Comparing neonatal morbidity and mortality estimates across specialty in periviable counseling (original) (raw)
Related papers
Ensuring Accurate Knowledge of Prematurity Outcomes for Prenatal Counseling: In Reply
PEDIATRICS, 2005
Objectives. To determine the accuracy of knowledge of different health care providers regarding survival and long-term morbidity rates for very premature infants and to examine whether a focused educational intervention improves the accuracy of this knowledge and influences health care decisions. Methods. Using hypothetical case scenarios with infants at <28 weeks of gestation, we surveyed a variety of caregivers involved in perinatal communication and decision-making processes at a tertiary center that provides intensive care for neonates. We asked physicians from the pediatrics and obstetrics services and nurses and nurse practitioners from the NICU and obstetrics ward for their best estimates of survival and major long-term disability rates and for their opinions regarding the appropriateness of resuscitation and life support at each week of gestation of <29 weeks. After the survey, we educated all providers about current data on survival and long-term disability rates for preterm infants and gave them pocket-sized cards summarizing this information for reference during prenatal counseling. One month after the educational intervention and complete dissemination of the cards, a questionnaire with questions identical to those in the first survey was mailed to the same individuals. Results. Fifty-one health care providers were involved in the baseline survey. The response rates for the postintervention survey were 100% for physicians (20 of 20 subjects) and nurses (20 of 20 subjects) and 91% (10 of 11 subjects) for the nurse practitioners. In the baseline survey, statistically significant underestimates of survival rates were seen for physicians and nurses at 23 to 28 weeks of gestation and for nurse practitioners at 23 to 27 weeks of gestation. Statistically significant overestimates of disability rates were seen for physicians and nurse practitioners at <26 weeks of gestation and for nurses at <28 weeks of gestation. After the intervention, respondents demonstrated significant improvements in the accuracy of survival and disability estimates at many, but not all, gestational ages. Although underestimation of survival rates and overestimation of disability rates decreased after the intervention, it persisted to some degree. After the intervention, a larger proportion of physicians (53% vs 21%) and a smaller proportion of nurses (10% vs 37%) were likely to recommend resuscitation for infants born at 23 weeks of gestation. Conclusions. Physicians, nurses, and nurse practitioners underestimated survival rates and overestimated long-term disability rates for very premature infants. After education, their estimates of survival and long-term disability rates for these infants improved significantly. More accurate estimates of survival and disability rates affected physicians' and nurses' theoretical decisionmaking regarding the appropriateness of resuscitation at 23 weeks of gestation.
Comparing obstetricians' and neonatologists' approaches to periviable counseling
Journal of perinatology : official journal of the California Perinatal Association, 2014
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 o...
Acta Paediatrica, 2018
Aim: American guidelines suggest that neonatal resuscitation be considered at 23 weeks of gestation, one week earlier than in the Netherlands, but how counselling practices differ at the threshold of viability is unknown. This pilot study compared prenatal periviability counselling in the two countries. Methods: In 2013, a cross-sectional survey was sent to 121 Dutch neonatologists as part of a nationwide evaluation of prenatal counselling. In this pilot study, the same survey was sent to a convenience sample of 31 American neonatologists in 2014. The results were used to compare the organisation, content and decision-making processes in prenatal counselling at 24 weeks of gestation between the two countries. Results: The survey was completed by 17 (55%) American and 77 (64%) Dutch neonatologists. American neonatologists preferred to meet with parents more frequently, for longer periods of time, and to discuss more intensive care topics, including long-term complications, than Dutch neonatologists. Neonatologists from both countries preferred shared decision-making when deciding whether to initiate intensive care. Conclusion: Neonatologists in the United States and the Netherlands differed in their approach to prenatal counselling at 24 weeks of gestation. Cross-cultural differences may play a role.
Joint periviability counseling between neonatology and obstetrics is a rare occurrence
Journal of Perinatology, 2020
Objective To investigate the frequency with which neonatal and maternal-fetal medicine (MFM) providers perform joint periviability counseling (JPC), compare content of counseling, and identify perceived barriers to JPC. Study design An anonymous REDCap survey was e-mailed to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine and to members of the Society for MFM. Results There were 424 neonatal and 115 MFM participants. Fifty-two percent of neonatal and 35% of MFM respondents reported rarely/never performing JPC (p < 0.001), while 80% and 82%, respectively felt it would improve counseling. Content of counseling was similar, except for length of stay with 93% of neonatal vs. 85% of MFM respondents addressing this (p = 0.03). The majority (>60%) of respondents in both groups reported that clinical duties posed a significant/great barrier to JPC. Conclusion JPC is recommended but infrequently performed, with both specialties interested in further collaboration to strengthen the counseling provided.
American Journal of Obstetrics and Gynecology, 1988
The purpose of this clinical investigation was to determine the maternal and perinatal results of continuing pregnancy in 118 consecutive patients with premature rupture of the membranes at 16 to 26 weeks. The mean gestational age at diagnosis of premature rupture of the membranes was 23.1 ± 2. 7 weeks, with a median of 23.5. The interval from rupture to delivery ranged from 1 to 152 days, with a mean of 13. There was no correlation between gestational age at the time of rupture and the latency period. Thirty-five patients received tocolytic agents and 24 received steroids. Forty-eight percent were delivered within 3 days, 67% within 1 week, and 83% within 2 weeks. There was one maternal death from sepsis; 46 (39%) had amnionitis, and 8 (6.8%) had abruptio placentae. The mean gestational age at the time of delivery was 24.7 ± 3.6 weeks. The 118 pregnancies resulted in 124 births. There were 17 stillbirths and 67 neonatal deaths, for a total perinatal mortality of 67.7%. In patients with premature rupture of the membranes at ,.;;23 weeks the perinatal survival rate was 13.3%, while it was 50% in patients with premature rupture of the membranes at 24 to 26 weeks (p < 0.0001). Information was charted at 3 to 36 months for 34 of 40 surviving infants. The intact survival rate in this group was 67%, and 33% had some form of developmental abnormality. Expectant management in such cases can be justified in only a limited number of patients (patients who understand and accept the risks and patients beyond 23 weeks of gestation).
Acta Obstetricia et Gynecologica Scandinavica, 2010
Objective. To compare maternal and neonatal outcomes in deliveries managed by a policy of expectant management and active management of women with preterm prelabor rupture of membranes (pPROM), at 34-36 completed weeks of gestation. Design. Retrospective multicenter cohort study. Setting. Three tertiary care teaching hospitals in France. Population. Women with pPROM were identified from the databases of three perinatal centers. Methods. Maternal and neonatal complications were compared according to the hospital policy in effect at pPROMexpectant or active management. Main outcome measures. Clinical chorioamnionitis, neonatal morbidity including neonatal infection, respiratory problems, and metabolic disorders. Results. During the seven-year study period, 634 women were admitted for pPROM at 34-36 completed weeks of gestation, 241 of whom were included in the study: 126 in the group with a policy of expectant management and 115 in the active management group. The incidence of clinical chorioamnionitis was 4.8% in the former and 0.9% in the latter (p = 0.07). Neonatal oxygen was still needed at 24 hours significantly more often in the active than in the expectant management group (7.0 vs. 1.6%, p = 0.05). However, after adjustment for gestational age at birth, only delivery at 34 weeks of gestation remained associated with the need for neonatal oxygen at 24 hours. The rate of hypoglycemia or hypocalcemia was 5.6% in the expectant management group versus 12.3% in the active management group (p = 0.07). There were no neonatal deaths. Conclusion. A policy of active management, especially at 34 weeks of gestation, was associated with greater neonatal morbidity, whereas an expectant management policy tended to be associated with an increased rate of clinical chorioamnionitis.
BMC Medical Ethics, 2019
Background: Differences in perception and potential disagreements between parents and professionals regarding the attitude for resuscitation at the limit of viability are common. This study evaluated in healthcare professionals whether the decision to resuscitate at the limit of viability (intensive care versus comfort care) are influenced by the way information on incurred risks is given or received. Methods: This is a prospective randomized controlled study. This study evaluated the attitude of healthcare professionals by testing the effect of information given through graphic fact sheets formulated either optimistically or pessimistically. The written educational fact sheet included three graphical presentations of survival and complication/morbidity by gestational age. The questionnaire was submitted over a period of 4 months to 5 and 6year medical students from the Geneva University as well as physicians and nurses of the neonatal unit at the University Hospitals of Geneva. Our sample included 102 healthcare professionals. Results: Forty-nine responders (48%) were students (response rate of 33.1%), 32 (31%) paediatricians (response rate of 91.4%) and 21 (20%) nurses in NICU (response rate of 50%). The received risk tended to be more severe in both groups compared to the graphically presented facts and current guidelines, although optimistic representation favoured the perception of "survival without disability" at 23 to 25 weeks. Therapeutic attitudes did not differ between groups, but healthcare professionals with children were more restrained and students more aggressive at very low gestational ages. Conclusion: Written information on mortality and morbidity given to healthcare professionals in graphic form encourages them to overestimate the risk. However, perception in healthcare staff may not be directly transferable to parental perception during counselling as the later are usually naïve to the data received. This parental information are always communicated in ways that subtly shape the decisions that follow.
Maternal features at time of preterm prelabor rupture of membranes and short-term neonatal outcomes
The Journal of Maternal-Fetal & Neonatal Medicine, 2020
Objective: The objective of this study was to assess if maternal and obstetric characteristics other than gestational age at the time of rupture impact short-term neonatal outcomes. Methods: This is a retrospective observational study from a single tertiary care referral center. This study reviewed women with a singleton pregnancy complicated by preterm prelabor rupture of membranes over a 3-year period from May of 2014 through May of 2017. Maternal characteristics and short term neonatal outcomes were collected. Results: We identified 210 pregnancies complicated by preterm prelabor rupture of membranes. Eighteen of these patients had rupture of membranes prior to viability. Of the maternal characteristics at time of admission studied, gestational age at rupture and race influenced short term neonatal outcomes. Women who identified as race other than white had neonates with lower rates of intubation than neonates born to white patients. Gestational age at rupture significantly influenced the neonatal intensive care unit length of stay. Each additional week gained before rupture occurred was associated with a 17.1% decrease in length of stay. Maternal age, gravidity, parity, body mass index, single deepest pocket, and amniotic fluid index did not influence short term neonatal outcomes. Conclusions: Gestational age at rupture of membranes is the most predictive factor associated with short term neonatal outcomes. Race may also influence short term neonatal outcomes. Other maternal characteristics do not seem to influence short term neonatal outcomes. This information can assist with patient counseling on admission for preterm prelabor rupture of membranes and expected neonatal course.