Determining Viability

Delivery of premature infants who are at the limits of viability is not an uncommon occurrence in the emergency department. Under these circumstances, the first priority of the physician caring for the infant is to determine whether resuscitation is justified. An infant born at a gestational age of less than 24 weeks, weighing less than 500 g, who has gelatinous skin and fused eyes should not, except under unusual circumstances, be resuscitated. By contrast, infants born at greater than 24 weeks are likely to have a relatively good outcome and should be supported aggressively after birth. The decision to initiate support must be made immediately. If the decision is not clear, proceed with resuscitation.

Death of an infant judged to be nonviable might not occur rapidly even in the absence of respiratory support. After a decision has been made to withhold aggressive care, it is important that the staff remain supportive and available to the parents. If the parents desire, the child can be held in a quiet place with a physician checking periodically to determine the time of death. This period, around the time of death, may be emotionally difficult for the staff as well as the family. However, families often recall these irreplaceable moments with fondness. Futile efforts at resuscitation or interfacility transport should not be a substitute for compassionate support without medical intervention.

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