Obstetric decision-making and counseling at the limits of viability

Barriers and facilitators to shared decision making: A qualitative study of families who delivered at the cusp of viability

OBJECTIVES

There is limited data regarding patients' experiences with periviable counseling. Exploring patient perspectives helps us improve provider communication and may aid in supporting high-quality decision-making. Our study explored patient-identified sources of support and conflict during discussions with their healthcare team when delivering during the periviable period with the goal of improving high-quality shared decision making (SDM).

METHODS

We conducted semi-structured interviews of birthing people who delivered between 20 0/7 and 25 6/7 weeks gestational age from 2010 to 2014. Interviews focused on shared decision making at the time of periviable birth with an emphasis on the three-talk model of SDM. Interviews were coded to perform thematic analysis.

RESULTS

We interviewed 20 patients who delivered during the periviable period and 6 important others. Participants valued providers aiding in their emotional processing. Conversely, participants identified lack of clarity during counseling and an emphasis on hopelessness as barriers to SDM.

CONCLUSION(S)

Participants highlighted the importance of using easy-to-understand language and focusing on hope. Finally, families emphasized the importance of explicitly eliciting values that might inform their choice and the positive impact of nursing staff.

PRACTICE IMPLICATIONS

Our findings underscore the importance of using a SDM model for periviability counseling and highlight areas for improvement.

Maternal fetal medicine, obstetric, and neonatology perspectives on joint prenatal counseling at periviable gestational ages

OBJECTIVE

To explore perspectives of maternal fetal medicine specialists (MFMs), obstetricians (OBs), and neonatologists (Neos) about antenatal counseling at periviable gestational ages and examine how those perceptions impact multidisciplinary counseling.

STUDY DESIGN

Semi-structured interviews were conducted and thematic analysis performed until thematic saturation.

RESULTS

Interviews of 7 Neos and 8 OB/MFMs identified three themes: (1) roles in periviability counseling; (2) training and lifelong learning to develop/enhance communication skills; and (3) managing interdisciplinary dynamics. Participants agreed on consult content and the appropriate subspecialist to discuss specific topics but differed in their approaches. Subspecialty perspectives differed on resuscitation, survival, and developmental outcomes. Formal communication skills training was identified as a means to scaffold conversations into a uniform approach.

CONCLUSION

Despite near universal agreement that joint perviability counseling would be beneficial, logistical barriers and lack of a shared framework may hinder its implementation. Formal communication skills training may support organized joint counseling.

Mode of delivery and outcomes among inborn extremely preterm singletons: A cohort study

INTRODUCTION

Cesarean delivery is the most common mode of delivery among extremely preterm infants but there are insufficient data regarding the best mode of delivery among extremely preterm singletons. The objective of this study was to compare the rate of death or severe neurodevelopmental impairment among extremely preterm singletons by actual mode of delivery.

MATERIAL AND METHODS

Observational study using prospectively collected data from 25 US medical centers. We included postnatally-treated singletons with birth weight 401-1000 g, gestational age 22 + 0/7-26 + 6/7 weeks, without a major birth defect, born 2006-2016. Death or severe neurodevelopmental impairment (Bayley Scales of Infant Development-3rd edition cognitive composite score<70, cerebral palsy (Gross Motor Function Classification Scale >3), bilateral blindness, or bilateral hearing loss) at 18-26 month follow-up were compared by mode of delivery (cesarean, vaginal including vertex or breech) using propensity score analysis to adjust for baseline characteristics.

RESULTS

There was no difference in death or severe neurodevelopmental impairment between cesarean and vaginal (vertex or breech) births (42.4% cesarean vs. 47.2% vaginal; adjusted odds ratio (aOR), 95% confidence intervals (CI); 1.03, 0.91-1.17). Both cesarean delivery (26.8% cesarean vs. 51.5% breech vaginal; aOR: 0.71; 95% CI: 0.55-0.92) and vertex vaginal delivery (28.5% vertex vaginal vs. 51.5% breech vaginal; aOR: 0.59; 95% CI: 0.45-0.76) were associated with lower mortality compared with breech vaginal delivery.

CONCLUSIONS

Among postnatally-treated extremely preterm singletons, there was no difference in death or severe neurodevelopmental impairment between cesarean or vaginal delivery. Both vertex vaginal and cesarean delivery were associated with lower mortality compared with breech vaginal delivery.

Development of a checklist for evaluation of shared decision-making in consultation for extremely preterm delivery

OBJECTIVE

Shared decision-making (SDM) between parents facing extremely preterm delivery and the medical team is recommended to develop the best course of action for neonatal care. We aimed to describe the creation and testing of a literature-based checklist to assess SDM practices for consultation with parents facing extremely preterm delivery.

STUDY DESIGN

The checklist of SDM counseling behaviors was created after literature review and with expert consensus. Mock consultations with a standardized patient facing extremely preterm delivery were performed, video-recorded, and scored using the checklist. Intraclass correlation coefficients and Cronbach's alpha were calculated.

RESULT

The checklist was moderately reliable for all scorers in aggregate. Differences existed between subcategories within classes of scorer, and between scorer classes. Agreement was moderate between expert scorers, but poor between novice scorers. Internal consistency of the checklist was excellent (Cronbach's alpha = 0.93).

CONCLUSION

This novel checklist for evaluating SDM shows promise for use in future research, training, and clinical settings.

Decision-Making for Extremely Preterm Infants: A Qualitative Systematic Review

OBJECTIVE

To synthesize and describe important elements of decision-making during antenatal consultation for threatened preterm delivery at the margin of gestational viability.

STUDY DESIGN

Data sources including PubMed, EMBASE, Web of Science, and CINAHL Plus were searched. We included all qualitative literature published on decision-making from 1990 to July 2021. Two authors independently screened and evaluated each study using the Critical Appraisal Skills Programme checklist; studies reaching moderate and high quality were included. We developed an extraction tool to collect and categorize data from each qualitative article, then used thematic analysis to analyze and describe the findings.

RESULTS

Twenty-five articles incorporating the views of 504 providers and 352 parents were included for final review. Thematic analysis revealed 4 main themes describing the experience of health care providers and parents participating in decision-making: factors that influence decision-making, information sharing, building a partnership, and making the decision. Parents and providers were not always in agreement upon which elements were most essential to the process of decision-making. Articles published in languages other than English were excluded.

CONCLUSIONS

Qualitative literature highlighting key factors which are important during antenatal counseling can inform and guide providers through the process of shared decision-making. Communicating clear, honest, and balanced information; avoiding artificially dichotomized options; and focusing on partnership building with families will help providers use the antenatal consultation to reach personalized decisions for each infant.

Potential missed opportunities for antenatal corticosteroid exposure and outcomes among periviable births: observational cohort study

OBJECTIVE

Test the hypothesis potential missed opportunities for antenatal corticosteroids increase as gestational age decreases and are associated with adverse outcomes.

DESIGN

Observational cohort study.

SETTING

24 US centers in the Neonatal Research Network.

POPULATION

Actively treated infants 22-25 weeks' gestation and birth weight 401-1000 grams, without major birth defects, born 2006-2018.

METHODS

Potential missed opportunity was defined as no antenatal corticosteroids but did have prenatal antibiotics, and/or magnesium sulfate, and/or prolonged rupture of membranes. Poisson regression models adjusted for baseline characteristics.

MAIN OUTCOME MEASURES

Antenatal corticosteroid exposure, mortality, and severe intracranial hemorrhage or periventricular leukomalacia.

RESULTS

6966 (87.5%) were exposed to antenatal corticosteroids, 454 (5.7%) had no exposure but potential missed opportunities for antenatal corticosteroid exposure, and 537 (6.7%) had no exposure and no evidence of potential missed opportunities. Compared with infants born at 25 weeks, potential missed opportunities for antenatal corticosteroid exposure were more likely at 22 weeks (adjusted relative risk (aRR) [95% CI] 11.06 [7.52-16.27]) and 23 weeks (3.24 [2.44-4.29]) but did not differ at 24 weeks (1.08 [0.82-1.42]). Potential missed opportunities for antenatal corticosteroids decreased over time at 22-23 weeks' gestation. Antenatal corticosteroid exposed infants had lower risk of death (31.0% vs 54.8%; 0.77 [0.70-0.84]) and survivors had lower risk of severe brain injury (25.0% v 44.5%; 0.64 [0.55-0.73]) compared with infants with potential missed opportunities.

CONCLUSION

Potential missed opportunities for antenatal corticosteroid exposure increased with decreasing gestational age and were associated with higher rates of death and severe brain injury among actively treated periviable births.

Addressing bias and disparities in periviable counseling and care

Addressing bias and disparities in counseling and care requires that we contend with dehumanizing attitudes, stereotypes, and beliefs that our society and profession holds towards people of color, broadly, and Black birthing people in particular. It also necessitates an accounting of the historically informed, racist ideologies that shape present-day implicit biases. These biases operate in a distinctly complex and damaging manner in the context of end-of-life care, which centers around questions related to human pain, suffering, and value. Therefore, this paper aims to trace biases and disparities that operate in periviable care, where end-of-life decisions are made at the very beginning of life. We start from a historical context to situate racist ideologies into present day stereotypes and tropes that dehumanize and disadvantage Black birthing people and Black neonates in perinatal care. Here, we review the literature, address historical incidents and consider their impact on our ability to deliver patient-centered periviable care.

Diverse perspectives on death, disability, and quality of life: an exploratory study of racial differences in periviable decision-making

OBJECTIVE

To qualitatively explore perceptions of pain/suffering, disability, and coping by race among pregnant women facing the threat of a periviable delivery (22 0/7-24 6/7 weeks).

STUDY DESIGN

Interviews were conducted in-hospital prior to delivery. Transcripts were coded verbatim and responses were stratified by race (white vs non-white). Conventional content analysis was conducted using NVivo 12.

RESULTS

We recruited 30 women (50% white, 50% non-white). Most women expressed love and acceptance of their babies and described pain as a "means to an end." Non-white women focused almost exclusively on immediate survival and perseverance, while white women expressed concerns about quality of life beyond the NICU. The majority of non-white women were unable to recall any discussions with their doctors about their baby's comfort, pain, or suffering.

CONCLUSIONS

These findings may suggest that culturally tailored approaches to counseling and decision-support may be beneficial for patients from marginalized or minoritized groups.

Communication in high risk ante-natal consultations: a direct observational study of interactions between patients and obstetricians

Background

Effective communication is crucial to any doctor-patient consultation, not least in pregnancy where the outcome affects more than one person. While higher levels of patient participation and shared decision making are recognised as desirable, there is little agreement on how best to achieve this. Most previous research in this area is based on reported data such as interviews or surveys and there is a need for more fine-grained analysis of authentic interaction. This study aimed to identify the discourse characteristics and patterns that exemplify effective communication practices in a high-risk ante-natal clinic.

Methods

We video-recorded 20 consultations in a high-risk ante-natal clinic in a large New Zealand city with patients attending for the first time. Post-consultation interviews were conducted with the 20 patients and 13 obstetricians involved. Discourse analysis of the transcripts and videos of the consultations was conducted, in conjunction with thematic analysis of interview transcripts.

Results

Most patients reported high quality communication and high levels of satisfaction; the detailed consultation analysis revealed a range of features likely to have contributed. On the clinician side, these included clear explanations, acknowledgement of the patient’s experience, consideration of patient wishes, and realistic and honest answers to patient questions. On the patient side, these included a high level of engagement with technical aspects of events and procedures, and appropriate questioning of obstetricians.

Conclusions

This study has demonstrated the utility of combining direct observation of consultations with data from patient experience interviews to identify specific features of effective communication in routine obstetric ante-natal care. The findings are relevant to improvements needed in obstetric communication identified in the literature, especially in relation to handling psychosocial issues and conveying empathy, and may be useful to inform communication training for obstetricians. The presence of the unborn child may provide an added incentive for parents to develop their own health literacy and to be an active participant in the consultation on behalf of their child. The findings of this study can lay the groundwork for further, more detailed analysis of communication in ante-natal consultations.

Prenatal counseling in extreme prematurity - Insight into preferences from experienced parents

OBJECTIVE

In-depth analysis of parental preferences in prenatal counseling in extreme prematurity.

METHODS

A nationwide qualitative interview study among experienced parents of extremely premature babies born at 24^+0/7 - 24^+6/7 weeks of gestation. Semi-structured interviews were held until saturation, transcribed and qualitatively analyzed to search for parental counseling preferences.

RESULTS

Thirteen parents were included, most parents decided on active care. Organisation: Parents wanted counseling as soon as possible, and for various reasons they wanted more than one conversation. Supportive material to help visualize complex information was suggested to be helpful, preferably with adjustable levels of detail. An empathetic, honest style with commitment of the counselor was regarded important.

CONTENT

Understandable statistics should be used for those who want it. Parents needed different information with respect to the decision-making as opposed to being prepared for future situations. Decision-making: The preferred share of parents' and doctors' input in decision-making varied among parents and among situations. Parents expressed that their roles were to take responsibility for and protect their infant.

CONCLUSIONS

Various parental preferences for prenatal counseling were found.

PRACTICE IMPLICATIONS

Common parental preferences for the organisation, content and decision-making elements can provide a starting point for personalized prenatal counseling.

Receiving a prenatal diagnosis of Down syndrome by phone: a qualitative study of the experiences of pregnant couples

OBJECTIVES

To examine how pregnant couples experience receiving a prenatal diagnosis of Down syndrome (DS) by phone-a practice that has been routine care in the Central Denmark Region for years.

DESIGN

Qualitative interview study.

SETTING

Participants were recruited from hospitals in Central Denmark Region, Denmark.

PARTICIPANTS

Couples who had received a prenatal diagnosis of DS by phone and decided to terminate the pregnancy. They were recruited from the obstetric department where the termination was undertaken. During the study period (February 2016 to July 2017), 21 semistructured, audio-recorded interviews were conducted by an experienced anthropologist. Interviews were conducted 4-22 weeks after the diagnosis and analysed using thematic analysis.

RESULTS

A prearranged phone call was considered an acceptable practice. However, the first theme 'Expected but unexpected' shows how the call often came earlier than expected. Consequently, most women were not with their partner and were thus initially alone with their grief and furthermore responsible for informing their partner, which some considered difficult. The second theme 'Now what?' shows how during the phone calls, physicians were quick to enquire about the couples' agendas. As the majority had already decided to seek termination of pregnancy, the dialogue focused on related questions and arrangements. Only half of the couples received additional counselling.

CONCLUSION

A prearranged phone call was considered an acceptable and appropriate practice. However, some aspects of this practice (particularly related to the context of the call) showed to be less than optimal for the couples. To make sure that a diagnostic result is delivered in accordance with the couples' needs and requests, the context of the call could be addressed and agreed on in advance by physicians and couples.

Prospective parents' perspectives on antenatal decision making for the anticipated birth of a periviable infant

OBJECTIVE

To examine prospective parents' perceptions of management options and outcomes in the context of threatened periviable delivery, and the values they apply in making antenatal decisions during this period.

STUDY DESIGN

Qualitative analysis of 46 antenatal interviews conducted at three tertiary-care hospitals with 54 prospective parents (40 pregnant women, 14 partners) who had received counseling for threatened periviable delivery (40 cases).

RESULTS

Participants most often recalled being involved in resuscitation, cerclage, and delivery mode decisions. Over half (63.0%) desired a shared decision-making role. Most (85.2%) recalled hearing about morbidity and mortality, with many reiterating terms like "brain damage", "disability", and "handicap". The potential for disability influenced decision making to variable degrees. In describing what mattered most, participant spoke of giving their child a "fighting chance"; others voiced concerns about "best interest", a "healthy baby", "pain and suffering", and religious faith.

CONCLUSIONS

Our findings underscore the importance of presenting clear information on disability and eliciting the factors that parents deem most important in making decisions about periviable birth.

Preterm premature rupture of membranes at 22-25 weeks' gestation: perinatal and 2-year outcomes within a national population-based study (EPIPAGE-2)

BACKGROUND

Most clinical guidelines state that with early preterm premature rupture of membranes, obstetric and pediatric teams must share a realistic and individualized appraisal of neonatal outcomes with parents and consider their wishes for all decisions. However, we currently lack reliable and relevant data, according to gestational age at rupture of membranes, to adequately counsel parents during pregnancy and to reflect on our policies of care at these extreme gestational ages.

OBJECTIVE

We sought to describe both perinatal and 2-year outcomes of preterm infants born after preterm premature rupture of membranes at 22-25 weeks' gestation.

STUDY DESIGN

EPIPAGE-2 is a French national prospective population-based cohort of preterm infants born in 546 maternity units in 2011. Inclusion criteria in this analysis were women diagnosed with preterm premature rupture of membranes at 22-25 weeks' gestation and singleton or twin gestations with fetus(es) alive at rupture of membranes. Latency duration, antenatal management, and outcomes (survival at discharge, survival at discharge without severe morbidity, and survival at 2 years' corrected age without cerebral palsy) were described and compared by gestational age at preterm premature rupture of membranes.

RESULTS

Among the 1435 women with a diagnosis of preterm premature rupture of membranes, 379 were at 22-25 weeks' gestation, with 427 fetuses (331 singletons and 96 twins). Median gestational age at preterm premature rupture of membranes and at birth were 24 (interquartile range 23-25) and 25 (24-27) weeks, respectively. For each gestational age at preterm premature rupture of membranes, nearly half of the fetuses were born within the week after the rupture of membranes. Among the 427 fetuses, 51.7% were survivors at discharge (14.1%, 39.5%, 66.8%, and 75.8% with preterm premature rupture of membranes at 22, 23, 24, and 25 weeks, respectively), 38.8% were survivors at discharge without severe morbidity, and 46.4% were survivors at 2 years without cerebral palsy, with wide variations by gestational age at preterm premature rupture of membranes. Survival at 2 years without cerebral palsy was low with preterm premature rupture of membranes at 22 and 23 weeks but reached approximately 60% and 70% with preterm premature rupture of membranes at 24 and 25 weeks.

CONCLUSION

Preterm premature rupture of membranes at 22-25 weeks is associated with high incidence of mortality and morbidity, with wide variations by gestational age at preterm premature rupture of membranes. However, a nonnegligible proportion of children survive without severe morbidity both at discharge and at 2 years' corrected age.

Genetic Counselors' Perspectives About Cell-Free DNA: Experiences, Challenges, and Expectations for Obstetricians

The expansion of cell-free fetal DNA (cfDNA) screening for a larger and diverse set of genetic variants, in addition for use among the low-risk obstetric population, presents important clinical challenges for all healthcare providers involved in the delivery of prenatal care. It is unclear how to leverage the different members of the healthcare team to respond to these challenges. We conducted interviews with 25 prenatal genetic counselors to understand their experience with the continued expansion of cfDNA screening. Participants supported the use of cfDNA screening for the common autosomal aneuploidies, but noted some reservations for its use to identify fetal sex and microdeletions. Participants reported several barriers to ensuring that patients have the information and support to make informed decisions about using cfDNA to screen for these different conditions. This was seen as a dual-sided problem, and necessitated additional education interventions that addressed patients seeking cfDNA screening, and obstetricians who introduce the concepts of genetic risk and cfDNA to patients. In addition, participants noted that they have a professional responsibility to educate obstetricians about cfDNA so they can be prepared to be gatekeepers of counseling and education about this screening option for use among the general obstetric population.

Preferred prenatal counselling at the limits of viability: a survey among Dutch perinatal professionals

Background

Since 2010, intensive care can be offered in the Netherlands at 24⁺⁰ weeks gestation (with parental consent) but the Dutch guideline lacks recommendations on organization, content and preferred decision-making of the counselling. Our aim is to explore preferred prenatal counselling at the limits of viability by Dutch perinatal professionals and compare this to current care.

Methods

Online nationwide survey as part of the PreCo study (2013) amongst obstetricians and neonatologists in all Dutch level III perinatal care centers (n = 205).The survey regarded prenatal counselling at the limits of viability and focused on the domains of organization, content and decision-making in both current and preferred practice.

Results

One hundred twenty-two surveys were returned out of 205 eligible professionals (response rate 60%). Organization-wise: more than 80% of all professionals preferred (but currently missed) having protocols for several aspects of counselling, joint counselling by both neonatologist and obstetrician, and the use of supportive materials. Most professionals preferred using national or local data (70%) on outcome statistics for the counselling content, in contrast to the international statistics currently used (74%). Current decisions on initiation care were mostly made together (in 99% parents and doctor). This shared decision model was preferred by 95% of the professionals.

Conclusions

Dutch perinatal professionals would prefer more protocolized counselling, joint counselling, supportive material and local outcome statistics. Further studies on both barriers to perform adequate counselling, as well as on Dutch outcome statistics and parents’ opinions are needed in order to develop a national framework.

Trial registration

Clinicaltrials.gov, NCT02782650, retrospectively registered May 2016.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1644-6) contains supplementary material, which is available to authorized users.

Professionals' preferences in prenatal counseling at the limits of viability: a nationwide qualitative Dutch study

Prenatal counseling practices at the limits of viability do vary, and constructing a counseling framework based on guidelines, professional and parental preferences, might achieve more homogeneity. We aimed to gain insight into professionals' preferences on three domains of counseling, particularly content, organization, and decision making and their influencing factors. A qualitative, nationwide in-depth exploration among Dutch perinatal professionals by semi-structured interviews in focus groups was performed. Regarding content of prenatal counseling, preparing parents on the short-term situation (delivery room care) and revealing their perspectives on "quality of life" were considered important. Parents should be informed on the kind of decision, on the difficulty of individual outcome predictions, on survival and mortality figures, short- and long-term morbidity, and the burden of hospitalization. For organization, the making of and compliance with agreements between professionals may promote joint counseling by neonatologists and obstetricians. Supportive materials were considered useful but only when up-to-date, in addition to the discussion and with opportunity for personalization. Regarding decision making, it is not always clear to parents that a prenatal decision needs to be made and they can participate, influencing factors could be, e.g., unclear language, directive counseling, overload of information, and an immediate delivery. There is limited familiarity with shared decision making although it is the preferred model.

CONCLUSION

This study gained insight into preferred content, organization, and decision making of prenatal counseling at the limits of viability and their influencing factors from a professionals' perspective. What is Known: • Heterogeneity in prenatal counseling at the limits of viability exists • Differences between preferred counseling and actual practice also exists What is New: • Insight into preferred content, organization, and decision making of prenatal periviability counseling and its influencing factors from a professionals' perspective. Results should be taken into account when performing counseling. • Particularly the understanding of true shared decision making needs to be improved. Furthermore, implementation of shared decision making in daily practice needs more attention.

Do maternal characteristics influence maternal-fetal medicine physicians' willingness to intervene when managing periviable deliveries?

OBJECTIVE

Determine the relative influence of patient characteristics on Maternal-Fetal Medicine (MFM) physicians' willingness to intervene when managing 23-week preterm premature rupture of membranes.

STUDY DESIGN

Surveyed 750 randomly sampled US members of the Society of Maternal-Fetal Medicine. Physicians rated their willingness to offer induction, order steroids and perform cesarean across eight vignettes; then completed a questionnaire querying expectations about neonatal outcomes and demographics.

RESULTS

Three hundred and twenty-five (43%) MFMs responded. Patient characteristics only influenced ⩽11% of participants' willingness ratings. Overall, provider characteristics and institutional norms were associated with willingness to perform antenatal interventions, for example, practice region was associated with willingness to offer induction (P<0.001), order steroids (P=0.008) and perform cesarean for distress (P=0.011); while institutional cesarean cutoffs were associated with willingness to order steroids and perform cesarean for labor and distress (all P<0.001).

CONCLUSION

Physician-level factors and institutional norms, more so than patient characteristics, may drive periviable care and outcomes.

Using simulation to assess the influence of race and insurer on shared decision making in periviable counseling

INTRODUCTION

Sociodemographic differences have been observed in the treatment of extremely premature (periviable) neonates, but the source of this variation is not well understood. We assessed the feasibility of using simulation to test the effect of maternal race and insurance status on shared decision making (SDM) in periviable counseling.

METHODS

We conducted a 2 × 2 factorial simulation experiment in which obstetricians and neonatologists counseled 2 consecutive standardized patients diagnosed with ruptured membranes at 23 weeks, counterbalancing race (black/white) and insurance status using random permutation. We assessed verisimilitude of the simulation in semistructured debriefing interviews. We coded physician communication related to resuscitation, mode of delivery, and steroid decisions using a 9-point SDM coding framework and then compared communication scores by standardized patient race and insurer using analysis of variance.

RESULTS

Sixteen obstetricians and 15 neonatologists participated; 71% were women, 84% were married, and 75% were parents; 91% of the physicians rated the simulation as highly realistic. Overall, SDM scores were relatively high, with means ranging from 6.4 to 7.9 (of 9). There was a statistically significant interaction between race and insurer for SDM related to steroid use and mode of delivery (P < 0.01 and P = 0.01, respectively). Between-group comparison revealed nonsignificant differences (P = <0.10) between the SDM scores for privately insured black patients versus privately insured white patients, Medicaid-insured white patients versus Medicaid-insured black patients, and privately insured black patients versus Medicaid-insured black patients.

CONCLUSIONS

This study confirms that simulation is a feasible method for studying sociodemographic effects on periviable counseling. Shared decision making may occur differentially based on patients' sociodemographic characteristics and deserves further study.

Maternal-Fetal Medicine physicians' practice patterns for 22-week delivery management

OBJECTIVE

To describe Maternal-Fetal Medicine (MFM) physicians' practice patterns for 22-week delivery management.

MEHODS

Surveyed 750 randomly-sampled members of the Society of Maternal-Fetal Medicine, querying MFMs' practices and policies guiding 22-week delivery management.

RESULTS

Three hundred and twenty-five (43%) MFMs responded. Nearly all (87%) would offer induction. Twenty-eight percent would order steroids, and 12% would perform cesarean for a patient desiring resuscitation. Offering induction differed significantly based on the provider's practice setting, region, religious service attendance and political affiliation. In multivariable analyses, political affiliation remained a significant predictor of offering induction (p = 0.03).

CONCLUSIONS

Most MFMs offer induction for PPROM at 22 weeks. A noteworthy proportion is willing to order steroids and perform cesarean. Personal beliefs and practice characteristics may contribute to these decisions. While little is known about the efficacy of these interventions at 22 weeks, some MFMs will offer obstetrical intervention if resuscitation is intended.

A national survey of obstetricians' attitudes toward and practice of periviable intervention

OBJECTIVE

Test the association between provider characteristics and antenatal interventions offered for periviable delivery.

STUDY DESIGN

Six hundred surveys mailed to members of the College's Collaborative Ambulatory Research Network. Items queried physicians' practices regarding administering steroids, recommending cesarean (for breech) and offering induction (for ruptured membranes) at 23 weeks.

RESULT

Three hundred and ten (52%) obstetricians (OBs) responded. Respondents reported institutional cutoffs of 23 weeks for resuscitation (34%) and 24 weeks for cesarean (35%), whereas personal preferences for cesarean were ⩾25 weeks (44%). At 23 weeks, two-thirds ordered steroids, 43% recommended cesarean and 23% offered induction. In multivariable analyses, institutional cutoffs and providers' personal preferences predicted steroid administration (odds ratio, OR=4.37; 95% confidence interval, CI=1.73 to 11.00; OR=0.30, 95% CI=0.13 to 0.70); institutional cutoffs and the impression that cesarean decreases neurodevelopmental disability predicted recommending cesarean (OR=3.09, 95% CI=1.13 to 8.44; OR=6.41, 95% CI=2.06 to 19.91). For offering induction, practice location and religious service attendance approached, but did not meet, statistical significance (P=0.06 and P=0.05).

CONCLUSION

OBs' willingness to intervene can impact periviable outcomes. These findings suggest that personal and institutional factors may influence obstetrical counseling and decision-making.

Comparing obstetricians' and neonatologists' approaches to periviable counseling

OBJECTIVE

To compare the management options, risks and thematic content that obstetricians and neonatologists discuss in periviable counseling.

STUDY DESIGN

Sixteen obstetricians and 15 neonatologists counseled simulated patients portraying a pregnant woman with ruptured membranes at 23 weeks of gestation. Transcripts from video-recorded encounters were qualitatively and quantitatively analyzed for informational content and decision-making themes.

RESULT

Obstetricians more frequently discussed antibiotics (P=0.005), maternal risks (<0.001) and cesarean risks (<0.005). Neonatologists more frequently discussed neonatal complications (P=0.044), resuscitation (P=0.015) and palliative options (P=0.023). Obstetricians and neonatologists often deferred questions about steroid administration to the other specialty. Both specialties organized decision making around medical information, survival, quality of life, time and support. Neonatologists also introduced themes of values, comfort or suffering, and uncertainty.

CONCLUSION

Obstetricians and neonatologists provided complementary counseling content to patients, yet neither specialty took ownership of steroid discussions. Joint counseling and/or family meetings may minimize observed redundancy and inconsistencies in counseling.

The influence of resuscitation preferences on obstetrical management of periviable deliveries

OBJECTIVE

To determine the relative influence of patients' resuscitation preferences on periviable delivery management.

STUDY DESIGN

Surveyed 295 obstetrician-gynecologists about managing periviable preterm premature rupture of membranes. Across 10 vignettes, we systematically varied gestational age, occupation, method of conception and resuscitation preference. Physicians rated their likelihood (0 to 10) of proceeding with induction, steroids and cesarean. Data were analyzed via conjoint analysis.

RESULT

Two hundred and five physician responses were included. Median ratings for management decisions were: induction 1.89; steroids 5.00; cesarean for labor 3.89; and cesarean for distress 4.11. Gestational age had the greatest influence on physician ratings across all decisions (importance values ranging from 72.6 to 86.6), followed by patient's resuscitation preference (range=9.3 to 21.4).

CONCLUSION

Gestational age is weighted more heavily than patients' resuscitation preferences in obstetricians' decision making for periviable delivery management. Misalignment of antenatal management with parental resuscitation preferences may adversely affect periviable outcomes. Interventions are needed to facilitate more patient-centered decision making in periviable care.

'Ultrasound is an invaluable third eye, but it can't see everything': a qualitative study with obstetricians in Australia

Background

Obstetric ultrasound has come to play a significant role in obstetrics since its introduction in clinical care. Today, most pregnant women in the developed world are exposed to obstetric ultrasound examinations, and there is no doubt that the advantages of obstetric ultrasound technique have led to improvements in pregnancy outcomes. However, at the same time, the increasing use has also raised many ethical challenges. This study aimed to explore obstetricians’ experiences of the significance of obstetric ultrasound for clinical management of complicated pregnancy and their perceptions of expectant parents’ experiences.

Methods

A qualitative study was undertaken in November 2012 as part of the CROss-Country Ultrasound Study (CROCUS). Semi-structured individual interviews were held with 14 obstetricians working at two large hospitals in Victoria, Australia. Transcribed data underwent qualitative content analysis.

Results

An overall theme emerged during the analyses, ‘Obstetric ultrasound - a third eye’, reflecting the significance and meaning of ultrasound in pregnancy, and the importance of the additional information that ultrasound offers clinicians managing the surveillance of a pregnant woman and her fetus. This theme was built on four categories: I:‘Everyday-tool’ for pregnancy surveillance, II: Significance for managing complicated pregnancy, III: Differing perspectives on obstetric ultrasound, and IV: Counselling as a balancing act. In summary, the obstetricians viewed obstetric ultrasound as an invaluable tool in their everyday practice. More importantly however, the findings emphasise some of the clinical dilemmas that occur due to its use: the obstetricians’ and expectant parents’ differing perspectives and expectations of obstetric ultrasound examinations, the challenges of uncertain ultrasound findings, and how this information was conveyed and balanced by obstetricians in counselling expectant parents.

Conclusions

This study highlights a range of previously rarely acknowledged clinical dilemmas that obstetricians face in relation to the use of obstetric ultrasound. Despite being a tool of considerable significance in the surveillance of pregnancy, there are limitations and uncertainties that arise with its use that make counselling expectant parents challenging. Research is needed which further investigates the effects and experiences of the continuing worldwide rapid technical advances in surveillance of pregnancies.

Perspectives on anticipated quality-of-life and recommendations for neonatal intensive care: a survey of neonatal providers

OBJECTIVE

Explore associations between neonatal providers' perspectives on survival, quality of life (QOL) and treatment recommendations.

METHODS

Providers attending a workshop on neonatal viability were surveyed about survival, perceived QOL and treatment recommendations for marginally viable infants. We assessed associations between estimated survival and perceived QOL and treatment recommendations.

RESULTS

In the 44 included surveys, estimates of survival and QOL varied widely. Maximum care was recommended 80% of the time when anticipated QOL was high, versus 20% when anticipated QOL was low (p < 0.001). Adjusted for confounders, odds of recommending maximum intervention were 4.4 times higher when anticipated QOL was high (95% CI 1.9 - 10.2, p = 0.001).

CONCLUSIONS

The perspectives of practitioners who provide care to critically ill neonates regarding potential survival and QOL vary dramatically and are associated with the treatments those practitioners recommend. Practitioners should take care to avoid basing treatment recommendations on their own perspectives if they are not well aligned with those of the parents.

Periviable births: communication and counseling before delivery

The potential delivery of an extremely premature infant presents a clinical situation that raises a complex combination of medical, social, ethical, religious, and economic issues. It is a unique medical encounter such that it is not all about "curing" the patient. Rather, it is an encounter where counseling is assisting families in deciding between life and death underscoring the stressful nature for both patients and providers. As with any other condition, health care providers are responsible for discussing all potential options and outcomes for families presented with the threat of an extremely premature infant. These decisions include but are not limited to place and mode of delivery, resuscitation decisions, and palliative management. Given the urgency of the situation, the emotionally charged nature of the decision, and the relative unpredictability prior to presentation, this particular situation poses unique challenges for all involved and mandates the need to have carefully constructed guidelines and processes for care and counseling that meet the needs of all involved.