The Subcommittee on Neonatal Attendance at Periviable Delivery

The meeting had been called by the Chair of Obstetrics, who had finally had enough. She had had enough, she said, of being telephoned at three in the morning by exhausted residents asking whether the on-call neonatologist could be persuaded to come down to Labor and Delivery for a twenty-three-week delivery.

She had had enough, more recently, of a case settled last quarter for fifty million dollars. The agenda noted the case in small italic type as Item 1(a). It did not name it.

There were eleven of us in the room. Six obstetricians, one of whom was the Chair, and five of whom were not. Two neonatologists. One ethicist. One quality officer. And a representative from Risk, who said nothing for the entire meeting but took copious notes.

Before the draft policy was proposed, the quality officer asked whether the committee should not first review the case that had occasioned the meeting.

The Chair of Obstetrics nodded.

The quality officer read aloud from a single sheet of paper.

A twenty-seven-year-old patient had presented to Labor and Delivery with ruptured membranes. Her last menstrual period placed her at twenty-one weeks and four days. She had not had a first-trimester ultrasound. Her cervix was dilated. Fetal heart tones were present. The obstetric attending documented previable preterm rupture of membranes. A comfort-care conversation was held with the patient by the obstetrician. Neonatology was not called.

Antenatal corticosteroids were not given, because the pregnancy had been deemed previable.

Magnesium for neuroprotection was not given, for the same reason. Thirty minutes later, the patient delivered a vigorous, crying infant weighing five hundred and twenty grams — too large for twenty-one weeks, consistent with twenty-three.

Neonatology was paged emergently.

They arrived thirty minutes after the delivery. In the interval, the infant received no surfactant, no intubation, and no thermoregulation beyond a hospital towel. Resuscitation was eventually performed. Cranial ultrasound on day two showed Grade IV intraventricular hemorrhage. The infant survived, with profound neurologic injury. The case was settled, last quarter, for fifty million dollars.

The quality officer set down the paper.

The room was silent.

The senior obstetric attending spoke first. I have known him for thirty years. He is a careful man. He stitches well. He thanked the quality officer for the review. He said it was a sobering reminder. He observed, however, that the case at issue was, properly understood, a dating discrepancy. The patient had been assigned the wrong gestational age at presentation. Better dating, in his view, would have prevented the outcome. Mandatory neonatology involvement, in his view, would not have, because no policy could substitute for accurate dating.

The senior neonatologist agreed. He added that if neonatology were summoned for every case of suspected previable rupture, the service would be paged for cases that were truly twenty-one weeks, twenty weeks, eighteen weeks, all of which would not have benefited from the page.

The case in question was, he said, regrettably an outlier.

The ethicist said the joint statement of ACOG, SMFM, and AAP specifically addressed this. The whole point of joint counseling, she said, was that dating uncertainty was itself an indication for joint counseling. When the obstetrician was not sure of the gestational age — and at twenty-one weeks by LMP without a first-trimester ultrasound, no one was sure — the case fell precisely within the gray zone where neonatology’s involvement was supposed to ensure the question of viability was not adjudicated by one tired physician at three in the morning.

The senior obstetric attending said this was an interesting interpretation of the joint statement.

The senior neonatologist said it was an aspirational reading.

The representative from Risk took a note.

The quality officer looked at the Chair of Obstetrics. The Chair of Obstetrics looked at her hands.

We proceeded to the draft policy. It read, in its entirety: A neonatologist shall counsel every patient at risk for periviable delivery, and shall be present at every delivery after twenty weeks gestation in which resuscitation may be required. The neonatologists read it carefully. The five other obstetricians read it more carefully than I had expected.

The senior neonatologist had concerns. He had a concern about every. He had a concern about counsel. He had a concern about twenty weeks. He had concerns, in fact, about most of the substantive nouns and all of the modal verbs.

The Chair of Obstetrics said no to each in turn.

It was then that the senior obstetric attending raised his hand a second time.

He wished to register a concern of his own.

The proposal, while admirable in spirit, presented a clinical risk no one had mentioned. The risk, he explained, was this: if a neonatologist were summoned to every periviable case, the family would believe resuscitation was the expected course.

The mere presence of a neonatologist at the bedside, in his view, conveyed an intention to intervene. To call neonatology was, in effect, to commit to active management. He had seen this happen many times. He did not wish to be forced into intervention by the geography of who was standing in the room.

I waited for the ethicist to correct him.

She did. The whole point of involving neonatology, she said, was the opposite.

Joint counseling exists precisely so the family hears, from the team that would manage the neonate, what active resuscitation entails, what comfort care entails, and which paths are available given the gestational age and circumstances. To exclude neonatology from the counseling is to deprive the family of the conversation in which non-intervention is an honest option. Without that conversation, comfort care is not a choice the family makes. It is a default the obstetrician issues alone in the corridor.

The senior obstetric attending said this was, in theory, correct. The difficulty was that in practice, once a neonatologist was at the bedside, the family interpreted presence as commitment. He had watched it happen. He had charts.

The senior neonatologist nodded slowly. He said this was, in fact, a concern he had not raised but should have. He thanked the senior obstetric attending for raising it.

The Chair of Obstetrics looked at the floor for a moment.

The two senior attendings — one from each service — proceeded to develop the concern in collaboration.

The senior obstetric attending observed that flexibility was, in his view, the soul of good clinical practice. The senior neonatologist observed that flexibility was, in his view, exactly what the joint statement had intended when it used the word recommend instead of require.

Together they observed that a policy phrased too rigidly would harm patients by removing the discretion necessary to serve them well.

The ethicist asked which patients.

The senior obstetric attending said: future patients, in aggregate.

The quality officer asked whether the case he had just read aloud counted as a past patient.

The senior obstetric attending said the past patient had been a dating discrepancy.

The representative from Risk took a note.

We tried again. The Chair of Obstetrics proposed: A neonatologist shall be available for consultation in any case of anticipated periviable delivery. The senior obstetric attending and the senior neonatologist each had a concern about the word available. They had the same concern. They expressed it almost in unison, which was, I will admit, the most collaborative moment of the morning.

We tried again. A neonatologist shall be reachable. They had a concern about by whom.

We tried again. A neonatologist shall be reachable by the obstetric team in any case of anticipated periviable delivery.

They had a concern about anticipated.

Anticipated, they observed jointly, was a clinical judgment. Clinical judgment varied.

The Chair of Obstetrics said quietly that this was, in fact, the problem the policy had been written to solve. The quality officer said this was, in fact, the problem fifty million dollars had failed to solve.

We broke for lunch.

After lunch, the senior obstetric attending and the senior neonatologist returned together. They had drafted a final compromise during the break. It read: Neonatology and Obstetrics shall maintain ongoing collaborative dialogue regarding patients at risk for periviable delivery, in keeping with national professional guidelines and institutional resources, and shall jointly determine the appropriate level of involvement on a case-by-case basis.

It was, they said, comprehensive.

It was, the Chair of Obstetrics agreed, comprehensive.

It was unanimously adopted. The five obstetricians who were not the Chair voted yes. The two neonatologists voted yes. The quality officer voted no, audibly. The ethicist abstained. The representative from Risk took a note.

On my way out, I passed the senior obstetric attending and the senior neonatologist getting coffee in the corridor. They were laughing at something. I do not know what.

I asked the Chair of Obstetrics what the policy would change. She said it would change nothing operationally, since shall jointly determine on a case-by-case basis meant each case would continue to be handled the way each case had always been handled, which was that the obstetrician on call would do the counseling alone, deliver the baby, perform the initial resuscitation, and then call neonatology to take over once the airway was secured.

I asked whether the new policy would have changed the outcome of the case the quality officer had read aloud. She said it would not have. Shall jointly determine on a case-by-case basis would have permitted the obstetrician to make the same call, alone, that the obstetrician had made.

I asked whether the next case would be different. She said she did not know.

I asked whether the fifty million dollars had figured into the committee’s deliberations. She said it had been mentioned.

I asked whether it had figured.

She said the fifty million dollars had not been on the agenda. The agenda had been definitions.