When making decisions and counseling about risk and management options for deliveries between 22 and 26 weeks (periviable deliveries), obstetricians are heavily influenced by family preferences, particularly by the impression that parents consistently prefer to have everything possible done to prolong a pregnancy or "save the baby" through interventions such as cesarean section. The results of a University of Pennsylvania study are published in the March issue of the American Journal of Obstetrics and Gynecology.
Periviable neonates bear the greatest burden of neonatal death and illness. As many as one half of the babies do not survive, and half of those who do survive experience moderate to severe neurologic disability. How these cases are obstetrically managed can influence neonatal outcomes. A previous study found that obstetricians' willingness to perform cesarean delivery at 24 weeks increased the odds of survival 3.7 times, but doubled the chance of survival with serious morbidity.
In the current study investigators conducted structured interviews of 21 obstetricians at academic medical centers in Philadelphia. Respondents were asked to describe their typical approach to managing periviable delivery, and the patient, institutional, and personal factors that influence their clinical decision making. They were also asked about their approach to counseling patients, and what challenges they faced in doing so.
The authors found that, although circumscribed by institutional norms, obstetric decision making and counseling for periviable deliveries were influenced primarily by patient preference, clinical presentation, and perspectives on patient autonomy. Most institutions had no formal policies to dictate practice standards for periviable care, and study participants described a considerable amount of variation in practice. Even within the same institution, thresholds vary for what would be considered "savable." "It's very much dependent upon who's on that night," commented one participant.
"While most participants said their first consideration was balancing maternal and child well-being, and the need to weigh the questionable benefits of cesarean delivery for neonatal survival against the known risks of maternal morbidity, many described a 'do everything default,' wherein interventions to prolong the pregnancy were universally pursued unless patients actively opted out," explains Brownsyne Tucker Edmonds, MD, MS, MPH, who completed this research during a fellowship at the University of Pennsylvania and is currently an assistant professor of Obstetrics and Gynecology at Indiana University.
How the obstetricians viewed patient autonomy weighed heavily in their approach to decision making and counseling. Some saw it as their job to offer information rather than direction. Others made recommendations to guide care, arguing that the complexity and emotionality of the situation make patients incapable of making decisions about their care. The greatest challenge described was in communicating the uncertainty about fetal outcomes and the ability of obstetrical interventions to actually improve those outcomes. "In counseling patients, the obstetricians prioritized objectivity and respect for autonomy but deemphasized hope. However, a recent study found that patients who faced these decisions prioritized hope. Such discordances contribute to the challenge of managing patients' expectations in periviable counseling," says Dr. Tucker Edmonds.
While most believed that patient sociodemographic factors did not influence their clinical decisions, they reported that it is more challenging to counsel patients with less education or poor English-speaking skills. They described treating older patients and those undergoing infertility treatments more aggressively than younger patients. "Obstetricians may be less attentive to the inherent social and economic implications of having an IVF pregnancy and therefore less aware of the potential bias that is created in appraising these pregnancies differently than others," notes Dr. Tucker Edmonds.
"Interventions and curricula to aid physicians in the communication of uncertainty, management of expectations, and assessment of patients' understanding, values, and goals are needed to equip physicians to provide more patient-centered periviable care," Dr. Tucker Edmonds concludes.
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