Neonatology consultations for preterm labour beyond the grey zone: reconceptualising our goals

The 30-Minute Sprint: Recognizing Intrapartum Prematurity Counseling Limitations

Describe the characteristics and content of intrapartum counseling provided to women hospitalized for premature birth between 23 and 34 weeks' gestation age (GA). The study was conducted between April and December 2009 in two teaching hospitals with labor and delivery units and level 3 neonatal intensive care units. Counselors completed a postcounseling survey. From 60 sessions, 46 surveys were collected. The median counseling duration was 30 minutes; this was not associated with gestational age. The support-person was not present for most (57%) counseling sessions. There was a positive correlation (p = 0.001) between the number of maternal questions and her education. There was no difference in counseling content across the 23 to 34 weeks' GA regarding delivery room care, physical/mental disability, and vision problems. This study of characteristics and content of premature birth counseling for birth between 23 and 34 weeks' GA found that the duration of most sessions is 30 minutes; the father of the baby is not present during counseling for most premature births, and the topics discussed by counselors are fairly similar and extensive irrespective of the GA. These findings highlight the existing contrast between the recommended counseling practices and the actual practice reported by counselors.

Antenatal consultations for preterm labour: how are future mothers reassured?

OBJECTIVE

To evaluate whether the antenatal consultation for preterm labour worries or reassures women, and to identify factors contributing to these feelings.

DESIGN

This is a prospective survey study from April 2012 to September 2013. This mixed-methodology tool was co-constructed with patients and first tested in a single-centre pilot study.

SETTING

Three university-affiliated, tertiary care, high-risk obstetrics inpatient units in Quebec, Canada.

PARTICIPANTS

Women hospitalised with threatened preterm labour between 26 and 32 weeks' gestational age completed the survey within 72 hours of an antenatal consultation by neonatology. 341 women were invited to participate and 226 mothers completed the survey (72% response rate), at a median gestational age of 30 weeks.

MAIN OUTCOME MEASURES

Participant worry, reassurance and change in perception after the antenatal consultation were the main outcome measures. Multivariable logistic regression was used to identify factors associated with these outcomes.

RESULTS

23% of participants were worried by the consultation, and 87% were reassured by it. Lower gestational age and higher maternal education were associated with feeling worried (adjusted OR=0.83, 95% CI 0.70 to 0.99; and adjusted OR=2.15, 95% CI 1.04 to 4.44, respectively). Longer consultations were associated with reassurance (adjusted OR=8.21, 95% CI 2.67 to 25.26). Women were reassured by (1) feeling well informed about prematurity with optimistic outlooks, and (2) a trusting and reassuring expert neonatology team. High-quality interactions with neonatologists were associated with reassurance, while poorer communications were associated with feelings of worry.

CONCLUSIONS

To be reassuring, neonatologists should strive to establish a trusting relationship with mothers, in which realistic and clear, but optimistic, information is offered.

Focusing on relationships, not information, respects autonomy during antenatal consultations

Policy statements regarding antenatal consultations for preterm labour are guided by physicians' concerns for upholding the legal doctrine of informed consent, through the provision of standardised homogeneous medical information. This approach, led by classical in-control conceptions of patient autonomy, conceives moral agents as rational, independent, self-sufficient decision-makers. Recent studies on these antenatal consultations have explored patients' perspectives, and these differ from guidelines' suggestions. Relational autonomy - which understands moral agents as rational, emotional, creative and interdependent - resonates impressively with these new data.

CONCLUSION

A model for antenatal consultations is proposed. This approach encourages clinicians to explore individual patients' lived experiences and engage in trusting empowering relationships. Moreover, it calls on physicians to enhance patients' relational autonomy by becoming advocates for their patients within healthcare institutions and professional organisations, while calling for broadscale policy changes to encourage further funding and support in investigations of the patient's voice.

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.

Personalized Antenatal Consultations for Preterm Labor: Responding to Mothers' Expectations

OBJECTIVE

To explore prospective mothers' perspectives regarding antenatal consultations by neonatology teams for threatened preterm delivery.

STUDY DESIGN

In a prospective multicenter study, women at risk of preterm delivery between 26 and 32 weeks of gestational age were surveyed during the 72 hours following their antenatal consultation. The questionnaire used was developed and validated during a single-center study.

RESULTS

Over 18 months, 229 mothers completed the survey (73% response rate), at a median gestational age of 30 weeks. Spouses/partners were present for 49% of consultations. Most women (90%) reported a positive experience. They found it important to discuss the outcomes of prematurity (96%), but 39% of them reported receiving too much information. Women wanted their spouse/partner to be present (71%) and wished to discuss parental concerns: their roles as mother of a premature baby (82%), their integration in their baby's care (83%), and a better understanding of the neonatal intensive care unit (NICU) environment, including antenatal NICU visits (69%). The majority (56%) wanted a follow-up consultation: this was less likely if a NICU visit had been offered (P < .001), if their role as decision-maker had been discussed (P < .05), or if the consultation had lasted longer (P = .001).

CONCLUSION

Policy statements recommend a standardized approach to providing parents with child-centered information. Although clinicians follow these guidelines, mothers want personalized information focusing on their individual concerns and questions, such as what they can do for their baby, how NICUs work, and the integration of their family.