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Pais-Cunha I, Peixoto S, Soares H, Costa S. Limits of Viability: Perspectives of Portuguese Neonatologists and Obstetricians. ACTA MEDICA PORT 2024; 37:617-625. [PMID: 39067866 DOI: 10.20344/amp.21473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/18/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Advances in neonatal care have improved the prognosis in extremely preterm infants. The gestational age considered for active treatment has decreased globally. Despite implemented guidelines, several studies show variability in practice. The aim of this study was to understand theperspectives of Portuguese neonatologists and obstetricians regarding the management of extremely preterm infants. METHODS An online survey was sent through the Portuguese Neonatology Society and the Portuguese Society of Obstetrics and Maternal-Fetal Medicine from August to September 2023. RESULTS We obtained 117 responses: 53% neonatologists, 18% pediatricians, and 29% obstetricians, with 62% having more than 10 years of experience. The majority (80%) were familiar with the Portuguese Neonatology Society consensus on the limits of viability and 46% used it in practice; 62% were unaware of Portuguese morbidity-mortality statistics associated with extremely preterm infants. Most (91%) informed parents about morbiditymortality concerning the gestational age more frequently upon admission (64%) and considered their opinion in the limit of viability situations (95%). At 22 weeks gestational age, 71% proposed only comfort care, while at 25 and 26 weeks, the majority suggested active care (80% and 96%, respectively). Less consensus was observed at 23 and 24 weeks. At 24 weeks, most obstetricians offered active care with the option of comfort care by parental choice (59%), while the neonatology group provided active care (65%), p < 0.001. Regarding the lower limit of gestational age for in utero transfer, corticosteroid administration, cesarean section for fetal indication, neonatologist presence during delivery, and endotracheal intubation; neonatologists considered a lower gestational age than obstetricians (23 vs 24 weeks; p = 0.036; p < 0.001; p < 0.001; p = 0.021; p < 0.001, respectively). CONCLUSION Differences in perspectives between obstetricians and neonatologists in limits of viability situations were identified. Neonatologists considered a lower gestational age in various scenarios and proposed active care earlier. Standardized counseling for extremely preterm infants is crucial to avoid ambiguity, parental confusion, and conflicts in perinatal care.
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Affiliation(s)
- Inês Pais-Cunha
- Serviço de Neonatologia. Unidade Autónoma de Gestão da Mulher e Criança. Unidade Local de Saúde São João. Porto.; Faculdade de Medicina. Universidade do Porto. Porto. Portugal
| | - Sara Peixoto
- Serviço de Neonatologia. Unidade Autónoma de Gestão da Mulher e Criança. Unidade Local de Saúde São João. Porto.; Serviço de Neonatologia. Hospital Pedro Hispano. Unidade Local de Saúde de Matosinhos. Matosinhos. Portugal
| | - Henrique Soares
- Serviço de Neonatologia. Unidade Autónoma de Gestão da Mulher e Criança. Unidade Local de Saúde São João. Porto.; Faculdade de Medicina. Universidade do Porto. Porto. Portugal
| | - Sandra Costa
- Serviço de Neonatologia. Unidade Autónoma de Gestão da Mulher e Criança. Unidade Local de Saúde São João. Porto.; Faculdade de Medicina. Universidade do Porto. Porto. Portugal
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2
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Vidaeff AC, Kaempf JW. The Ethics and Practice of Periviability Care. CHILDREN (BASEL, SWITZERLAND) 2024; 11:386. [PMID: 38671603 PMCID: PMC11049503 DOI: 10.3390/children11040386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/28/2024]
Abstract
Since the 1960s, the gestational age at which premature infants typically survive has decreased by approximately one week per decade [...].
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Affiliation(s)
- Alex C. Vidaeff
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX 77030, USA
- Texas Children’s Hospital Pavilion for Women, 6651 Main Street, Suite F1020, Houston, TX 77030, USA
| | - Joseph W. Kaempf
- Women & Children’s Institute, Providence Health System Oregon, Portland, OR 97232, USA;
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3
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Ferrand A, Poleksic J, Racine E. Factors Influencing Physician Prognosis: A Scoping Review. MDM Policy Pract 2022; 7:23814683221145158. [PMID: 36582416 PMCID: PMC9793048 DOI: 10.1177/23814683221145158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/08/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction. Prognosis is an essential component of informed consent for medical decision making. Research shows that physicians display discrepancies in their prognostication, leading to variable, inaccurate, optimistic, or pessimistic prognosis. Factors driving these discrepancies and the supporting evidence have not been reviewed systematically. Methods. We undertook a scoping review to explore the literature on the factors leading to discrepancies in medical prognosis. We searched Medline (Ovid) and Embase (Ovid) databases for peer-reviewed articles from 1970 to 2017. We included articles that discussed prognosis variation or discrepancy and where factors influencing prognosis were evaluated. We extracted data outlining the participants, methodology, and prognosis discrepancy information and measured factors influencing prognosis. Results. Of 4,723 articles, 73 were included in the final analysis. There was significant variability in research methodologies. Most articles showed that physicians were pessimistic regarding patient outcomes, particularly in early trainees and acute care specialties. Accuracy rates were similar across all time periods. Factors influencing prognosis were clustered in 4 categories: patient-related factors (such as age, gender, race, diagnosis), physician-related factors (such as age, race, gender, specialty, training and experience, attitudes and values), clinical situation-related factors (such as physician-patient relationship, patient location, and clinical context), and environmental-related factors (such as country or hospital size). Discussion. Obtaining accurate prognostic information is one of the highest priorities for seriously ill patients. The literature shows trends toward pessimism, especially in early trainees and acute care specialties. While some factors may prove difficult to change, the physician's personality and psychology influence prognosis accuracy and could be tackled using debiasing strategies. Exposure to long-term patient outcomes and a multidisciplinary practice setting are environmental debiasing strategies that may warrant further research. Highlights Literature on discrepancies in physician's prognostication is heterogeneous and sparse.Literature shows that physicians are mostly pessimistic regarding patient outcomes.Literature shows that a physician's personality and psychology influence prognostic accuracy and could be improved with evidence-based debiasing strategies.Medical specialty strongly influences prognosis, with specialties exposed to acutely ill patients being more pessimistic, whereas specialties following patients longitudinally being more optimistic.Physicians early in their training were more pessimist than more experienced physicians.
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Affiliation(s)
- Amaryllis Ferrand
- Amaryllis Ferrand, Pragmatic Health Ethics
Research Unit, Montreal Clinical Research Institute, 10 Pine Ave West, Montreal,
QC H2W 1R7, Canada; ()
| | - Jelena Poleksic
- Pragmatic Health Ethics Research Unit, Montreal
Clinical Research Institute, Montreal, QC, Canada,Faculty of Medicine, University of Western
Ontario, London, ON, Canada
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Montreal
Clinical Research Institute, Montreal, QC, Canada,Departments of Medicine and Social and
Preventive Medicine, University of Montreal, Montreal, Canada,Biomedical Ethics Unit, McGill University,
Montreal, QC, Canada
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4
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Cascio A, Ferrand A, Racine E, St-Hilaire M, Sanon PN, Gorgos A, Wintermark P. Discussing brain magnetic resonance imaging results for neonates with hypoxic-ischemic encephalopathy treated with hypothermia: A challenge for clinicians and parents. eNeurologicalSci 2022; 29:100424. [PMID: 36147866 PMCID: PMC9485039 DOI: 10.1016/j.ensci.2022.100424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 11/27/2022] Open
Abstract
Context Clinicians use brain magnetic resonance imaging (MRI) to discuss neurodevelopmental prognosis with parents of neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia (TH). Purpose To investigate how clinicians and parents discuss these MRI results in the context of HIE and TH and how these discussions could be facilitated and more meaningful for parents. Procedures Mixed-methods surveys with open-ended and closed-ended questions were completed by two independent groups. (1) Clinicians responded to clinical vignettes of neonates with HIE treated with TH with various types of clinical features, evolution and extent of brain injury and questions about how they discuss brain MRI results in this context. (2) Parents of children with HIE treated with TH responded to questions about the discussion of MRI that they had while still in the neonatal intensive care unit and were asked to place it in perspective with the outcomes of their child when he/she reached at least 2 years of age. Open-ended responses were analyzed using a thematic analysis approach. Closed-ended responses are presented descriptively. Results Clinicians reported uncertainty, lack of confidence, and limitations when discussing brain MRI results in the context of HIE and TH. Brain MRI results were "usually" (53%) used in the prognostication discussion. When dealing with day-2 brain MRIs performed during TH, most clinicians (40%) assumed that the results of these early MRIs were only "sometimes" accurate and only used them "sometimes" (33%) to discuss prognosis; a majority of them (66%) would "always" repeat imaging at a later time-point to discuss prognosis. Parents also struggled with this uncertainty, but did not discuss limitations of MRI as often. Parents raised the importance of the setting where the discussion took place and the importance to inform them as quickly as possible. Clinicians identified strategies to improve these discussions, including interdisciplinary approach, formal training, and standardized approach to report brain MRI. Parents highlighted the importance of communication skills, the stress, the hope surrounding their situation, and the need to receive answers as soon as possible. The importance of showing the pictures or making representative drawing of the injury, but also highlighting the not-injured brain, was also highlighted by parents. Conclusions Discussing brain MRI results for neonates with HIE treated with TH are challenging tasks for clinicians and daunting moments for parents.
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Affiliation(s)
- Ariel Cascio
- College of Medicine, Central Michigan University, Mount Pleasant, USA
| | - Amaryllis Ferrand
- Pragmatic Health Ethics Research Unit, Montreal Clinical Research Institute, Montreal, Canada
- Division of Newborn Medicine, Department of Pediatrics, Jewish General Hospital, McGill University, Montreal, Canada
- Faculty of Medicine, Department of Biomedical Sciences, University of Montreal, Montreal, Canada
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Montreal Clinical Research Institute, Montreal, Canada
- Departments of Medicine and Social and Preventive Medicine, University of Montreal, Montreal, Canada
- Departments of Neurology and Neurosurgery, Medicine, and Biomedical Ethics Unit, McGill University. Montreal, Canada
| | - Marie St-Hilaire
- Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada
| | - Priscille-Nice Sanon
- Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada
| | - Andreea Gorgos
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Pia Wintermark
- Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
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Factors influencing appropriate use of interventions for management of women experiencing preterm birth: A mixed-methods systematic review and narrative synthesis. PLoS Med 2022; 19:e1004074. [PMID: 35998205 PMCID: PMC9398034 DOI: 10.1371/journal.pmed.1004074] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 07/12/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Preterm birth-related complications are the leading cause of death in newborns and children under 5. Health outcomes of preterm newborns can be improved with appropriate use of antenatal corticosteroids (ACSs) to promote fetal lung maturity, tocolytics to delay birth, magnesium sulphate for fetal neuroprotection, and antibiotics for preterm prelabour rupture of membranes. However, there are wide disparities in the rate and consistency in the use of these interventions across settings, which may underlie the differential health outcomes among preterm newborns. We aimed to assess factors (barriers and facilitators) affecting the appropriate use of ACS, tocolytics, magnesium sulphate, and antibiotics to improve preterm birth management. METHODS AND FINDINGS We conducted a mixed-methods systematic review including primary qualitative, quantitative, and mixed-methods studies. We searched MEDLINE, EMBASE, CINAHL, Global Health, and grey literature from inception to 16 May 2022. Eligible studies explored perspectives of women, partners, or community members who experienced preterm birth or were at risk of preterm birth and/or received any of the 4 interventions, health workers providing maternity and newborn care, and other stakeholders involved in maternal care (e.g., facility managers, policymakers). We used an iterative narrative synthesis approach to analysis, assessed methodological limitations using the Mixed Methods Appraisal Tool, and assessed confidence in each qualitative review finding using the GRADE-CERQual approach. Behaviour change models (Theoretical Domains Framework; Capability, Opportunity, and Motivation (COM-B)) were used to map barriers and facilitators affecting appropriate use of these interventions. We included 46 studies from 32 countries, describing factors affecting use of ACS (32/46 studies), tocolytics (13/46 studies), magnesium sulphate (9/46 studies), and antibiotics (5/46 studies). We identified a range of barriers influencing appropriate use of the 4 interventions globally, which include the following: inaccurate gestational age assessment, inconsistent guidelines, varied knowledge, perceived risks and benefits, perceived uncertainties and constraints in administration, confusion around prescribing and administering authority, and inadequate stock, human resources, and labour and newborn care. Women reported hesitancy in accepting interventions, as they typically learned about them during emergencies. Most included studies were from high-income countries (37/46 studies), which may affect the transferability of these findings to low- or middle-income settings. CONCLUSIONS In this study, we identified critical factors affecting implementation of 4 interventions to improve preterm birth management globally. Policymakers and implementers can consider these barriers and facilitators when formulating policies and planning implementation or scale-up of these interventions. Study findings can inform clinical preterm birth guidelines and implementation to ensure that barriers are addressed, and enablers are reinforced to ensure these interventions are widely available and appropriately used globally.
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6
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Wood K, Di Stefano LM, Mactier H, Bates SE, Wilkinson D. Individualised decision making: interpretation of risk for extremely preterm infants-a survey of UK neonatal professionals. Arch Dis Child Fetal Neonatal Ed 2022; 107:281-288. [PMID: 34413095 PMCID: PMC9046748 DOI: 10.1136/archdischild-2021-322147] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/17/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND The British Association of Perinatal Medicine (BAPM) published a revised framework for perinatal management of extremely preterm infants (EPIs) in 2019. We aimed to assess UK neonatal professionals' interpretation of elements of this framework, as well as the consistency of their estimates of outcome for EPIs. METHODS An online survey gave participants five cases involving anticipated extremely preterm birth with different favourable and unfavourable risk factors. Respondents were asked to assign a risk category and management option using the BAPM framework and to estimate the chance of survival if the baby received active resuscitation and the chance of severe disability if they survived. RESULTS Respondents were consistent in interpretation of risk categories. The majority would follow parental wishes about management. Management decisions did not always correspond with risk assessment, with less inclination to recommend palliative (comfort) care. There were wide estimates of survival or severe disability (5%-90%) with consultants providing lower estimates of severe disability than other groups. CONCLUSION UK neonatal professionals deferred to parental wishes in the cases presented, indicating an emphasis on shared decision making. However, they did not necessarily use the risk stratification approach for management decisions. Variation in estimates of outcome raises questions about the accuracy of informed decision making and suggests support is needed for UK clinicians to incorporate risk factors into individualised counselling. There may be value in validating existing online risk calculators for UK infants or in developing a UK specific risk model.
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Affiliation(s)
- Katherine Wood
- Department of Newborn Care, John Radcliffe Hospital, Oxford, UK
| | - Lydia Mietta Di Stefano
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Helen Mactier
- Department of Neonatology, Princess Royal Maternity, Glasgow, UK,School of Medicine, University of Glasgow, Glasgow, UK
| | - Sarah Elizabeth Bates
- Department of Women & Childrens, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Dominic Wilkinson
- Department of Newborn Care, John Radcliffe Hospital, Oxford, UK .,Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
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7
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Marlow N, Adams E, David AL. Refining regional organization of services in the UK to improve outcomes of pregnancies delivering at extremely low gestational age. Semin Perinatol 2022; 46:151534. [PMID: 34879981 DOI: 10.1016/j.semperi.2021.151534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Care for pregnant women and their infants at extremely low gestational ages challenges clinical teams. The continuing rise in survival at gestational ages below 25 weeks has prompted re-evaluation of practice guidelines within the UK and other countries. This paper describes the background data that have guided our practice, the approach that has been taken to deliver optimal outcomes for pregnancies delivering at extremely low gestational age in the UK, mainly through centralising care, and discusses the research and audit data that support our practice. In particular, we emphasize the importance of a coordinated perinatal approach to both mother and infant, and careful assessment of the risks to both, to ensure that we develop the highest quality personalized care for each family, supported by national quality improvement and research evidence.
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Affiliation(s)
- Neil Marlow
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, 74 Huntley Street, London WC1E 6AU, UK.
| | - Eleri Adams
- Getting it Right First Tim (GIRFT) Clinical Lead for Neonatology and Consultant Neonatologist, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anna L David
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, 74 Huntley Street, London WC1E 6AU, UK
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8
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Sherriff R, Preisz A, Adams S, Smyth J, Coudanaris E, Jacobs M, Tan K, Oei JL. Complex survival in extreme prematurity parents, their options and the need for a unified team approach. J Paediatr Child Health 2020; 56:1959-1962. [PMID: 32043681 DOI: 10.1111/jpc.14804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 01/15/2020] [Accepted: 01/20/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Renee Sherriff
- Department of Newborn Care, the Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Anne Preisz
- Department of Newborn Care, the Royal Hospital for Women, Randwick, New South Wales, Australia.,Clinical Ethics, Clinical Governance Unit, Sydney Children's Hospital Network, Westmead, New South Wales, Australia
| | - Susan Adams
- Department of Paediatric Surgery, Sydney Children's Hospital, Randwick, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - John Smyth
- Department of Newborn Care, the Royal Hospital for Women, Randwick, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Eric Coudanaris
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of General Paediatrics, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Mark Jacobs
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Ophthalmology, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Kimberley Tan
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Ophthalmology, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Ju L Oei
- Department of Newborn Care, the Royal Hospital for Women, Randwick, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
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9
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Stanak M, Hawlik K. Decision-making at the limit of viability: the Austrian neonatal choice context. BMC Pediatr 2019; 19:204. [PMID: 31221128 PMCID: PMC6585118 DOI: 10.1186/s12887-019-1569-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 06/03/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aimed to explore the shared decision-making context at the limit of viability (weeks 22-25 of gestation) through analyzing neonatologist's communication strategies with parents and their possible impact on survival and neurodevelopmental impairment (NDI) outcomes. METHODS A mixed methods approach was applied where a systematic literature search and in-depth semi-structured interviews with five heads of neonatology departments and one clinical ethicist from the Austrian context were integrated into a literature review. The aim was to identify decision practice models and the choice context specific to Austria. RESULTS Professional biases, parental understanding, and the process of information giving were identified as aspects possibly influencing survival and NDI outcomes. Institutions create self-fulfilling prophecies by recommending intensive/palliative care based upon their institutional statistics, yet those vary considerably among high-income countries. Labelling an extremely preterm (EP) infant by the gestational week was shown to skew the estimates for survival while the process of information giving was shown to be subject to framing effect and other cognitive biases. CONCLUSION Communication strategies of choice options to parents may have an impact on the way parents decide and hence also on the outcomes of EP infants.
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Affiliation(s)
- Michal Stanak
- Ludwig Boltzmann Institute for Health Technology Assessment, Garnisongasse 7/20, 1090, Vienna, Austria. .,Department of Philosophy, University of Vienna, Vienna, Austria.
| | - Katharina Hawlik
- Ludwig Boltzmann Institute for Health Technology Assessment, Garnisongasse 7/20, 1090, Vienna, Austria
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10
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Abstract
Neonatal professionals encounter many ethical challenges especially when it comes to interventions at the limit of viability (weeks 22-25 of gestation). At times, these challenges make the moral dilemmas in neonatology tragic and they require a particular set of intellectual and moral virtues. Intellectual virtues of episteme and phronesis, together with moral virtues of courage, compassion, keeping fidelity to trust, and integrity were highlighted as key virtues of the neonatal professional. Recognition of the role of ethics requires a recognition that answering the obvious question (what shall we do?) does not always suffice. Acknowledging the tragic question (is any of the alternatives open to us free from serious moral wrongdoing) and recognizing the ethical dilemmas, where the lines between right and wrong are blurred, leads to actions taken towards establishing ethics frameworks to support decision-making. In neonatology units, such organizational support can help in allowing the team members to recognize the ethical dilemmas, avoid moral distress, and improve team cohesion and the quality of care provided. Only when the organizational structure allows ethical dilemmas to be recognized, adequate decisions can be made.
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Affiliation(s)
- Michal Stanak
- Ludwig Boltzmann Institute for Health Technology Assessment, Vienna, Austria.
- Department of Philosophy, University of Vienna, Vienna, Austria.
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Rysavy MA, Bell EF, Iams JD, Carlo WA, Li L, Mercer BM, Hintz SR, Stoll BJ, Vohr BR, Shankaran S, Walsh MC, Brumbaugh JE, Colaizy TT, Das A, Higgins RD. Discordance in Antenatal Corticosteroid Use and Resuscitation Following Extremely Preterm Birth. J Pediatr 2019; 208:156-162.e5. [PMID: 30738658 PMCID: PMC6486854 DOI: 10.1016/j.jpeds.2018.12.063] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 12/08/2018] [Accepted: 12/31/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To describe discordance in antenatal corticosteroid use and resuscitation following extremely preterm birth and its relationship with infant survival and neurodevelopment. STUDY DESIGN A multicenter cohort study of 4858 infants 22-26 weeks of gestation born 2006-2011 at 24 US hospitals participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network, with follow-up through 2013. Survival and neurodevelopmental outcomes were available at 18-22 months of corrected age for 4576 (94.2%) infants. We described antenatal interventions, resuscitation, and infant outcomes. We modeled the effect on infant outcomes of each hospital increasing antenatal corticosteroid exposure for resuscitated infants born at 22-24 weeks of gestation to rates observed at 25-26 weeks of gestation. RESULTS Discordant antenatal corticosteroid use and resuscitation, where one and not the other occurred, were more frequent for births at 22 and 23 but not 24 weeks (rate ratio [95% CI] at 22 weeks: 1.7 [1.3-2.2]; 23 weeks: 2.6 [2.2-3.2]; 24 weeks: 1.0 [0.8-1.2]) when compared with 25-26 weeks. Among infants resuscitated at 23 weeks, adjusting each hospital's rate of antenatal corticosteroid use to the average at 25-26 weeks (89.2%) was projected to increase infant survival by 7.1% (95% CI 5.4-8.8%) and survival without severe impairment by 6.4% (95% CI 4.7-8.1%). No significant change in outcomes was projected for infants resuscitated at 22 weeks, where few (n = 22) resuscitated infants received antenatal corticosteroids. CONCLUSIONS Infants born at 23 weeks were more frequently resuscitated without antenatal corticosteroids than other extremely preterm infants. When resuscitation is intended, consistent provision of antenatal corticosteroids may increase infant survival and survival without impairment. TRIAL REGISTRATION ClinicalTrials.govNCT00063063 (Generic Database) and NCT00009633 (Follow-Up Study).
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Affiliation(s)
| | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Jay D Iams
- Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Lei Li
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - Brian M Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH
| | - Susan R Hintz
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Barbara J Stoll
- Dean's Office, University of Texas Medical School at Houston, Houston, TX
| | - Betty R Vohr
- Department of Pediatrics, Women & Infants' Hospital, Brown University, Providence, RI
| | | | - Michele C Walsh
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH
| | - Jane E Brumbaugh
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | | | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, MD
| | - Rosemary D Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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12
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Geurtzen R, Van Heijst A, Hermens R, Scheepers H, Woiski M, Draaisma J, Hogeveen M. Preferred prenatal counselling at the limits of viability: a survey among Dutch perinatal professionals. BMC Pregnancy Childbirth 2018; 18:7. [PMID: 29298669 PMCID: PMC5751814 DOI: 10.1186/s12884-017-1644-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 12/21/2017] [Indexed: 01/10/2023] Open
Abstract
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.
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Affiliation(s)
- R Geurtzen
- Amalia Children's Hospital, Department of Pediatrics, Radboud university Medical Center, PO Box 9101, 6500HB, Nijmegen, The Netherlands.
| | - Arno Van Heijst
- Amalia Children's Hospital, Department of Pediatrics, Radboud university Medical Center, PO Box 9101, 6500HB, Nijmegen, The Netherlands
| | - Rosella Hermens
- Scientific Institute for Quality of Care, Radboud university medical center, Nijmegen, The Netherlands
| | | | - Mallory Woiski
- Amalia Children's Hospital, Department of Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jos Draaisma
- Amalia Children's Hospital, Department of Pediatrics, Radboud university Medical Center, PO Box 9101, 6500HB, Nijmegen, The Netherlands
| | - Marije Hogeveen
- Amalia Children's Hospital, Department of Pediatrics, Radboud university Medical Center, PO Box 9101, 6500HB, Nijmegen, The Netherlands
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Counselling about the Risk of Preterm Delivery: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2017; 2017:7320583. [PMID: 28848765 PMCID: PMC5564059 DOI: 10.1155/2017/7320583] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/17/2017] [Accepted: 07/10/2017] [Indexed: 11/24/2022]
Abstract
We aimed to describe the outcomes of counselling for preterm delivery. PubMed, Embase, and PsycInfo were systematically searched (from 2000 to 2016) using the following terms: counselling, pregnancy complications, high-risk pregnancy, fetal diseases, and prenatal care. A total of nine quantitative studies were identified, five randomized and four nonrandomized. All studies were conducted in the USA, and half of them were based on a simulated counselling session. Two main clinical implications can be drawn from the available studies: firstly, providing written information before or during the consultation seems to have a positive effect, while no effect was detected when written material was provided after the consultation. Secondly, parents' choices about treatment seemed to be influenced by spiritual-related aspects and/or preexisting preferences, rather than by the level of detail or by the order with which information was provided. Therefore, the exploration of parents' beliefs is crucial to reduce the risks of misconception and to guarantee choice in line with personal values. More research is necessary to validate these findings in cross-cultural contexts and in real world settings of care. Moreover, the centeredness of conversations and the characteristics of the clinician involved in counselling should be addressed in future studies.
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Geurtzen R, van Heijst A, Draaisma J, Ouwerkerk L, Scheepers H, Woiski M, Hermens R, Hogeveen M. Professionals' preferences in prenatal counseling at the limits of viability: a nationwide qualitative Dutch study. Eur J Pediatr 2017; 176:1107-1119. [PMID: 28687856 PMCID: PMC5511326 DOI: 10.1007/s00431-017-2952-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 06/12/2017] [Accepted: 06/13/2017] [Indexed: 11/27/2022]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Rosa Geurtzen
- Department of Pediatrics, Radboud University Medical Center Amalia Children's Hospital, PO Box 9101, 6500HB, Nijmegen, Internal Code 804, The Netherlands.
| | - Arno van Heijst
- Department of Pediatrics, Radboud University Medical Center Amalia Children’s Hospital, PO Box 9101, 6500HB Nijmegen, Internal Code 804, The Netherlands
| | - Jos Draaisma
- Department of Pediatrics, Radboud University Medical Center Amalia Children’s Hospital, PO Box 9101, 6500HB Nijmegen, Internal Code 804, The Netherlands
| | - Laura Ouwerkerk
- Department of Pediatrics, Radboud University Medical Center Amalia Children’s Hospital, PO Box 9101, 6500HB Nijmegen, Internal Code 804, The Netherlands
| | | | - Mallory Woiski
- Department of Gynecology, Radboud university medical center, Nijmegen, The Netherlands
| | - Rosella Hermens
- Scientific Institute for Quality of Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Marije Hogeveen
- Department of Pediatrics, Radboud University Medical Center Amalia Children’s Hospital, PO Box 9101, 6500HB Nijmegen, Internal Code 804, The Netherlands
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15
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Gallagher K, Aladangady N, Marlow N. The attitudes of neonatologists towards extremely preterm infants: a Q methodological study. Arch Dis Child Fetal Neonatal Ed 2016; 101:F31-6. [PMID: 26178462 PMCID: PMC4717384 DOI: 10.1136/archdischild-2014-308071] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 06/11/2015] [Indexed: 11/14/2022]
Abstract
OBJECTIVES The attitudes and biases of doctors may affect decision making within Neonatal Intensive Care. We studied the attitudes of neonatologists in order to understand how they prioritise different factors contributing to decision making for extremely preterm babies. DESIGN Twenty-five neonatologists (11 consultants and 14 senior trainees) participated in a Q methodological study about decision making that involved the ranking of 53 statements from agree to disagree in a unimodal shaped grid. Results were explored by person factor analysis using principle component analysis. RESULTS The model of best fit comprised 23 participants contributing a three-factor model, which represented three different attitudes towards decision making and accounted for 59% of the variance. Fourteen statements were ranked in statistically significant similar positions by 23 participants; consensus statements included placing the baby and family at the centre of care, limitation of intervention based upon perceived risk and non-mandatory intervention at birth. Factor 1 participants (n=12) believed that treatment should not be limited based on gestational age and technology should be used to improve treatment. Five factor 2 participants identified strongly with a limit of 24 weeks for treatment, one of whom being polar opposite, believing in treatment at all costs at all gestations. The remaining six factor 3 participants identified strongly with statements that treatment should be withheld on quality of life grounds. CONCLUSIONS This study has identified differences in attitudes towards decision making between individual neonatologists and trainees that may impact how decisions are communicated to families.
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Affiliation(s)
- Katie Gallagher
- Florence Nightingale School of Nursing and Midwifery, King's College London, London, UK
| | - Narendra Aladangady
- Neonatal Unit, Homerton University Hospital NHS Foundation Trust, London, UK,Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Neil Marlow
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
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Perinatal practice in extreme premature delivery: variation in Dutch physicians' preferences despite guideline. Eur J Pediatr 2016; 175:1039-46. [PMID: 27251669 PMCID: PMC4930484 DOI: 10.1007/s00431-016-2741-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/19/2016] [Accepted: 05/25/2016] [Indexed: 11/04/2022]
Abstract
UNLABELLED Decisions at the limits of viability about initiating care are challenging. We aimed to investigate physicians' preferences on treatment decisions, against the background of the 2010 Dutch guideline offering active care from 24(+0/7) weeks of gestational age (GA). Obstetricians' and neonatologists' opinions were compared. An online survey was conducted amongst all perinatal professionals (n = 205) of the 10 Dutch level III perinatal care centers. Response rate was 60 % (n = 122). Comfort care was mostly recommended below 24(+0/7) weeks and intensive care over 26(+0/7) weeks. The professional views varied most at 24 and 25 weeks, with intensive care recommended but comfort care at parental request optional being the median. There was a wide range in perceived lowest limits of GA for interventions as a caesarian section and a neonatologist present at birth. Obstetricians and neonatologists disagreed on the lowest limit providing chest compressions and administering epinephrine for resuscitation. The main factors restricting active treatment were presence of congenital disorders, "small for gestational age" fetus, and incomplete course of corticosteroids. CONCLUSION There was a wide variety in individually preferred treatment decisions, especially when aspects were not covered in the Dutch guideline on perinatal practice in extreme prematurity. Furthermore, obstetricians and neonatologists did not always agree. WHAT IS KNOWN • Cross-cultural differences exists in the preferred treatment at the limits of viability • In the Netherlands since 2010, intensive care can be offered starting at 24 (+0/7) weeks gestation What is new: • There was a wide variety in preferred treatment decisions at the limits of viability especially when aspects were not covered in the Dutch national guideline on perinatal practice in extreme prematurity.
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Manktelow BN, Seaton SE, Field DJ, Draper ES. Population-based estimates of in-unit survival for very preterm infants. Pediatrics 2013; 131:e425-32. [PMID: 23319523 DOI: 10.1542/peds.2012-2189] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Estimates of the probability of survival of very preterm infants admitted to NICU care are vital for counseling parents, informing care, and planning services. In 1999, easy-to-use charts of survival according to gestation, birth weight, and gender were published in the United Kingdom. These charts are widely used in clinical care and for benchmarking survival, and they form the core of the Clinical Risk Index for Babies II score. Since their publication, the survival of preterm infants has improved, and the charts therefore need updating. METHODS A logistic model was fitted with gestational age, birth weight, and gender. Nonlinear functions were estimated by using fractional polynomials. Bootstrap methods were used to assess the internal validity of the final model. The final model was assessed both overall and for subgroups of infants by using Farrington's statistic, the c-statistic, Cox regression coefficients, and the Brier score. RESULTS A total of 2995 white singleton infants born at 23(+0) to 32(+6) weeks' gestation in 2008 through 2010 were identified; 2751 (91.9%) infants survived to discharge. A prediction model was estimated and good model fit confirmed (area under receiver-operating characteristics curve = 0.86). Survival ranged from 27.7% (23 weeks) to 99.1% (32 weeks) for boys and from 34.5% (23 weeks) to 99.3% (32 weeks) for girls. Updated charts were produced showing estimated survival according to gestation, birth weight and gender, together with contour plots displaying points of equal survival. CONCLUSIONS These survival charts have been updated and will be of use to clinicians, parents, and managers.
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Affiliation(s)
- Bradley N Manktelow
- Department of Health Sciences, University of Leicester, 22-28 Princess Rd West, Leicester LE1 6TP, United Kingdom.
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Guinsburg R, Branco de Almeida MF, Dos Santos Rodrigues Sadeck L, Marba STM, Suppo de Souza Rugolo LM, Luz JH, de Andrade Lopes JM, Martinez FE, Procianoy RS. Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists. J Perinatol 2012; 32:913-9. [PMID: 22460546 DOI: 10.1038/jp.2012.28] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To verify, in extremely preterm infants, if disagreement between obstetricians and neonatologists regarding proactive management is associated with early death. STUDY DESIGN Prospective cohort of 484 infants with 23(0/7) to 26(6/7) weeks, without malformations, born from January 2006 to December 2009 in eight Brazilian hospitals. Pro-active management was defined as indication of ≥1 dose of antenatal steroid or cesarean section (obstetrician) and resuscitation at birth according to the international guidelines (neonatologist). Main outcome was neonatal death in the first 24 h of life. RESULT Obstetricians and neonatologists disagreed in 115 (24%) patients: only neonatologists were proactive in 107 of them. Disagreement between professionals increased 2.39 times the chance of death in the first day (95% confidence interval 1.40 to 4.09), adjusted for center and maternal/neonatal clinical conditions. CONCLUSION In infants with 23 to 26 weeks of gestation, disagreement between obstetricians and neonatologists, translated as lack of antenatal steroids and/or vaginal delivery, despite resuscitation procedures, increases the odds of death in the first day.
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Affiliation(s)
- R Guinsburg
- Department of Pediatrics, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil.
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Danerek M, Maršál K, Cuttini M, Lingman G, Nilstun T, Dykes AK. Attitudes of Swedish midwives towards management of extremely preterm labour and birth. Midwifery 2011; 28:e857-64. [PMID: 22169524 DOI: 10.1016/j.midw.2011.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 10/19/2011] [Accepted: 10/24/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVE the aim of the study was to ascertain the attitudes of Swedish midwives towards management of very preterm labour and birth and to compare the attitudes of midwives at university hospitals with those at general hospitals. DESIGN this cross-sectional descriptive and comparative study used an anonymous self-administrated questionnaire for data collection. Descriptive and analytic statistics were carried out for analysis. PARTICIPANTS the answers from midwives (n=259) were collected in a prospective SWEMID study. SETTING the midwives had experience of working on delivery wards in maternity units with neonatal intensive care units (NICU) in Sweden. FINDINGS in the management of very preterm labour and birth, midwives agreed to initiate interventions concerning steroid prophylaxis at 23 gestational weeks (GW), caesarean section for preterm labour only at 25 GW, when to give information to the neonatologist before birth at 23 GW, and when to suggest transfer to NICU at 23 GW. Midwives at university hospitals were prone to start interventions at an earlier gestational age than the midwives at general hospitals. Midwives at university hospitals seemed to be more willing to disclose information to the parents. KEY CONCLUSIONS midwives with experience of handling very preterm births at 21-28 GW develop a positive attitude to interventions at an earlier gestational age as compared to midwives without such experience. IMPLICATIONS FOR PRACTICE based on these results we suggest more communication and transfer of information about the advances in perinatal care and exchange of knowledge between the staff at general and university hospitals. Establishment of platforms for inter-professional discussions about ethically difficult situations in perinatal care, might benefit the management of very preterm labour and birth.
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Affiliation(s)
- Margaretha Danerek
- Department of Health Sciences, Faculty of Medicine, University Lund, Box 157, 221 00 Lund, Sweden.
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