540g baby survives against the odds

A baby whom a hospital specialist left to die in her mother's arms because she was so premature and breathing poorly is now a "lovely little girl", aged 2.

The case has exposed the ethical quandary over the resuscitation of extremely premature babies.

The girl, whose case was investigated by Health and Disability Commissioner Ron Paterson, was born weighing 540g at just over 24 weeks' gestation - 16 weeks early.

After an initial resuscitation attempt, efforts to keep her alive were abandoned for two hours.

The mother says she asked before the birth that her baby be resuscitated. But the neonatal specialist who initially decided resuscitation should stop, in what he considered the baby's best interests, says he was not told of this request.

Hospitals have no formal policies on the gestational age at which they try to keep babies alive and their practice is influenced strongly by each case's circumstances.

Mr Paterson's report states the mother said another doctor recommended terminating the pregnancy but the doctor denies this, saying he raised the issue so the mother would be "aware of all possible options".

This doctor says that of babies born at 24 weeks' gestation a quarter will die, a quarter will have a severe handicap, a quarter will have mild disabilities and a quarter will have a normal life.

The guidelines at Middlemore and National Women's hospitals are to resuscitate babies over 500g birthweight from 24 weeks - and from 23 weeks if their parents wish.

Middlemore neonatal specialist Dr Lindsay Mildenhall, an independent adviser to Mr Paterson, says in the commissioner's report on the case: "The level of medical intervention for babies born at 24 weeks' gestation in the Western world is a topic of huge debate and angst."

The report, from which names - including the name of the hospital - have been deleted, says the pregnancy was Mrs A's ninth. She has a history of premature births.

When the baby was born, in July 2002, doctors thought she was unlikely to survive for more than an hour, because of the mother's bleeding and loss of amniotic fluid leading up to the birth, and neonatal specialist Dr C decided to stop resuscitation attempts.

Her heart rate was normal but she was suffering significant breathing problems.

The midwife recorded that the girl was "given to [Mrs A] to cuddle until baby passes away".

But after she was seen to be "pink, active, cold with regular grunting [breaths]", Dr C returned to the delivery room and decided to transfer her to the newborn unit.

"I was most surprised to find [Baby A] still alive," he told Mr Paterson.

The commissioner said the mother had told him her daughter was "now a 'lovely little girl' who has no adverse outcome from her difficult start to life except for some scarring on her lungs, which she is likely to grow out of".

He found that only the hospital had breached the patients' rights code. "There is no documented communication between obstetric and neonatal staff regarding Mrs A's resuscitation wishes for her baby before delivery."

The hospital was at fault for not having processes to ensure her resuscitation wishes were documented and to require staff to regularly reassess newborns such as Baby A.

Premature babies

No NZ babies of less than 24 weeks' gestation and under 500g birthweight have survived.

The lightest surviving baby was 385g, but older than 24 weeks.

The youngest age at which NZ babies have survived is 23 weeks.