Making the best decisions when faced with the risks of premature delivery

December 01, 2005

Mothers who give birth to premature babies must often make critical and difficult decisions. Because premature babies have lower survival rates and could suffer long term disabilities, the decision to resuscitate can be complex. Doctors typically converse with parents about treatment options and the need for resuscitation for premature babies. A study in the November issue of The Journal of Pediatrics shows that what happens in the delivery room is not always reflective of these conversations.

Keith Barrington, MB, CHB, and Annie Janvier, MD, from the Royal Victoria Hospital in Canada, reviewed the hospital records of 72 babies who were at risk for preterm delivery between 1999 and 2002. They found that the conversations between doctors and parents were often not well-documented. Women who are at risk of delivering a premature baby are usually presented with three options: 1) resuscitate the baby or initiate intensive care if necessary with the opportunity to withdraw the request if the prognosis at birth is poor; 2) comfort care only (keep the baby comfortable without medical care procedures); 3) resuscitate if the baby's condition is good, but only comfort care if the prognosis is poor. However, parents may have the misconception that resuscitation counseling and procedures are the same at different hospitals. The authors were surprised to find that all 27 infants who were delivered at 23 to 24 weeks gestation were resuscitated. They point out that this finding is not because resuscitation occurred against the wishes of the parents, but rather that the atmosphere and policies of the hospital may have an effect on the parents' final decision. The experience, expectations, and training of the hospital staff could also play a role in the outcomes of neonatal counseling. Dr. J.M. Lorenz concurs with this idea in his editorial, stating that some doctors may impose their own values on parents rather than acting on their medical knowledge, expertise, and experience.

"There is a need for more complete documentation of the conversations between parents and medical staff to ensure that the decision-making process is clear to everyone concerned," says Dr. Barrington. After the completion of this study, Royal Victoria Hospital has introduced a procedure that includes an information sheet that is given to all parents facing an extremely preterm delivery. The sheet emphasizes the parents' role in the decision making at 23 to 24 weeks gestation and highlights the long- and short-term outcomes according to gestational age.
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The study is reported in "The ethics of neonatal resuscitation at the margins of viability: informed consent and outcomes" by Annie Janvier, MD, and Keith J. Barrington, MB, CHB. The article appears in The Journal of Pediatrics, Volume 147, Number 5 (November 2005), published by Elsevier.

The Journal of Pediatrics is a primary reference for the science and practice of pediatrics and its subspecialties. This authoritative resource of original, peer-reviewed articles oriented toward clinical practice helps physicians stay abreast of the latest and ever-changing developments in pediatric medicine. The Journal of Pediatrics ranks 3rd of 70 pediatric journals receiving the most citations (Science Citation Index). The Journal is published by Elsevier, a leading global publisher of scientific, technical, and medical journals, books, and reference works. It is a member of the Reed Elsevier plc group. URL: www.jpeds.com

Elsevier Health Sciences

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