An Evidence-Based Overview of Prenatal Consultation With a Focus on Infants Born at the Limits of Viability

Abstract

Before the delivery of a premature infant, a prenatal consultation between parents and physicians provides the opportunity to establish a trusting relationship and create a supportive environment for decision-making concerning neonatal resuscitation. The ideal consult enables physicians to educate parents about preterm delivery and potential outcomes for their infant while providing parents with the time to ask questions and express their values. The uncertainty that surrounds many decisions in the treatment and resuscitation of infants born at the limits of viability creates a situation in which joint responsibility for decision-making between parents and physicians is vital. In this review we examine ethical considerations regarding the resuscitation of infants born at the limits of viability and present the current policies established by the Neonatal Resuscitation Program and the American Academy of Pediatrics. The parental and physician perspectives regarding the consultation experience are presented also. Finally, a model for the prenatal consultation is introduced with suggestions for the incorporation of morbidity and mortality data as well as the structure and approach to discussion with parents with threatened preterm delivery.

Teaching antenatal counseling skills to neonatal providers

“…[2][3][4][5][6] During the simulation, the fellows dutifully presented, from "head-to-toe," a detailed and accurate description of the common risks facing an infant born at this gestational age, including intra-ventricular hemorrhage, respiratory distress syndrome, chronic lung disease, patent ductus arteriosus, and necrotizing enterocolitis. They discussed umbilical lines and blood transfusions.…”

Differing Attitudes Toward Fetal Care by Pediatric and Maternal-Fetal Medicine Specialists

“…5 Pregnant women carrying fetuses with a range of surgical and nonsurgical fetal conditions are now increasingly referred to pediatric subspecialists who, in some cases, refine the fetal diagnosis, and, in most cases, provide further counseling on the conditions and their expected short-and long-term postnatal sequelae. [7][8][9][10][11][12][13][14] With such counseling no longer the sole domain of obstetricians, the possibility arises that pediatrics specialists may provide counseling that sometimes contrasts with that of their obstetric counterparts. 3,4,15 Fetal conditions currently cared for at fetal care centers (eg, Down syndrome, congenital diaphragmatic hernia, and spina bifida) are rare compared with many maternal conditions (eg, diabetes, substance use, and abuse) that also are known to affect a child' s health postnatally.…”

Etiology and Manifestations of Iatrogenesis in Pediatrics

“…Physicians are under no obligation to provide treatment that is not medically appropriate [33]. It is ethically permissible to decline to escalate treatment in such circumstances, including resuscitation when no means to treat the underlying condition exists [34]. M's case exemplifies how, once started, nonindicated interventions can "cascade," causing more harm [35].…”