Information Informing Decisions Surrounding Perinatal Interventions

Obstetricians are taught that their first obligation and priority is the mother's health but that women and families are willing to accept some degree of increased risk to the mother if it will benefit her fetus (see Appendix C for a discussion of ethical issues). A decision to arrest pre-term labor may increase the risk to both the mother and the fetus if the pregnancy is complicated by bleeding, hypertension, or infection. A lesser risk usually attends uncomplicated preterm labor; but intrauterine fetal stress or compromise may contribute to the onset of preterm labor, and tests of fetal well-being are imperfect. Tocolytic drugs, which are used to arrest labor, can have serious maternal and fetal side effects, especially if they are used in increasing doses, for prolonged periods, or in combination with one another. The decision about whether to arrest preterm labor, to transfer the mother and the fetus in utero to another hospital, or to administer antenatal glucocorticoids is made against this background in an environment of spoken and unspoken assumptions about their wisdom, according to current information and beliefs. The quality of this information necessarily varies with the dissemination and local application of advancements in perinatal and neonatal care. Beliefs about the anticipated rates of morbidity and mortality for pre-term infants according to gestational age are the foundation for decisions regarding obstetric and perinatal care.

Reports of improved perinatal outcomes for preterm infants could be expected to and do apparently result in an increased willingness to choose delivery and neonatal care over the uncertainties of continuing the pregnancy. The mortality and morbidity of prematurely born infants are discussed in Chapter 10. Recent data from one center are shown in Figures 9-2 and 9-3 to illustrate how improved outcomes for infants born after 32 weeks of gestation might lead to a decision to allow preterm delivery rather than initiate treatment with drugs that may prolong the pregnancy for only a few days (Mercer, 2003).

Finding 9-5: The goal of prevention of preterm birth is subordinate to the goal of improved perinatal morbidity and mortality outcomes. This goal is important, because the continuation of pregnancy in women with preterm parturition in some instances may increase the health risk for the mother or the fetus, or both.

Although the expectations of obstetric and neonatal doctors and nurses about neonatal and infant outcomes are known to influence decision making in perinatal care (Bottoms et al., 1997), these same practitioners' assessments are not necessarily accurate. Morse et al. (2000) found that both obstetric and neonatal care providers' predictions of neonatal survival and survival without handicap were substantially below the actual rates, indicating a need for improved information before and after delivery (Figures 9-4 and 9-5). Finally, the medical-legal environment may also be a consideration; however, the extent of its influence on this decision-making process is unknown.

Finding 9-6: The knowledge and beliefs of health care providers influence their attitudes toward and their management of mothers with threatened preterm delivery and their infants.

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