Health-care provider communication with expectant parents during a prenatal diagnosis: an integrative review

An Observational Study of Dialogue about Uncertainty in Clinician-Family Counseling Conversations Following Prenatal Diagnosis of Complex Congenital Heart Disease

Objective

Families who receive a prenatal diagnosis of complex congenital heart disease (cCHD) often experience severe psychological distress and identify uncertainty as a key source of that distress. This study examined clinician-family conversations during initial fetal cardiology consultations to identify the topics of uncertainty discussed.

Methods

In this observational, qualitative study, initial fetal cardiology consultations were audio-recorded, transcribed verbatim, and coded by two independent coders. A codebook was inductively and deductively developed and applied. This content analysis focused on uncertainty-related codes and associated themes.

Results

During 19 consultations including five clinicians, 13 different cardiac diagnoses were discussed (seven with high mortality risk). Median consultation length was 37 min (IQR: 26-51), with only 11% of words spoken by families. On average, 51% of total words spoken focused on uncertainty in relation to cardiac diagnosis, etiology, comorbidities, prognosis, childbirth, therapeutics, and logistics. Family-initiated discussion on uncertainty largely focused on childbirth and pregnancy and postpartum logistics.

Conclusions

Half of dialogue within initial fetal cardiology encounters discussed uncertainty surrounding prenatally diagnosed cCHD. Parent and clinician perspectives should be gathered on the essential content and optimal delivery of uncertainty-related topics.

Innovation

This study is conceptually and methodologically innovative as one of the first to examine audio-recorded dialogue between fetal cardiology clinicians and families.

Parents' experiences of receiving their child's diagnosis of congenital heart disease: A systematic review and meta-synthesis of the qualitative literature

PURPOSE

This systematic review aimed to synthesize qualitative research on parents' psychological experiences following their child's diagnosis of congenital heart disease (CHD).

METHODS

A systematic search of six electronic databases (CINAHL, Embase, MEDLINE, PsycINFO, PubMed and Web of Science) was completed, inclusive of all years up to May 2022. Any included articles were synthesized using thematic synthesis and appraised using the Critical Appraisal Skills Programme Qualitative Checklist.

RESULTS

Twenty-six articles were included. Four main themes, and 11 subthemes, emerged from the synthesis. Theme 1 (unpreparedness for the diagnosis) concerned parents' shock, guilt and anger regarding the diagnosis. Theme 2 (the overwhelming reality of CHD) described parental fear about decision-making and the child's prognosis, and the influence of professionals on parents' well-being. Theme 3 (mourning multiple losses) detailed parents' sadness at losing their envisioned pregnancy, birth and parenthood experiences. Theme 4 (redefining hopes to reach an acceptance of CHD) described parents' adjustment to the diagnosis.

CONCLUSIONS

Receiving a child's CHD diagnosis was a uniquely challenging situation for parents. The findings provided insight into the emotions parents experienced and how they adjusted to the diagnosis psychologically. As parents' experiences were significantly influenced by their interactions with professionals, clinicians should offer compassion, validation and clear information throughout the diagnosis process.

Nurse-guided Mobile Health Care Program to Reduce Emotional Distress Experienced by Parents of Infants Prenatally Diagnosed with Critical Congenital Heart Disease: A Pilot Study

Background

Following prenatal diagnosis of critical congenital heart disease (CCHD), parents encounter emotional distress while facing caregiving challenges. Supportive psycho-educational interventions using mobile health (mHealth) can make care more accessible.

Objectives

We tested a novel nurse-guided mHealth care program, Preparing Heart and Mind™ (PHM™), with the objectives of examining feasibility and estimating the effect of the intervention on parents' emotional distress.

Methods

This pilot study design randomized participants using a 2:1 intervention to control ratio. Analysis involved description of retention, and intervention attendance and engagement, and adjusted linear mixed models to estimate group differences in depressive (CES-D), anxiety (STAI-S), and traumatic stress (IES-r) symptoms.

Results

The sample included 55 parents (n=38 PHM™ group, n=17 control). Complete retention of 37 (67%) parents included 29 (76%) in the PHM™ group and 8 (47%) control. Most attrition was due to infant death (7 parents), transplant referral (2 parents), or postnatal diagnostic ineligibility (4 parents). For the PHM™ group, ≥96% of parents attended pre- and postnatal sessions and most (65%) messaged with the nurse. mHealth engagement was highest prenatally, with handling uncertainty the most viewed topic (average 94% pages viewed). In linear mixed models analyses, the PHM™ group had on average 4.84 points lower depression (95% CI: -10.68-1.04), 6.56 points lower anxiety (-14.04-0.92), and 6.28 points lower trauma (-14.44-1.88) scores by study end.

Conclusion

Findings suggest that a nurse-guided mHealth approach is feasible and may contribute to a clinically important reduction in parents' emotional distress.

Interdisciplinary fetal neurology care: Current practice, challenges, and future directions

As the field of fetal-neonatal neurology has expanded over the past 2 decades with increasingly complex diagnoses, multidisciplinary collaboration with many subspecialties including genetics, neonatology, obstetrics, maternal fetal medicine, surgical sub-specialties, cardiology, radiology, palliative care, and ethics has needed to evolve to strive to offer optimal patient care. While comprehensive care delivery with an inter-disciplinary approach is preferred, there are often barriers based on numerous health disparities especially in resource limited settings. Even in the context of comprehensive care, diagnostic and prognostic uncertainty lead to challenges for providers during fetal neurology consultations. We present a case that highlights advantages of a comprehensive multi-disciplinary team in caring for the medical and social challenges of patients faced with a fetal neurologic diagnosis. Inter-disciplinary training focusing on maternal, fetal, neonatal, and childhood neurodevelopmental course and collaboration among the numerous stakeholders that contribute to fetal neurology practice is needed to provide optimal counseling and care for families faced with a fetal neurological diagnosis.

"It's not just the medical aspects that are important": A qualitative exploration of first-time parents' experiences of antenatal imaging and their influence on parent-fetal bonding

INTRODUCTION

Antenatal imaging provides clinical information regarding fetal growth and development. The additional benefit afforded by imaging for expectant parents in developing an emotional connection (bond) to the unborn baby is also acknowledged. However, the relationship between imaging and bonding is not fully understood, particularly where there are differing parental and pregnancy circumstances, for example use of advanced imaging techniques or the prenatal diagnosis of a congenital fetal condition. This study aimed to explore the role of antenatal imaging in enhancing the developing parent-fetal bond in first-time parents.

METHODS

A descriptive, qualitative methodology was used. Semi-structured telephone interviews were conducted with first-time expectant parents attending a London hospital for clinical ultrasound (n = 20) or research MRI (n = 8) imaging during pregnancy. The sample included parents receiving specialist antenatal care for a diagnosed fetal cardiac condition (n = 8). Thematic analysis was conducted.

RESULTS

The analysis generated three themes: 1) Our baby, our scan too; 2) Destination parenthood; and 3) Being in the dark, then finding the light. These themes highlight the important, but transient role of antenatal imaging in enhancing parent-fetal bonding, as well as the differing care needs of expectant parents. The integral role of healthcare professionals in providing a personalised, supportive, imaging experience to facilitate bonding is also reflected.

CONCLUSION

Adopting parent-centred care approaches which involve expectant parents in fetal imaging influences bonding by helping parents to consider the reality of their impending parenthood. Knowledge acquired during scans is used to create an identity for the unborn baby, which parents can develop an emotional connection to.

IMPLICATIONS FOR PRACTICE

To optimise the potential for enhanced parent-fetal bonding, care provision in fetal imaging should be tailored to the individual needs of expectant parents.

An mHealth, patient engagement approach to understand and address parents' mental health and caregiving needs after prenatal diagnosis of critical congenital heart disease

Objective

To provide an overview of the development of the Preparing Heart and Mind™ (PHM™) care program designed for parents with a prenatal diagnosis of critical congenital heart disease (CCHD) and describe issues of parental concern, caregiving competencies, and type and timing of PHM™ topics.

Methods

Guided participation theory underpinned intervention development and a mixed methods pilot of a novel, nurse-guided mHealth intervention. Parents were enrolled from the third trimester of pregnancy-12 weeks postnatally. Online surveys, session transcripts, and app use were descriptively analyzed.

Results

The sample included 19 mothers/birthing persons and 15 caregiving partners randomized to the intervention group. In 49 sessions, mental health/wellbeing (94%) and condition-specific information (86%) were top issues. Many caregiving competencies were developed, with mothers/birthing persons often focused on feeding (86%). Regulating emotions and co-parenting consistently needed support. PHM™ topics of preparing for hospitalization (47%) and handling uncertainty (45%) were most discussed. Two cases further characterize findings.

Conclusion

Nurse-parent collaborative understanding of issues emphasized the need for mental health assessments. Prenatal intervention opportunities were underscored through discussions of caregiving issues and PHM™ topics.

Innovation

PHM™ represents an innovative approach that holds promise for supporting parents' mental health and caregiving needs outside the healthcare setting.

Clinician communication after discovery of a soft marker of aneuploidy during pregnancy: A mixed methods assessment of a communication workshop

BACKGROUND

Soft markers of aneuploidy are common findings on obstetric ultrasounds but disclosure often increases patient anxiety. It is unknown whether communication training affects patient experience of soft marker disclosure. Our objective was to evaluate clinician experience of a simulation-based communication workshop and assess workshop influence on patient anxiety, understanding, and perception of communication quality.

METHODS

We implemented a communication workshop for clinicians at an academic institution in 2019, and assessed clinician anxiety and confidence with counseling before and after. To assess effect of the workshop on patients, we surveyed pregnant people before and after workshop implementation for whom an echogenic intracardiac focus, choroid plexus cyst, or urinary tract dilation was identified. The primary outcome was anxiety. Some respondents completed a semi-structured interview. Interviews were analyzed using thematic analysis.

RESULTS

Twelve clinicians participated. Twenty-one out of 49 eligible patients (43%) completed a survey before the workshop and 40 out of 90 eligible patients (44%) completed a survey after. The risk of high anxiety after was similar to before the workshop (aRR 1.7, 95% CI 0.6-4.2). Twenty patients were recruited for an interview. Qualitative analysis revealed that patients' backgrounds, emotional impact of the conversation and clinician manner influenced perception of communication quality.

CONCLUSION

While a single clinician workshop did not affect patient anxiety, clinician manner and personalization play a large role in perception of counseling about soft markers of aneuploidy.

Exploring continuity of care for women with prenatal diagnosis of congenital anomaly: A mixed method study

AIMS

To map the pathway and service provision for pregnant women whose newborns require admission into the surgical neonatal intensive care unit at or soon after birth, and to examine the nature of continuity of care (COC) provided and the facilitators and barriers to woman- and family-centred care from the perspective of women/parents and health professionals.

BACKGROUND

Limited research exists on current service and care pathways for families whose babies are diagnosed with congenital abnormality requiring surgery.

DESIGN

A mixed method sequential design adhering to EQUATOR guidelines for Good Reporting of a Mixed Methods Study.

METHODS

Data collection methods included: (1) a workshop with health professionals (n = 15), (2) retrospective maternal record review (n = 20), prospective maternal record review (17), (3) interviews with pregnant women given a prenatal diagnosis of congenital anomaly (n = 17) and (4) interviews with key health professionals (n = 7).

RESULTS/FINDINGS

Participants perceived care delivered by state-based services as problematic prior to admission into the high-risk midwifery COC model. Once admitted to the high-risk maternity team women described care 'like a breath of fresh air' with a 'contrast in support', where they felt supported in their decisions.

CONCLUSION

This study highlights provision of COC, in particular relational continuity between health providers and women as essential to achieve optimal outcomes.

RELEVANCE TO CLINICAL PRACTICE

Provision of individualised COC offers an opportunity for perinatal services to reduce the negative consequences of pregnancy-related stress associated with diagnosis of foetal anomaly.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public was involved in the design, analysis, preparation or writing of this review.

Fetal Anomaly: Family Experiences and Preferences for Care: An Integrative Review

BACKGROUND

The prenatal diagnosis of a fetal anomaly is unexpected, creating a family crisis. Expectant parents are at an increased risk for perinatal depression and traumatic stress. Prior reviews examined parents' experiences when terminating but not continuing the pregnancy. This review synthesized qualitative research to describe the experiences, emotional responses, and needs of families continuing their pregnancy.

METHODS

An integrative review was performed using the Whitemore and Knafl methodology and PRISMA guidelines. A systematic review of peer-reviewed articles published between 2000 and 2200 on the experiences of fetal anomaly was performed using 5 databases. Eligible articles included qualitative studies describing families' experiences with a fetal anomaly diagnosis who elected to continue their pregnancy. Methodological quality was evaluated using the Critical Skills Appraisal Program checklist.

RESULTS

Of the 678 article results, 16 met inclusion criteria. There were 298 participants from 5 countries. The major overarching theme of Response to the Diagnosis of Fetal Anomaly was identified. The major categories were emotional response, coping strategies, influences, health care experiences, and family needs. Uncertainty and grief were the most common emotions.

DISCUSSION

Parents choosing to continue pregnancy benefit from compassionate, sensitive care, and accurate, concise information, provided in tailored instruction using multiple styles.

'You have a little human being kicking inside you and an unbearable pain of knowing there will be a void at the end': A meta-ethnography exploring the experience of parents whose baby is diagnosed antenatally with a life limiting or life-threatening condition

BACKGROUND

Parents of babies diagnosed with life limiting conditions in the perinatal period face numerous challenges. Considerations include the remainder of the pregnancy, delivery of the baby and decisions around care in the neonatal period.

AIM

To increase understanding of how parents experience the diagnosis of a life-limiting or life-threatening condition, during pregnancy and following the birth of their baby, by answering the question: 'what is known about the perinatal experiences of parents of babies with a life-limiting or life-threatening diagnosis?'

DESIGN

A meta-ethnography was conducted to synthesise findings from existing qualitative evidence.

DATA SOURCES

British Nursing Database, CINAHL, Medline, PsycINFO and Embase databases were searched in January 2023.

FINDINGS

Relationships between parents and their families and friends, and with professionals influence the needs and experiences of parents, which oscillate between positive and negative experiences, throughout parents' perinatal palliative care journey. Parents highlighted the need for control and a sense of normality relating to their parenting experience. Validation was central to the experience of parents at all stages of parenthood. Relationships between the parent and the baby were unwavering, underpinned with unconditional love.

CONCLUSION

Professionals, family members and friendship groups influence the experience, validating parents and their baby's identity and supporting parents in having a sense of control and normality by demonstrating empathy, and providing time and clear communication.

"We All Want to Be Able to Tell You Something Hopeful": Clinicians' Experiences Providing Maternal-Fetal Surgery Counseling

INTRODUCTION

Prenatal counseling about maternal-fetal surgery can be traumatic and confusing for pregnant people. It can also be technically and emotionally complex for clinicians. As maternal-fetal surgery rapidly advances and becomes more common, more evidence is needed to inform counseling practices. The objective of this study was to develop a deeper understanding of the methods clinicians currently use to train for and provide counseling, as well as their needs and recommendations for future education and training.

METHODS

We used interpretive description methods and interviewed interprofessional clinicians who regularly counsel pregnant people about maternal-fetal surgery.

RESULTS

We conducted 20 interviews with participants from 17 different sites who were maternal-fetal medicine specialists (30%), pediatric surgeons (30%), nurses (15%), social workers (10%), a genetic counselor (5%), a neonatologist (5%), and a pediatric subspecialist (5%). Most were female (70%), non-Hispanic white (90%), and practiced in the Midwest (50%). We identified four overarching themes: (1) contextualizing maternal-fetal surgery counseling; (2) establishing shared understanding; (3) supporting decision-making; and (4) training for maternal-fetal surgery counseling. Within these themes, we identified key practice differences among professions, specialties, institutions, and regions.

CONCLUSION

Participants are committed to practicing informative and supportive counseling to empower pregnant people to make autonomous decisions about maternal-fetal surgery. Nevertheless, our findings indicate a dearth of evidence-based communication practices and guidance. Participants identified significant systemic limitations affecting pregnant people's decision-making options related to maternal-fetal surgery.

What is Known About Critical Congenital Heart Disease Diagnosis and Management Experiences from the Perspectives of Family and Healthcare Providers? A Systematic Integrative Literature Review

The experience of diagnosis, decision-making and management in critical congenital heart disease is layered with complexity for both families and clinicians. We synthesise the current evidence regarding the family and healthcare provider experience of critical congenital heart disease diagnosis and management. A systematic integrative literature review was conducted by keyword search of online databases, MEDLINE (Ovid), PsycINFO, Cochrane, cumulative index to nursing and allied health literature (CINAHL Plus) and two journals, the Journal of Indigenous Research and Midwifery Journal from 1990. Inclusion and exclusion criteria were applied to search results with citation mining of final included papers to ensure completeness. Two researchers assessed study quality combining three tools. A third researcher reviewed papers where no consensus was reached. Data was coded and analysed in four phases resulting in final refined themes to summarise the findings. Of 1817 unique papers, 22 met the inclusion criteria. The overall quality of the included studies was generally good, apart from three of fair quality. There is little information on the experience of the healthcare provider. Thematic analysis identified three themes relating to the family experience: (1) The diagnosis and treatment of a critical congenital heart disease child significantly impacts parental health and wellbeing. (2) The way that healthcare and information is provided influences parental response and adaptation, and (3) parental responses and adaptation can be influenced by how and when support occurs. The experience of diagnosis and management of a critical congenital heart disease child is stressful and life-changing for families. Further research is needed into the experience of minority and socially deprived families, and of the healthcare provider, to inform potential interventions at the healthcare provider and institutional levels to improve family experience and support.

Information needs of parents of children with congenital anomalies across Europe: a EUROlinkCAT survey

BACKGROUND

Parents of children who have a congenital anomaly can experience significant worry about their child's health. Access to clear, helpful, and trustworthy information can provide a valuable source of support. In this study the aim was to explore the information needs of parents/carers of children with congenital anomalies across Europe.

METHOD

A cross-sectional online survey was developed in nine languages to measure parents' information needs, including: (1) the 'helpfulness'/'trustworthiness' of information received from eight relevant sources, and (2) overall satisfaction with information received. Parents/carers of children (0-10 years) with cleft lip, spina bifida, congenital heart defect [CHD] requiring surgery, and/or Down syndrome were recruited online via relevant organisations in 10 European countries from March-July 2021. Quantitative analyses using multivariable logistic regressions were performed.

RESULTS

One thousand seventy parents/carers of children with a cleft lip (n = 247), spina bifida (n = 118), CHD (n = 366), Down syndrome (n = 281), and Down syndrome with CHD (n = 58) were recruited in Poland (n = 476), the UK (n = 120), Germany (n = 97), the Netherlands/Belgium (n = 74), Croatia (n = 68), Italy (n = 59), other European countries (n = 92), and not specified/non-European countries (n = 84). Most participants were mothers (92%) and aged 31-40 years (71%). Participants were most likely to rate support groups (63%), patient organisations (60%), specialist doctors/nurses (58%), and social media (57%) as 'very helpful' information sources. 'Very trustworthy' ratings remained high for specialist doctors/nurses (61%), however, they declined for support groups (47%), patient organisations (48%), and social media (35%). Germany had the highest proportion of participants who were 'very satisfied' (44%, 95% CI = 34%-54%) with information, whereas this percentage was lowest in Croatia (11%, 95% CI = 3%-19%) and Poland (15%, 95% CI = 11%-18%). Parents of children with Down syndrome had significantly lower satisfaction ratings than parents of children with CHD; 13% (95% CI = 8%-18%) reported being 'very satisfied' compared to 28% (95% CI = 23%-33%) in the CHD group.

CONCLUSIONS

Findings suggest that informal sources of information (e.g. support groups) are of value to parents, however, they are not deemed as trustworthy as specialist medical sources. Satisfaction ratings differed across countries and by anomaly, and were particularly low in Croatia and Poland, as well as for parents of children with Down syndrome, which warrants further investigation.

Parents' Needs and Their Perceived Obstacles With Team Members in Perinatal Palliative Care: A Qualitative Phenomenological Study

Advances in prenatal diagnosis have made medical, psychological, and ethical issues regarding the diagnosis of fetal anomalies a crucial topic of research. This study identified the needs of parents of unborn babies with fetal anomalies and their views regarding the services of interdisciplinary team members in charge of assisting them. The sample consisted of 30 parents and 40 team members from a women's health education and research hospital. Data were collected through face-to-face interviews and were qualitatively analyzed using the phenomenological method of interpretation. The results showed that parents' physical, psychological, social, and spiritual needs during pregnancy, childbirth, and postpartum were not fully met after their unborn babies were diagnosed with fetal anomalies. The results also showed that team members needed a structured program, legal regulations, and training to provide holistic care.

The parental journey of fetal care: a systematic review and metasynthesis

OBJECTIVE

This study aimed to synthesize the qualitative literature on parental experiences of fetal care to reflect events that happened across the continuum of care and to better understand parents' positive and negative experiences with care delivery.

DATA SOURCES

Eligible studies published until June 2020 were retrieved from MEDLINE, Embase, Cochrane Central Register of Controlled Trials, EBSCO CINAHL, Web of Science, and ProQuest.

STUDY ELIGIBILITY CRITERIA

Studies must have been: (1) published in English in a peer-reviewed journal or in ProQuest, (2) available in full text, (3) contained a qualitative component, and (4) focused on expectant parents' experiences of tertiary, coordinated, multidisciplinary prenatal diagnosis and care related to a fetal anomaly.

STUDY APPRAISAL AND SYNTHESIS METHODS

Researchers used the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. A metastudy and an interpretive description approach was taken to synthesize the events that happened across the continuum of care and the themes associated with a positive care experience.

RESULTS

The metasynthesis included 13 studies and 217 patients from 11 different multidisciplinary fetal diagnosis and intervention practices across North America and Europe. We identified key events that influenced parental experience of fetal care across the continuum. The themes associated with a positive care experience are parents (1) gaining understanding and feeling understood, (2) realizing agency and control, and (3) finding hope and meaning. We identified aspects of healthcare delivery that served as barriers or facilitators to these positive experiences.

CONCLUSION

Understanding the commonalities of the parental experience of fetal care across diverse settings creates a foundation for improving care and better meeting the needs of parents undergoing a painful and life-defining event. Although health outcomes are not always positive, a positive experience of care is possible and can assist parents to cope with their grief, manage their expectations, and engage in their care. The findings of this study illustrate the ways in which healthcare delivery can facilitate or obstruct a positive care experience.

The Voice of Parents of Children With a Congenital Anomaly - A EUROlinkCAT Study

EUROlinkCAT aims to investigate the health and educational outcomes of children with congenital anomalies for the first 10 years of their lives. We also aim to facilitate the development of a more reciprocal relationship between families with children with congenital anomalies, health and social care professionals, and researchers by conducting focus groups. The aim of the focus groups and parent interviews was to investigate parental experiences of having a child with a heart defect requiring surgery, cleft lip, spina bifida or Down Syndrome and to identify their research priorities. In total, seven interviews with 12 parents and eight focus groups with 58 parents and two caregivers were conducted in four European countries. We found that parents request more positive information with a focus on quality of life and what the children can achieve rather than solely on the negative aspects and limitations of the congenital anomaly. Some parents also highlighted discrepancies between the family's need for support and the lack of support received from the local authority. Finally, it was challenging for the parents to address specific research priorities. Future research should therefore focus on the potential of a child with a congenital anomaly.

What should we tell parents? Congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is characterized by a defect in the muscle dividing the thoracic and abdominal cavities. This leads to herniation of the abdominal organs into the thorax and a disturbance of lung development. Two-thirds of cases are identified by prenatal ultrasound in the second trimester, which should prompt referral to a tertiary center for prognosis assessment and counseling by a multidisciplinary team familiar with this condition. In this review, we summarize evidence on prenatal diagnosis and postnatal management of CDH. There is a focus on information that should be provided to expecting parents during prenatal counseling.

Joint periviability counseling between neonatology and obstetrics is a rare occurrence

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.

On "Not Recommending" ECMO

The neonatologist was describing the dire situation, the complexity of the fetus's anomalies, and the options-comfort care, some resuscitation-and finished by saying, "We would not recommend ECMO …" "We would not recommend" is a curious phrase. There is something ambiguous, very nebulous about it, something passive, noncommittal, maybe even deflective. As a bioethics researcher, I wondered how this phrase is interpreted, how it influences parents' moral deliberation over their options.

The impact of prenatal counselling on mothers of surviving children with hypoplastic left heart syndrome: A qualitative interview study

Objective

To explore the role of antenatal counselling in how parents make treatment decisions following an antenatal diagnosis of Hypoplastic Left Heart Syndrome (HLHS).

Background

Antenatal counselling is a critical part of patient management following a diagnosis of fetal congenital heart disease; however, there is a very limited evidence base examining how parents actually experience antenatal counselling and make decisions in this context.

Methods

Semi‐structured interviews were conducted with women who had received an antenatal diagnosis of HLHS. Interviews were digitally recorded, anonymised and transcribed verbatim. A thematic content analysis was performed using a constant comparative approach.

Results

Eight mothers of surviving children with HLHS were interviewed. Eight key themes emerged including new perspectives on how women receive antenatal counselling and how it affects their decision making. Three themes in particular are new to the literature: (a) Mothers of children with HLHS reported feelings of intense guilt that arose in the antenatal period around potentially causing the condition in their child. (b) For this group of women, recollections of perceived pessimism during antenatal counselling had a lasting impact. (c) Despite support from partners or extended family, women nevertheless experienced a strong sense that antenatal decision making was largely a ‘maternal’ responsibility.

Conclusions

When recounting their experiences of antenatal counselling, mothers of surviving children with HLHS offer new perspectives that can guide fetal cardiologists in how best to support their individual patients. Further research is needed to comprehensively understand the experience of prospective parents counselled for severe forms of fetal congenital heart disease.

Active or passive guidance? Decision-making in fetal health consultation

Prenatal consults are full of uncertainty. But, what are physicians contributing to this, and what is parents understanding of the intricacies of the complex decisions we present to them? Might the way we actively or passively guide parents affect how they make decisions in the complex world of fetal health consultations? For instance, how does "recommending" versus "not recommending" impact how parents view their choices? Reviewing the literature, there is a paucity of data on this topic. There are studies detailing experience but not of how guidance affects decision-making. We review some of this literature and discuss concepts relevant to this observation. We hypothesize that passive or active guidance by fetal health consultation members influences the moral deliberation and ethical decision-making of parents in different ways and propose a possible research idea.

Family experiences and attitudes about receiving the diagnosis of sex chromosome aneuploidy in a child

The most common sex chromosome aneuploidies (SCA) (47, XXY; 47, XYY; 47, XXX) frequently result in a milder phenotype than autosomal aneuploidies. Nevertheless, these conditions are highly variable and more symptomatic phenotypes may require significant clinical involvement, including specialty care. While historically most individuals with mild phenotypes remained undiagnosed during their lifetime, the increasing use of genetic testing in clinical care has increased the prenatal and postnatal diagnosis of SCAs. These genetic tests are frequently ordered by nongenetic providers who are also responsible for delivering the diagnosis. We surveyed parents of children (n = 308) to evaluate their experience of receiving a diagnosis and their support needs. The majority (73.3%) received the diagnosis from a nongenetic medical provider. Following a prenatal diagnosis parents reported experiencing depression, anxiety, and less optimism than those receiving a postnatal diagnosis. Few parents reported receiving materials explaining their child's condition that they found to be up-to-date, accurate, and unbiased. The frequently negative reported experiences of parents at time of diagnosis suggests more educational opportunities should be provided for nongenetic providers in order to become more informed about these conditions and communicate the diagnosis in a way parents experience as supportive.

Family and Practitioner Perspectives on Prenatal Early Intervention

Increasingly, families know prenatally of certain diagnoses with a high probability of developmental delays. These diagnoses could result in eligibility for Part C early intervention (EI) postnatally. Although prenatal developmental interventions (e.g., Early Head Start, Nurse Family Partnership) are common for families with environmental risks, no research has explored the potential of prenatal EI for those families with EI eligible diagnoses. This online survey research explored family and practitioner perspectives of potential prenatal EI and project-identified prenatal outcomes (i.e., health and well-being, parent-child interactions, parenting to family culture, and navigating systems and supports). Overall, both samples reported the prenatal outcomes were clear and important prenatally. Families preferred EI practitioners help with all outcomes. Practitioners preferred to take the lead on some outcomes (e.g., knowledge of and comfort with EI services, intention of EI), whereas the medical community took the lead on others. Findings support the need for further research on the potential of prenatal EI and resulted in implications for current postnatal EI.

Experiences and outcomes following diagnosis of congenital foetal anomaly and medical termination of pregnancy: A phenomenological study

AIM

To determine and describe the experiences of pregnant women who receive a diagnosis of chromosomopathy and/or foetal malformation during a prenatal check-up and who decide to legally terminate the pregnancy.

BACKGROUND

When a pregnancy is terminated, the woman must cope with frustrated motherhood. The psychological consequences of this will largely depend on the care and support provided by health professionals. When a congenital anomaly is diagnosed, a patient-centred communication helps understanding, influences adaptation to the new situation and ensures the person concerned has sufficient (autonomy or independence or ability) to make appropriate decisions.

METHODS

A qualitative study, based on a phenomenological approach, was carried out through nonparticipant observation and semi-structured interviews with 27 obstetric patients. NVivo 11 software was used, and content analysis was performed. The manuscript was developed using the COREQ guidelines to inform qualitative studies.

RESULTS

The clinical relationship may be affected by communication problems such as patients' perceptions of scarce emotional involvement by obstetricians, by poor psychosocial support during the termination of the pregnancy and by insufficient follow-up after discharge.

CONCLUSION

Nurses are in a privileged position to promote the empowerment of affected women. It is necessary to improve aspects related to the privacy of patients and the awareness and training of the interdisciplinary team in interpersonal communication. Post-loss follow-up is recommended to assess individual needs, thus facilitating an optimal approach to ease the grieving process.

RELEVANCE TO CLINICAL PRACTICE

During the prenatal diagnosis, the existence of a fetal anomaly is emphasized, but support and follow up of the mother may be neglected; therefore, exhaustive knowledge about the obstetric history, the state of health and the expectations of patients is as important as a multidisciplinary team trained in counseling strategies and with a comprehensive care plan that covers all areas, especially those that control maternal emotions.

Perinatal Palliative Care Birth Planning as Advance Care Planning

Purpose of Review: A significant number of pregnancies are complicated by a fetus with a life-limiting diagnosis. As diagnoses are made earlier in the pregnancy, families experience anticipatory grief and are faced with navigating goals of care for a baby that has yet to be born. With the support of the care team, families can begin to grieve, plan, and make meaningful memories during the duration of the pregnancy, the birth of their baby, and life of the child. Creating a palliative care birth plan, which expands beyond the traditional concept for delivery planning to include prenatal, perinatal, and neonatal care has become an important method for parents to process the diagnosis, for parents to document their wishes, and for members of the care team to communicate with the goal of supporting and enhancing the experience of the family. This articles reviews recent and relevant literature on the importance of birth planning and the role of perinatal palliative care when a life-limiting fetal diagnosis is made. Recent Findings: The process of birth planning is an important component of perinatal palliative care. Through this process, families can express their fears, values, hopes, and wishes. It also offers an opportunity for providers to communicate these wishes for the remainder of the pregnancy, the delivery, birth, and time afterwards. This has been demonstrated to decrease maternal stress and promote family centered care. Summary: Perinatal birth planning is an important component of perinatal palliative care when a fetus has a life-limiting diagnosis. The process of birth planning can be supportive and therapeutic as well as an important communication tool. With multiple practices and designs of perinatal palliative care programs, there are no standard tools even though important components have been identified. Ultimately, the strategies outlined here can be used as advance care planning tools.

Medically high-risk pregnancy: Women's perceptions of their relationships with health care providers

The purpose of this article is to examine women's perceptions of the patient-provider relationship in the context of medically high-risk pregnancy (MHRP). Sixteen in-depth interviews were conducted with women hospitalized for MHRP on a maternal-fetal medical unit in the US. Tenets of phenomenology guided the data analysis. We found that beyond normative stress related to managing physical aspects of MHRP, women reported added emotional stressors associated with navigating the fragmented health care environment. This study suggests that improved care coordination and systematic integration of psychosocial professionals within the perinatal interdisciplinary health care team are vital to reduce care-related stressors on this vulnerable patient group.

Clinical practice guidelines for perinatal bereavement care - An overview

BACKGROUND

High quality perinatal bereavement care is critical for women and families following stillbirth or newborn death. It is a challenging area of practice and a difficult area for guideline development due to a sparse and disparate evidence base.

AIM

We present an overview of the newly updated Perinatal Society of Australia and New Zealand/Stillbirth Centre of Research Excellence guideline for perinatal bereavement care. The guideline aims to provide clear guidance for maternity health care providers and their services to support the provision of care that meets the needs of bereaved parents.

DISCUSSION

The Guideline for Respectful and Supportive Perinatal Bereavement Care is underpinned by a review of current research combined with extensive stakeholder consultation that included parents and their organisations and clinicians from a variety of disciplines. The Guideline contains 49 recommendations that reflect five fundamental goals of care: good communication; shared decision-making; recognition of parenthood; effective support; and organisational response.

CONCLUSION

Best available research, parents' lived experiences and maternity care providers' insights have contributed to a set of implementable recommendations that address the needs of bereaved parents.

Support, information, and integration of genetics for children with congenital lower limb deficiencies in British Columbia, Canada

Objectives

Children and families affected by congenital limb deficiencies (CLD) require a unique level of emotional support from diagnosis through to adolescence. The following study aims to collect data on Canadian paediatric patients affected by a CLD followed at BC Children's Hospital (BCCH), Department of Orthopaedics.

Methods

Parents of children with a CLD were asked to complete a written questionnaire examining their experiences. Qualitative and quantitative data were collected concerning parent satisfaction with patient referrals, emotional support, and knowledge of their child's diagnosis.

Results

Twenty-five completed questionnaires were returned. Fifty per cent of the parents reported they were either very satisfied, or satisfied, with the emotional support provided by health care providers (HCPs). Twenty-five per cent of the parents were unsatisfied with the emotional support received by HCPs. Forty-eight per cent of the parents could not recall the specific name of their child's diagnosis; 20% of the parents reported their child did not have diagnosis. All the patients in our study had received a clinical diagnosis. Twenty-eight per cent of the parents in this study were also seen in medical genetics.

Conclusions

Families require additional resources for emotional support, peer support, and referrals to support organizations. Gaps in parent knowledge regarding their child's CLD suggest the need for formalized communication strategies for HCPs. Furthermore, patients with CLDs and their families may benefit from improved communication between orthopaedic and medical genetic services at the time of diagnosis. Integration of genetic counsellors may improve emotional supports and education for families with regards to testing and reproductive planning.

Parental experiences after prenatal diagnosis of fetal abnormality

For many pregnant women, prenatal testing is a routine component of contemporary pregnancy care. Receiving a prenatal diagnosis is frequently associated with intense feelings of shock and grief; the extent of which may be unrelated to the pregnancy gestation or the condition diagnosed. During this time of crisis, parents are often faced with important choices about their pregnancy. Levels of understanding and experiences of professional support throughout this time likely impact decisions that are made and how they are subsequently perceived. Despite considerable advances in prenatal testing technologies over the last 20 years there is a paucity of research examining parental experiences in-depth. Future advances such as prenatal exome sequencing will further increase the scope of prenatal testing and numbers of parents who receive a prenatal diagnosis. It is imperative that large-scale studies are performed to ensure that protocols are in place to adequately support couples at this time.