Neonatal ICU Issues: Case 1
M.S. is a married 35-year-old pregnant childless woman who has lost four previous pregnancies between 16 and 23 weeks gestation. She currently has reached 23 weeks and 3 days of gestation, her fetus is seemingly healthy, and has an estimated weight of 550 grams (+/-1.2 lbs). She has ruptured her bag of waters and is now having labor that seems unstoppable with tocolytics. Delivery seems inevitable.
What are the management options and who decides what form of care should be instituted following delivery?
This gestational age and estimated birth weight represent the "gray zone" in terms of viability vs. non-viability. Accordingly, the parents have a choice to make. They can choose a palliative care mode of treatment (with non-survival being a virtual certainty) or alternatively, assisted ventilation, pressors, antibiotics, parenteral nutrition, etc. The role of the physician is to provide continuity, regularly updated information,  and guide the parents through the decision-making process throughout the infant’s clinical course, whatever it may be.
This situation 40 years ago would have presented no ethical dilemma. Indeed, the 1972 Roe v. Wade Supreme Court case defined the limit of viability as 28 weeks gestation. Any form of aggressive care involving newborn infants below this gestational was thought to be medically futile. Today, however, aggressive measures at birth are sometimes initiated with a modest degree of success achieved in terms of promoting survival (nearing 50% for 23-24 week infants). Notably, survival is accompanied by a long stay in the hospital following delivery (3-4 months), enormous costs (see above), considerable suffering, and morbidity (in at least 50% of the cases there is significant handicap).