Physician decisions to resuscitate ELBW infants in the delivery room (DR) and antenatal parent counseling have been poorly studied. To assess current neonatal practices of initiating life-support in the DR for ELBW infants, we surveyed 447 neonatologists in California, 263 (59%) returned completed surveys; they were typically white (61%), male (65%), parents (83%), 46(± 1, SEM) yrs old, 13 (± 1, SEM) yrs in practice, board-certified (83%), and on-service 8 mo/yr. 34% had made life-support decisions for family members, 18% for their own premature infants.

Results: Before the delivery of an extremely premature infant, neonatologists were asked by obstetrics to counsel parents antenatally (33% at 22 wks, 60% at 23 wks, 83% at 24 wks). In counseling parents at an estimated fetal weight < 800 gm or gestational age (GA) < 26 wks, neonatologists discussed survival (99.6%), death vs resuscitation in the DR (72%), withdrawal of life-support (70%), and death in the nursery (92%). Physicians' presentation of treatment options were rarely affected by parental age, education, language, insurance, or maternal risk factors. The majority considered parental wishes, quality of life, and congenital anomalies in deciding not to resuscitate premature infants. The proportion who support a parental role in resusci- tation decisions decreased with increasing GA (from 70% at 22 wks to 15% at 27 wks). A minority felt parents had no role in decision-making (<20% at 22-25 wks, 37% at 26 wks, and 47% at 27 wks) for ELBW resuscitation. The range of birthweight and GA thresholds for resuscitation were 350-1000 gm and 20-28 wks. Mean birth-weight thresholds(± SEM) varied by intervention: intubation (478 ± 4 gm), cardiac massage or drug resuscitation (513 ± 6 gm). GA thresholds (± SEM) also varied: intubation (22 4/7 wks ± 1 d), cardiac massage (23 2/7 wks ± 1 d), and drug resusci- tation (23 3/7 wks ± 1 d). 71% of neonatologists decided based on GA rather than weight; 82% practiced without a written policy regarding life-support in ELBW infants.

Conclusions: Physician criteria for DR resuscitation, perceptions of viability, and life-support practices vary by birthweight and GA. At GA≥ 25 wks, parental decision-making may be restricted by some neonatologists. At GA < 24 wks, neonatologists are not routinely consulted by obstetrics to counsel parents regarding resuscitation and life-support for ELBW infants.