Case: Baby Girl M

Ms. M, an unmarried 15-year-old primigravida, presented at a community hospital accompanied by her mother. She reported a history of sporadic spotting for approximately four weeks, and a recent spontaneous rupture of membranes. Though she had not had prenatal care, she was confident that the pregnancy was at 23 weeks gestation as measured from dates. She was febrile and suspected to have chorioamnionitis, so she was started on intravenous antibiotics. Given the initial diagnosis of chorioamnionitis, neither tocolytics nor steroids were given. The maternal grandmother clearly expressed her desire that the baby should be supported aggressively if deemed viable at the time of birth. The neonatologist present at that time understood her wishes. The mother's desires were not appreciated, however.

The mother progressed to a spontaneous vaginal delivery approximately ten hours after the rupture of membranes. At delivery, the baby girl was obviously less mature than would be expected of a 24-week gestation. The one-minute Apgar score was 2. A partial placental abruption was noted. Her birth weight was 550 g. The neonatologist present at the delivery, who was different from the admitting neonatologist, felt that the patient probably was not viable, and chose not to aggressively intervene. This care plan was explained to the mother and grandmother, neither of whom expressed any disagreement with the plan, which was not to initiate mechanical ventilation and to provide comfort care only. The baby was kept warm in an incubator and given oxygen by hood.