Obstetric decision-making and counseling at the limits of viability

摘要

Objective: The purpose of this study was to examine factors that influence obstetric decision-making and counseling for periviable deliveries and to describe counseling challenges. Study Design: Twenty-one semistructured interviews were conducted with obstetricians who were recruited from 5 academic medical centers in Philadelphia. Two trained reviewers independently coded transcripts using grounded theory methods. Research software facilitated qualitative analysis. Results: Circumscribed by institutional norms and clinical acuity, obstetric decision-making and counseling were influenced primarily by patient preferences. Perspectives on patient autonomy guided approaches to counseling. Thresholds for intervention varied from "attending to attending" and "institution to institution." Sociodemographic factors were not believed to influence clinical decision-making. However, obstetricians admittedly managed in vitro fertilization pregnancies more aggressively. Communicating uncertainty, managing expectations, assessing understanding, and relaying consistent messages across specialties were frequently described counseling challenges for obstetricians. Conclusion: The impact of institutional variation and in vitro fertilization on periviable decision-making warrants further consideration. Interventions to train and support obstetricians in communicating uncertainty, managing expectations, and assessing values and understanding are needed.