate for a neonatal doctor to see the parents where a preterm delivery at this gestation is suspected but we must be clear that no resuscitation or intervention is offered. A neonatal doctor does not need to attend the delivery.

 

Below 22 weeks of gestation – no baby should be resuscitated.

 

Uncertain gestational age
If gestational age is uncertain (e.g. no dating ultrasound scan) but thought to be around 23 weeks, further information from the Obstetrician and midwife needs to be sought. An ultrasound scan may be carried out by the obstetric team if time permits.

If the fetus is potentially viable and fetal heart rate is heard during labour, the neonatal team should be called to attend the delivery. At delivery, the baby needs to be assessed for its gestation and viability by a senior member(s) of the team. A decision should be made, in the best interest of the baby, as to whether resuscitation should begin with mask ventilation. Once begun, the response of the heart rate to lung inflation will be crucial in judging how long to continue resuscitation. If there is any uncertainty about management, guidance from more senior staff should be sought urgently

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5.0 Key Points to Consider:

When deciding whether to resuscitate and institute life support immediately after birth, the infant’s best interests should take regard of the following points:

  • the gestation
  • the initial assessment of the baby’s vitality
  • the likelihood of survival and severe disability
  • any significant abnormalities
  • the views and feelings of the parents

It is important that we are prepared to withhold resuscitation and intensive care when this is appropriate. This is as important as providing full and skilled resuscitation and intensive care for those infants in whom this is in their best interest. If resuscitation is not planned, parents should be prepared for the palliative care of the infant. Some infants may make respiratory movements. Some may survive for a short period, and even for hours. Agonal gasping is common and can be disturbing, so we should explain that it is a reflex response in the baby who is dying. The baby must be kept warm as part of comfort care. An incubator may be required. Multidisciplinary support for the family at this time is paramount.

When a baby dies, a clear plan for bereavement counselling should be established. This is usually led by the Obstetric team. If the baby was of a viable gestation, then the neonatal consultant should discuss their involvement in counselling with the obstetric team. In the case of prematurity, a post mortem is usually not required. Further information on palliative care can be found in the LTHT guidelines.

In any such tragic situation, it is essential to provide:

  • a high standard of comfort care for the infant
  • support for the family at the time and to offer follow up from the perinatal team or contact with other agencies
  • provide a supportive environment for the multiprofessional team

Provenance

Record: 1366
Objective:
Clinical condition:
Target patient group: Mother, father and infant
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Allied Health Professionals
Midwives
Adapted from:

Evidence base

References

  1. Nuffield Council (Nov. 2006) Bi0ethics Report: Critical care in fetal and neonatal medicine – Ethical Issues. www.nuffieldbioethics.org.
  2. BAPM: The Management of Babies born Extremely Preterm at less than 26 weeks of gestation. A Framework for Clinical Practice at the time of Birth. October 2008.
  3. Al-Jilaihawi S, Huertas-Ceballos A. Survey of delivery room practice: resuscitation of extreme preterm infants Arch Dis Child 2015;100: A53-A54.
  4. BAPM: Practical guidance for the management of palliative care on neonatal units. February 2014
  5. RCPCH A framework for practice. Making decisions to limit treatment in life-limiting and life-threatening conditions in children: a framework for practice Arch Dis Child 2015;100:s1-s23

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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