Perinatal practice in extreme premature delivery: variation in Dutch physicians’ preferences despite guideline

Abstract

Decisions at the limits of viability about initiating care are challenging. We aimed to investigate physicians’ preferences on treatment decisions, against the background of the 2010 Dutch guideline offering active care from 24+0/7 weeks of gestational age (GA). Obstetricians’ and neonatologists’ opinions were compared. An online survey was conducted amongst all perinatal professionals (n = 205) of the 10 Dutch level III perinatal care centers. Response rate was 60 % (n = 122). Comfort care was mostly recommended below 24+0/7 weeks and intensive care over 26+0/7 weeks. The professional views varied most at 24 and 25 weeks, with intensive care recommended but comfort care at parental request optional being the median. There was a wide range in perceived lowest limits of GA for interventions as a caesarian section and a neonatologist present at birth. Obstetricians and neonatologists disagreed on the lowest limit providing chest compressions and administering epinephrine for resuscitation. The main factors restricting active treatment were presence of congenital disorders, “small for gestational age” fetus, and incomplete course of corticosteroids.Conclusion: There was a wide variety in individually preferred treatment decisions, especially when aspects were not covered in the Dutch guideline on perinatal practice in extreme prematurity. Furthermore, obstetricians and neonatologists did not always agree. What is known: • Cross-cultural differences exists in the preferred treatment at the limits of viability • In the Netherlands since 2010, intensive care can be offered starting at 24 +0/7 weeks gestation What is new: • There was a wide variety in preferred treatment decisions at the limits of viability especially when aspects were not covered in the Dutch national guideline on perinatal practice in extreme prematurity.

Intensity of perinatal care for extremely preterm babies and outcomes at a higher gestational age: evidence from the EPIPAGE-2 cohort study

“…There is broad agreement in developed countries that all deliveries above 26 weeks should receive active perinatal care, whereas in 2011 there was greater variation at 24 and 25 weeks in France and elsewhere. For example, the attitudes of Dutch health care professionals varies most towards births at 24 and 25 weeks' gestation [35], and the largest differences in survival seen in five European regions were at 24 weeks' gestation, with much greater consistency in outcomes above this gestational age [36].…”

Preferred prenatal counselling at the limits of viability: a survey among Dutch perinatal professionals

“…Statistics may not always be of additional value to parents. Boss found that physicians’ predictions of morbidity and death are not central to parental decision-making regarding delivery room resuscitation [ 33 ]. Janvier rightly appoints the disadvantages of using statistics, i.e.…”

“…We developed the current survey in three stages just as described elsewhere. The first version was based on a combination of literature on prenatal counselling, several prenatal counselling surveys that were kindly shared with us [ 5 , 16 , 17 , 33 – 35 ], observations from previous Dutch studies [ 28 ], and on public discussions generated by the Dutch guideline on perinatal practice in extreme premature delivery [ 27 ]. This survey was improved in two Delphi rounds containing both four team members and two independent professionals.…”

Opinions of Argentinean neonatologists on the initiation of life‐sustaining treatment in preterm infants

“…The decision to begin life‐sustaining treatment (LST) on critically ill neonates is an internationally debated issue that continues to provoke widespread discussion . The care of babies born at the threshold of viability raises questions about their chances of survival and about their expected quality of life .…”