Family Preference Largely Determines Periviable Deliveries

Lara C. Pullen, PhD

March 02, 2012

March 2, 2012 — Patient preferences are a major factor in directing obstetric decision-making and counseling during the periviable window (22 - 26 weeks). Most physicians perceive that parents consistently prefer to have "everything done" to save the life of the neonate.

Brownsyne Tucker Edmonds, MD, MS, MPH, and colleagues from the University of Pennsylvania, Philadelphia, described the results of 21 semistructured interviews in the March issue of the American Journal of Obstetrics and Gynecology. The study focused on physicians (6 maternal-fetal medicine physicians, 2 maternal-fetal medicine fellows, and 13 obstetric/gynecology generalists) in academic medical centers in Philadelphia. The compilation of interviews highlights the institutional variations in periviable care.

A previous study found that obstetricians' willingness to perform cesarean delivery at 24 weeks increased the odds of the neonate’s survival 3.7 times but doubled the chance of survival with serious morbidity. Results from the interviews suggest that viability judgment and gestational age thresholds for routine intervention differ depending on the practice type of the physician, number of years in practice, and region of practice. Thus, thresholds for intervention varied between attending physicians and institutions.

Most physicians interviewed focused initially on clinical presentation, including imminence of delivery, signs of infection, and malpresentation. All physicians described pursuing interventions to prolong the pregnancy unless patients actively opted out. Physicians also considered the capability of their institutions' neonatal intensive care unit as well as the neonatologists' practices when assessing management options.

Race, class, and culture were not mentioned as major factors in determining which options were offered and chosen in the delivery room. Women with in vitro fertilization pregnancies, however, were managed aggressively. Most physicians prioritized objectivity and respect for patient autonomy when advising women who were at risk for periviable delivery and deemphasized hope.

"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," the authors conclude.

The study was supported by the Eisenberg pilot grant from the University of Pennsylvania School of Medicine and by the Robert Wood Johnson Foundation Clinical Scholars Program at the University of Pennsylvania at the time of the study. The authors have disclosed no relevant financial relationships.

Am J Obstet Gynecol. 2012;206:248e1-5. Abstract

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