Preterm counselling

Counselling of parents prior to the expected delivery of a preterm infant is a difficult, but important, part of a neonatologist’s workload. In an attempt to provide parents with consistent and up to date information, there is an outline of discussion points and current data that may be helpful to read through prior to the counselling. Of course, every discussion will be different, dependant on gestational age, the expected condition of the baby, the amount of information the mother/parents want and the questions they ask. A clear plan for delivery and care of the baby should be made and documented. This should be reviewed regularly. We are planning to audit parental feedback and assessment of the antenatal counselling. Please complete an audit form for each of the preterm delivery discussions you have with parents. Forms should be put into the folder in the neonatal unit.



Things to consider for discussion with parents prior to an expected preterm delivery


What might happen at the delivery
· Resuscitation (dependant on gestational age)
· Interventions
· Transfer of babies from Kingston <26 weeks/ when full · Comfort/ palliative care for babies not resuscitated (if appropriate) Expected/ possible problems for babies born preterm · Lungs:Ventilation/Surfactant/Oxygen · GI:Feeding / breastfeeding/ NGT/ TPN/NEC · Brain: IVH/ Cranial USS · ROP · Infections/Antibiotics · Haematology: Blood tests/Blood transfusion/Jaundice · Monitoring:monitoring equipment/Leads/incuabator/lines-UAC,UVC The neonatal unit · Visiting · Expected stay Not all parents want information on mortality/ morbidity but these are things that the doctor should be prepared to discuss if the parents request information. Other things to consider in discussion: · Steroid administration · Predicted fetal weight · Multiple pregnancies · Sex · IUGR · Sepsis · Fetal anomaly Parental factors Cultural Religious Medical Past obstetric history





The following information has been taken from ‘The Management of Babies born Extremely Preterm at less than 26 weeks of gestation: A Framework for Clinical Practice at the Time of Birth’ by the British Association of Perinatal Medicine.


Gestation <23 weeks
If the gestation is CERTAIN and less than 23 + 0, it would be considered in the best interests of the baby, and standard practice, for resuscitation not to be carried out. If parents wish, they should have the opportunity to discuss outcomes with a second senior member of the perinatal team.

Gestation 23+0 – 23+6
If gestation is certain at 23+ 0 - 23 + 6 week, and the fetal heart is heard during labour, a professional experienced in resuscitation should be available to attend the birth. In the best interests of the baby a decision not to start resuscitation is an appropriate approach particularly if the parents have expressed this wish. However, if resuscitation is started with lung inflation using a mask, the response of the heart rate will be critical in deciding whether to continue or to stop and sensitively explain to the parents the futility of further interventions.
The EPICure study (1995) reported in 2000 that at 23 weeks 121/241 (50%) of live born babies were admitted for intensive care of whom 105 (80%) died in hospital. 26 babies were discharged home, one died and 14 (54%) have a moderate or severe disability at 6 years.
Early findings in the EPICure 2 study (2006) show that at this gestational age survival has not increased significantly and there has been no change in early major morbidity.

Gestation 24+0 – 24+6
If gestational age is certain at 24 + 0 – 24 + 6 weeks, resuscitation should be commenced unless the parents and clinicians have considered that the baby will be born severely compromised. However the response of the heart rate to lung inflation using a mask will be critical in deciding whether to proceed to intensive care. If the baby is assessed to be more immature than expected, deciding not to start resuscitation may be considered in the best interest of the baby.

In the 1995 study, although 313/382 (78%) of babies born at this gestational age were given intensive care, 198 (66%) died. Half of the survivors (52) have a moderate or severe disability at 6 years. Early findings in the EPICure 2 study (2006) show that at this gestational age, survival has increases significantly by 12%. More babies were treated for retinopathy of prematurity but there is no evidence of any change in other early major morbidity.


23 weeks -- 10 to 35 % survival ----> than 50 % long-term disability


<5% long term disabilities


24 weeks -- 40 to 70 % survival ----- 25 to 50 % long-term disability


25 weeks - 50 to 80 % survival ---- 15 to 25 % long-term disability


26 weeks -- 80-90% survival ----- 10-25% long term disabilities


27-29weeks -- 90+% survival ---- 10% long term disabilities


30-33weeks -- 95+% survival ---- 5% long term disabilities


34-37weeks -- 98% survival <5% long term disabilities



25 Weeks and Greater
When the gestational age is 25 + 0 weeks or more, survival is now considerably greater than in 1995. It is appropriate to resuscitate babies a this gestation and, if the response is encouraging, to start intensive care.

In the 1995 study 389/424 (92%) babies born alive at 25 weeks were admitted for intensive care but 171 (48%) died. 27% of the survivors had no identifiable impairment at 6 years. In 2006 survival had increased significantly from 54% to 67% (by 13%), but there is no evidence or change in early major morbidity.




Audit form for Antenatal Counselling undertaken by Doctors


Please attach mother’s hospital sticker below







Counselled by

Date

Gestation at time of counselling

Time spent (mins)

Place

People present







Were the following areas discussed?

Resuscitation  Infections 

Lung development/ ventilation  Total stay 

Cr.USS/ IVH  haematology 

Feeding/ NGT/ TPN  monitoring/lines