Article Text

Download PDFPDF
Recommendations in the face of uncertainty: should extremely preterm infants receive chest compressions and/or epinephrine in the delivery room?
  1. Dominic Wilkinson1,
  2. Neil Marlow2,
  3. Dean Hayden1,
  4. Helen Mactier3
  1. 1 Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, Oxfordshire, UK
  2. 2 Institute for Women’s Health, University College London, London, UK
  3. 3 Neonatology, Princess Royal Maternity, Glasgow, UK
  1. Correspondence to Dr Dominic Wilkinson, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford OX1 1PT, UK; dominic.wilkinson{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

The 2009 British Association of Perinatal Medicine (BAPM) framework recommended against advanced resuscitation measures (delivery room cardiopulmonary resuscitation, DR-CPR) in extremely preterm infants, noting that: “There is no evidence to support the use of epinephrine by any route, or chest compressions, during resuscitation at gestational age <26 weeks’.1

However, in the updated 2019 framework, published in this issue, the working group reached the opposite conclusion: ‘In the absence of sufficient evidence to justify a different approach in extremely preterm babies, if advanced resuscitation is considered appropriate, the Working Group recommends applying newborn resuscitation algorithms as used in more mature babies”.2

This was one of the more controversial elements of the new framework, generating a number of comments during the consultation phase. In this commentary, we will outline the arguments behind the changed recommendation.


There are three essential reasons why neonatologists might be concerned about providing DR-CPR to extremely preterm infants. First, these measures seem to be antagonistic to the philosophy of providing gentle support and maintaining physiological stability in the critical early phase of their care. Sudden changes in intrathoracic pressure or blood pressure might increase the risk of intraventricular haemorrhage. Second, DR-CPR might be associated with such low survival that it is regarded as futile.3 Third, there may be a worry that even if infants survive after DR-CPR, they would be so severely impaired that it would have been better if they had died. The 2009 BAPM framework cites a single-centre study from the early 1990s, in which 9 of …

View Full Text


  • Twitter @NeonatalEthics, @HMactier

  • Contributors DW drafted and edited the commentary. NM and HM edited the commentary. DH performed a literature search and edited the commentary. All authors approved the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.

Linked Articles

  • Editorial
    Helen Mactier Sarah Elizabeth Bates Tracey Johnston Caroline Lee-Davey Neil Marlow Kate Mulley Lucy K Smith Meekai To Dominic Wilkinson BAPM Working Group Erica Everett Tara Selman
  • Fantoms
    Ben J Stenson