This case involves a 20-week preterm neonate with conflicting Apgars recorded post delivery. Following the second Apgar reading, the neonate was presumed dead and taken to a warmer. Because of the estimated gestational age, the neonate was not given any NICU intervention. It was also noted that there was no documented discussion between the mother and the physician regarding intervention considerations prior to delivery. Approximately 30 minutes post delivery, the father went to visit the neonate and heard a cry from the warmer. The father alerted the NICU staff and they intervened with appropriate management. The neonate was recorded with grade 4 bleeding in the brain and passed away 8 days later. NICU maturational assessment later placed the neonate at approximately 25 weeks gestation. It was alleged that the neonate was not initially given proper NICU intervention because of the incorrect gestational age reading. A neonatologist was sought to opine on the standard of care in this case and determine if a more accurate gestational age reading would have changed the post-natal course.
Question(s) For Expert Witness
- 1. How many peri-viable births have you consulted on as a neonatologist?
- 2. What is the role of the neonatologist in the delivery of a neonate that is peri-viable?
- 3. What is the most accurate method to determine a fetus' gestational age?
- 4. Would a more accurate gestational age reading have changed the post-natal course in the above case? Please explain.
Expert Witness Response E-103744
I have consulted on close to 100 peri-viable births. The role depends upon agreed upon plans of care. Some obstetricians would not even call or consult a neonatologist to be present for a 20-week resuscitation depending on their views of “viability” — which is a somewhat nebulous thing to define and subject to significant bias. If the neonatologist has met with the parents ahead of time a number of different courses might be agreed upon including comfort care interventions at birth only, a trial of limited resuscitation, or full standard resuscitative efforts. If the neonatologist is present at delivery, they will usually try to validate the gestational age clinical by at least a cursory physical exam. The most important thing is that the obstetrician and neonatologist have clearly outlined a plan of care with the family so that once the baby is delivered there is no confusion and what will and won’t be offered. EGA based on ultrasound has a significant margin of error depending on when it was obtained and the clinical features of the pregnancy. Frequently the margin of error is plus or minus 1 to 2 weeks of gestational age. EGA is not always more or less accurate than Ballard, both need to be used in concert with good clinical judgment to come up with the best estimate of gestational age. If a neonate was known with certainty to be at least 25 weeks gestational age, the vast majority of U.S. neonatologists would encourage full resuscitative efforts and some would not give families a choice not to resuscitate.
Expert Witness Response E-103748
I regularly provide consultation for fetuses at different developmental stages. Our unit cares for 600+ neonates per year and 1,400+ deliveries of which 600+ are considered high risk. The role of the neonatologist is to provide an overview of developmental progression and, in consultation with maternal care team and parents, determine an appropriate course of action for post-natal care. The estimated gestational age based on ultrasound can be very reliable if done early in pregnancy and confirmed with accurate dating of last menstrual period. Generally, the Ballard exam is considered to be more reliable for post-natal assessment if there is a discrepancy of greater than 2 weeks. Dating and size are critical to determining the post-natal course. It is difficult to say if the dating would have impacted the care of this particular neonate considering the size and physical features of the neonate are not part of the vignette. Additionally, the discrepancy in the APGAR scores makes any additional comment on survival difficult to determine.