Antenatal and intrapartum care of pregnancy complicated by lethal fetal anomaly

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.

Best Mode of Delivery for Fetal Life-Limiting Conditions

A 38-year-old woman, gravida 3 para 2, with a history of two prior vaginal deliveries, at 18 weeks of gestation is diagnosed with fetal anencephaly. The patient asks: "May I undergo a scheduled primary cesarean delivery to optimize my baby's chance of survival?"

An ethical framework for counseling about mode of delivery for desired psychosocial benefit in pregnancies complicated by severe fetal anomalies

Background

A fetal diagnosis poses ethical challenges when a woman requests elective cesarean delivery for psychosocial reasons. We address the ethical challenges of counseling such patients.

Case presentation

A 36-year-old G4P2012 has chosen to continue a pregnancy despite a high likelihood of trisomy 18. At 36.5 weeks she was admitted for preeclampsia with severe features and requested to be delivered by primary cesarean section. Due to the poor prognosis associated with trisomy 18, the patient’s request for cesarean delivery was declined even when her baby changed to breech presentation with Category 2 fetal heart rate (FHT). The patient subsequently experienced a traumatic stillbirth and post-traumatic shock disorder (PTSD).

Conclusion

The obstetrician’s goal should be to transform the patient’s request into an informed decision. The obstetrician should explain that, while a cesarean could increase the likelihood of a live birth, it will not alter long-term neonatal outcomes and entails net biomedical risk for the current and future pregnancies. The obstetrician should ensure that the patient understands these clinical realities. The obstetrician should support the patient’s decision-making about whether to accept the risks of cesarean delivery for psychosocial benefit. The obstetrician should initiate counseling during prenatal visits to empower the patient with information to meaningfully exercise her autonomy. If the patient makes an informed decision for cesarean delivery, it becomes ethically permissible. Plans regarding intrapartum management and mode of delivery should be documented in case the patient is delivered by a physician who was not involved in prenatal counseling.

Birth Planning in Uncertain or Life-Limiting Fetal Diagnoses: Perspectives of Physicians and Parents

Background: Providers often use birth plans to document parents' wishes for their fetus with a life-limiting condition. Objective: The objective of the study was to (1) discover important components of a birth plan for parents and providers who carry them out, and (2) understand the experience of parents and providers with birth plans. Methods: The study design involves mixed-methods, descriptive, exploratory survey. This involves parents (n = 20) of a pregnancy complicated by a life-limiting diagnosis and providers who care for them (n = 116). The approach involves descriptive and univariate analyses for quantitative data and thematic analysis for qualitative data. Results: Consistent components for families and physicians were diagnosis and medical management of the infant. Families gave greater emphasis on memory-making preferences. Parents feel birth plans give them a sense of control. Themes emerged from parents' experience of creating a birth plan are as follows: sense of control, therapeutic, memory making, effective communication, feeling prepared, and unexpected events. Most physicians feel comfortable discussing goals of care with families but report insufficient time. The importance of components of birth plans and perception of the parents' understanding of the prognosis varied by specialty. Discussion: Birth plans are beneficial and provide a greater sense of control for parents. Most physicians feel comfortable utilizing them. More than one-third of the physicians do not feel that they have time to complete a birth plan with parents. Communication between physicians and families about limitations of the plan and the potential trajectories could be improved. Communication between maternal and neonatal care providers regarding parent expectations and understanding could also be improved.

Anencephaly; the maternal experience of continuing with the pregnancy. Incompatible with life but not with love

OBJECTIVE

As advances in prenatal diagnosis increasingly enable detection of life-limiting conditions, end-of-life care may start before birth. Termination of these pregnancies may have been default management, but in the Republic of Ireland, where termination is not a legal option, skilled experience in caring for mothers who continue their pregnancies has developed. This study examines the lived experience of four such mothers.

METHOD

A qualitative study was designed using interpretive phenomenological analysis, which examined the maternal experience of continuing pregnancy with a prenatal diagnosis of anencephaly. Four mothers participated in semi-structured interviews on their experience of pregnancy and delivery of a baby with anencephaly.

RESULTS

A profoundly emotional journey represented an adaptive grieving process, which culminated in rich experiences of transformative growth for all the parents. The parents' relationship with their caregivers facilitated this process and the development of a meaningful parenting relationship with their babies. This positive finding coexists alongside a parallel experience of ongoing deep sense of loss and sadness.

CONCLUSION

Perinatal palliative care for those with a prenatal lethal diagnosis is a positive life experience for some mothers. The role of relationship with healthcare professionals is vital to the process and consideration must be given to a comprehensive multi-disciplinary team approach.