Family preferences strongly influence decision making in very premature deliveries

March 2, 2012, Elsevier

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 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 . 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 making. They were also asked about their approach to counseling , and what challenges they faced in doing so.

The authors found that, although circumscribed by institutional norms, obstetric and counseling for periviable deliveries were influenced primarily by patient preference, clinical presentation, and perspectives on . Most institutions had no formal policies to dictate practice standards for periviable care, and 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.

Explore further: Study finds in women with prior cesarean, optimal gestational age for elective delivery is week 39

Related Stories

Study finds in women with prior cesarean, optimal gestational age for elective delivery is week 39

February 10, 2012
In a study to be presented today at the Society for Maternal-Fetal Medicine's annual meeting, The Pregnancy Meeting, in Dallas, Texas, researchers will report findings that indicate that for women with prior delivery via ...

Poor understanding of anesthesiologist's role during labor may affect maternal and fetal outcomes

May 20, 2011
Today, one in four or five women in Ontario will give birth through a cesarean or "C-section." A new study, led by researchers from St. Michael's Hospital and The Wilson Centre for Research in Education and the Department ...

Study finds pregnant women with prior cesarean choose the delivery method preferred by their doctor

February 9, 2012
In a study to be presented today at the Society for Maternal-Fetal Medicine's annual meeting, The Pregnancy Meeting, in Dallas, Texas, researchers will report findings that women who have undergone one prior delivery via ...

Recommended for you

Essure female sterilization device appears safe: study

January 23, 2018
(HealthDay)—Essure implants used in female sterilization have come under fire in recent years, with women reporting a wide array of problems to the U.S. Food and Drug Administration.

Premature births linked to changes in mother's bacteria

January 23, 2018
Changes to the communities of microbes living in the reproductive tract of pregnant women could help to spot those at risk of giving birth prematurely.

Study shows how fetal infections may cause adult heart disease

January 23, 2018
Recent studies have shown that infants born prematurely have a higher risk of developing heart disease later in life. Now, a study led by researchers at the University of Washington School of Medicine in Seattle shows that, ...

Rise in preterm births linked to clinical intervention

January 18, 2018
Research at the University of Adelaide shows preterm births in South Australia have increased by 40 percent over 28 years and early intervention by medical professionals has resulted in the majority of the increase.

New report calls into question effectiveness of pregnancy anti-nausea drug

January 17, 2018
Previously unpublished information from the clinical trial that the U.S. Food and Drug Administration relied on to approve the most commonly prescribed medicine for nausea in pregnancy indicates the drug is not effective, ...

New study finds 'baby brain' is real, but the cause remains mysterious

January 15, 2018
So-called "baby brain" refers to increased forgetfulness, inattention, and mental "fogginess" reported by four out of five pregnant women. These changes in brain function during pregnancy have long been recognised in midwifery ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.