Medical staff guidelines for periviability pregnancy counseling and medical treatment of extremely premature infants

OBJECTIVES. The goal of this report is to describe the collaborative formation of rational, practical, medical staff guidelines for the counseling and subsequent care of extremely early-gestation pregnancies and premature infants between 22 and 26 weeks. The purposes of the guidelines were to improve knowledge regarding neonatal outcomes, to provide consistency in periviability counseling, and to promote informed, supportive, responsible choices. METHODS. To formulate the guidelines, a 5-step process was conducted; it began with a series of multidisciplinary meetings among maternal-fetal medicine specialists (MFMs), obstetricians, neonatologists, neonatal nurse practitioners, and nurses from both the labor and delivery unit and the NICU at Providence St Vincent Medical Center (Portland, OR). First, our discussions reviewed mortality rates, morbidity rates, and long-term neurodevelopmental outcomes for extremely premature infants. Second, we explored the variations in counseling that pregnant women received, based on providers' individual beliefs and disparate knowledge of neonatal outcomes. Third, we asked participants to complete a survey that focused on the theoretical impending delivery of a premature infant, presenting at each week between 22 and 26 weeks of gestation. Participants indicated their recommendations for NICU care at each gestational age by using a numeric scale. Fourth, the survey results were tabulated and used as a basis for the formation of guidelines related to the recommended obstetric and neonatal care at each week of gestation. MFMs and neonatologists were urged to use these specific guidelines as a framework for counseling pregnant women between 22 and 26 weeks of gestation. Fifth, we surveyed women similar to 3 days after they were counseled by their MFM and neonatologist, to assess comprehension, utility, consistency, and comfort with the periviability counseling. RESULTS. Twenty pregnant women with the possibility of delivery between 22(0)/(7) and 26(6)/(7) weeks of gestation (mean: 24(6)/(7) weeks) received periviability counseling with our consensus medical staff guidelines. The respondents rated the counseling process as highly understandable (80%), useful (95%), consistent (89%), and performed in a comfortable manner (100%). All (100%) of the pregnant women thought they were given enough information to make critical decisions related to the potential level of care of their infant. CONCLUSIONS. Informative, supportive, clear, medical staff guidelines developed to assist in the counseling of women delivering extremely premature infants have been designed and implemented successfully at our hospital. These guidelines form the basis of periviability counseling, which is appreciated by our at-risk pregnant patients. We recommend that all hospitals that provide high-risk obstetric and neonatal intensive care develop similar consensus guidelines based on published outcomes and local provider experience.