Babies are usually delivered pre-term if they are failing to thrive in utero; however, no study has assessed the effect of altered delivery time on infant mortality or disability. Jim Thornton (University of Nottingham, UK) and colleagues compared the effect of delivering early with delaying birth for as long as possible. 548 pregnant women (with fetal trauma at 24-36 weeks gestation) were recruited by 69 hospitals in 13 European countries. Before birth, 588 babies were randomly assigned to immediate delivery (296) or delayed delivery (292).
Deferred delivery until physicians were certain that delivery was essential resulted in an average 4-day delay in delivery compared with babies born immediately. The overall rate of death was not altered by delay. However, the rate of disability at 2 years of age was 8% for immediate births and 4% for delayed births. Most of the observed difference was in babies younger than 31 weeks of gestation at randomisation: 13% for immediate compared with 5% for delayed deliveries.
Jim Thornton comments: "The lack of difference in mortality suggests that obstetricians are delivering sick preterm babies at about the correct moment to minimise mortality. However, they could be delivering too early to minimise brain damage. The present study should discourage doctors who deliver pre-term fetuses before the point at which they believe delivery can be delayed no longer. This caution applies particularly to pregnancies for which early delivery is considered before 30 weeks. In this situation, we believe that the obstetrician should delay".
In an accompanying commentary (p 483), David A Grimes (Family Health International) discusses the challenges concerning research into a number of possible prognostic tests that could guide clinical practice in this field. He concludes: "Rigorous randomised trials of interventions based on those tests, like the GRIT trial, and application of evidence-based practice guidelines will help ensure that fetuses in peril are born at the optimum time."
The Lancet