Opinion: The Terrible Hours: Counseling patients carrying a periviable fetus

July 1, 2008

Although caring for a woman whose unborn is at the edge of viability can be heart-wrenching, NICHD now offers a clinical tool to individualize counseling and provide a more accurate prognosis.

The reality is that we have no truly effective method of prolonging a pregnancy much beyond 48 hours when patients present in advanced preterm labor. Corticosteroids appear to have some benefit in the periviable setting but are no panacea. Worse still, even with optimal management, given the current medicolegal climate, every such patient also represents a potential plaintiff in a high stake's trial. Then there are the potential future complications of periviable classical cesarean deliveries-previa, accreta, and uterine rupture near term. But the most challenging aspect of these scenarios is that expectant parents want individualized answers about their infant's prognosis-not vague generalities. They want to know whether their baby will be normal?

At the edges of viability

Many factors must be considered by physicians and parents in making crucial obstetric management decisions at the edges of viability. Some couples will have strong religious or ethical beliefs about the option of terminating the pregnancy or have strong emotional attachments to their future child; and they will generally want all reasonable measures taken to maximize viability. Others will seek termination to avoid any risk of handicap if they are within their state's acceptable gestational age limits. Still others, when faced with a poor prognosis, will decline intervention for fetal benefit, but are uncomfortable with terminating the pregnancy. In consultation with a neonatologist, such couples may decline cesarean delivery for malpresentation, opt to forego fetal monitoring or intervention based on nonreassuring fetal status, and may even decline resuscitation of the newborn even though this may exacerbate fetal injury and worsen handicaps should the infant survive.

These are all heart-wrenching situations for all involved. The key to management is providing such couples with accurate, practical, and individualized information to help them navigate through these monumental decisions. As providers, we're compelled to inform the couple not only about chances for survival, but also about the future challenges their child will likely face and about the impact of possible disabilities on the overall quality of life of the entire family.