OBs' willingness to intervene can impact periviable outcomes. These findings suggest that personal and institutional factors may influence obstetrical counseling and decision-making.

Introduction Sociodemographic differences have been observed in the treatment of extremely premature (periviable) neonates, but the source of this variation is not well understood. We assessed the feasibility of using simulation to test the effect of maternal race and insurance status on shared decision-making (SDM) in periviable counseling. Methods We conducted a 2 × 2 factorial simulation experiment in which obstetricians and neonatologists counseled two consecutive standardized patients (SPs) diagnosed with ruptured membranes at 23 weeks, counterbalancing race (black/white) and insurance status using random permutation. We assessed verisimilitude of the simulation in semi-structured debriefing interviews. We coded physician communication related to resuscitation, mode of delivery, and steroid decisions using a 9-point SDM coding framework; then compared communication scores by SP race and insurer using ANOVA. Results Sixteen obstetricians and 15 neonatologists participated; 71% were women, 84% married, and 75% parents; 91% of physicians rated the simulation as highly realistic. Overall, SDM scores were relatively high, with means ranging from 6.4–7.9 (out of 9). There was a statistically significant interaction between race and insurer for SDM related to steroid use and mode of delivery (p<0.01 and p=0.01, respectively). Between group comparison revealed non-significant differences p=<0.10) between SDM scores for privately-insured black patients vs privately-insured white patients, Medicaid-insured white patients vs Medicaid-insured black patients, and privately-insured black patients vs Medicaid-insured black patients. Conclusions This study confirms that simulation is a feasible method for studying sociodemographic effects on periviable counseling. SDM may occur differentially based on patients’ sociodemographic characteristics and deserves further study.

Objective To qualitatively assess obstetricians’ and neonatologists’ responses to standardized patients (SPs) asking “What would you do?” during periviable counseling encounters. Methods An exploratory single-center simulation study. SPs, portraying a pregnant woman presenting with ruptured membranes at 23 weeks, were instructed to ask, “What would you do?” if presented options regarding delivery management or resuscitation. Responses were independently reviewed and classified. Results We identified 5 response patterns: ‘Disclose’ (9/28), ‘Don't Know’ (11/28), ‘Deflect’ (23/28), ‘Decline’ (2/28), and ‘Ignore’ (2/28). Most physicians utilized more than one response pattern (22/28). Physicians ‘deflected’ the question by: restating or offering additional medical information; answering with a question; evoking a hypothetical patient; or redirecting the SP to other sources of support. When compared with neonatologists, obstetricians (40% vs. 15%) made personal or professional disclosures more often. Though both specialties readily acknowledged the importance of values in making a decision, only one physician attempted to elicit the patient's values. Conclusion “What would you do?” represented a missed opportunity for values elicitation. Interventions are needed to facilitate values elicitation and shared decision-making in periviable care. Practice Implications If physicians fail to address patients’ values and goals, they lack the information needed to develop patient-centered plans of care.

Objective To estimate the odds of morbidity and mortality associated with cesarean compared to vaginal delivery for breech fetuses delivered from 23 to 24 6/7 weeks gestational age (GA). Study Design Retrospective cohort study of state-level maternal and infant hospital discharge data linked to vital statistics for breech deliveries occurring between 23 and 24 6/7 weeks gestation in California, Missouri and Pennsylvania from 2000–2009 (N=1854). Analyses were stratified by GA (23–23 6/7 vs. 24–24 6/7). Results Cesarean was performed for 46% (335) and 77% (856) of 23- and 24-week breech fetuses. In multivariable analyses, overall survival was greater for cesarean-born neonates (AOR=3.98 95% CI=2.24, 7.06; AOR=2.91, 95% CI=1.76, 4.81). When delivered for non-emergent indications, cesarean-born survivors were more than twice as likely to experience ‘Major Morbidity’ (IVH, BPD, NEC, asphyxia composite) (AOR 2.83, 95% CI=1.37, 5.84; AOR=2.07, 95% CI=1.11, 3.86 at 23 and 24 weeks). Among intubated neonates, despite a short-term survival advantage, there was no difference in survival to >6-month corrected age (AOR=1.77, 95% CI =0.83, 3.74; AOR=1.50, 95% CI=0.81, 2.76). There was no difference in survival for intubated 23-week neonates delivered by cesarean for non-emergent indications, nor cesarean-born neonates weighing <500g. Conclusion Cesarean increased overall survival and major morbidity for breech periviable neonates. However, among intubated neonates, despite a short-term survival advantage, there was no difference in 6-month survival. Also, cesarean did not increase survival for neonates weighing <500g. Patients and providers should explicitly discuss the trade-offs related to neonatal mortality and morbidity, maternal morbidity, and implications for future pregnancies.

Objective Compare the management options, risks and thematic content that obstetricians and neonatologists discuss in periviable counseling. Study Design Sixteen obstetricians and 15 neonatologists counseled simulated patients portraying a pregnant woman with ruptured membranes at 23 weeks gestation. Transcripts from video-recorded encounters were qualitatively and quantitatively analyzed for informational content and decision-making themes. Results Obstetricians more frequently discussed antibiotics (p=0.005), maternal risks (<.001), and cesarean risks (<.005). Neonatologists more frequently discussed neonatal complications (p=.044), resuscitation (p=.015), and palliative options (p=.023). Obstetricians and neonatologists often deferred questions about steroid administration to the other specialty. Both specialties organized decision-making around Medical Information, Survival, Quality of Life, Time, and Support. Neonatologists also introduced themes of Values, Comfort or Suffering, and Uncertainty. Conclusion Obstetricians and neonatologists provided complementary counseling content to patients, yet neither specialty took ownership of steroid discussions. Joint counseling and/or family meetings may minimize observed redundancy and inconsistencies in counseling.