23 weeks, parents request everything, a colleague says no
You are called to a precipitous delivery at 23 weeks 2 days by best obstetric estimate, with an estimated fetal weight of 560 g. The mother received a single dose of betamethasone 6 hours ago; there is no chorioamnionitis and no other antenatal complication. The parents were counselled in the office and say they want 'everything done.' A senior colleague tells you, 'At 23 weeks we don't resuscitate, it's futile.' The obstetric team needs a decision within minutes and the infant is about to deliver.
1. How do you approach the decision itself, and how do you handle your senior colleague's statement?
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Frame the decision
- At 23 weeks the outcome is at the margin: survival is possible but substantially lower than at 25 weeks, and the risk of severe neurodevelopmental impairment among survivors is high. This is the zone in which guidelines call for individualized, shared decision-making, not a categorical rule in either direction.
- The relevant variables include estimated weight, sex, exposure to antenatal corticosteroids (she has had one dose), singleton versus multiple gestation, infection, and the volume and outcomes of my own unit. A unit that rarely resuscitates 23-week infants will not reproduce the outcomes published by units that do.
Handling the colleague
- I would not accept 'it's futile' as the decision rule, and I would not simply override the colleague either. I would say plainly that at 23 weeks both a trial of resuscitation and comfort-focused care are defensible, that the parents' informed preference is a legitimate tiebreaker in this grey zone, and that we should decide now as a team rather than argue at the warmer.
- If the disagreement persists, the attending-of-record and the clinical ethics service are the right escalation, but not in front of the family and not after delivery.
Reasoning: the failure mode to avoid is a decision made by default - either an automatic 'do everything' or an automatic 'do nothing' - that no one in the room actually believes in.
2. What do you tell the parents in the few minutes before delivery, and what do you say about the possibility of changing course later?
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Content of the conversation
- State the numbers honestly and with uncertainty: at 23 weeks, survival with intensive care is possible but well below that of more mature infants, and a substantial proportion of survivors have significant disability. Be explicit that my unit's own outcomes may differ from published figures.
- Present the two paths as real options: a trial of full resuscitation, or comfort-focused care with the parents holding the infant. Neither is abandonment.
- Explain what a 'trial' means concretely: we will resuscitate at birth, and we will reassess against defined markers - response to ventilation, heart rate at 10 minutes, and the clinical picture over the first hours. If the infant's condition is worse than anticipated, we will come back and talk again before continuing.
- Ask what matters most to them and reflect it back; document who was present and what was agreed.
Why the framing matters
- 'Everything done' is not a plan; it is a request that I translate into a plan the team can execute and re-evaluate. Saying this in advance protects the family from the sense that a later decision to stop is a betrayal, and protects the team from improvising at 3 a.m.
- Reasoning: consent in this setting is not a single signature, it is an ongoing conversation with defined checkpoints.
3. Resuscitation is in progress. At 10 minutes, despite intubation, effective ventilation, compressions, and two doses of epinephrine, the heart rate remains 40/min with no spontaneous effort. How do you reason about stopping, and what else must happen?
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Reasoning about discontinuation
- First exclude the reversible: tube position and patency, a pneumothorax, inadequate compression depth, and whether the doses actually reached the circulation.
- If those are excluded, then after roughly 20 minutes of an absent or severely bradycardic heart rate despite complete and adequate resuscitation, continuing is generally considered inappropriate and discontinuing is reasonable. A 10-minute Apgar of 0 is a strong but not absolute predictor, which is why the emphasis is on adequacy of the resuscitation rather than on the clock alone.
- At 23 weeks this threshold is reached sooner in practice because the infant's underlying chance of survival is already low; that belongs in the antenatal conversation, not in the delivery room as a surprise.
What else must happen
- Involve the parents in the decision, in words they can absorb in the moment, and give them the choice to be present and to hold the infant.
- Transition explicitly to comfort-focused care: warmth, positioning, analgesia as needed, and no further invasive interventions.
- Debrief the team - this resuscitation will have consumed every person in the room, and unprocessed moral distress affects the next delivery.
- Document the antenatal discussion, the agreed plan, each reassessment, and the rationale for stopping.
Reasoning: the decision to stop is a clinical and ethical judgement made with the family, and the quality of that process is judged as much as the resuscitation itself.