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Am J Perinatol 2022; 39(13): 1383-1388
DOI: 10.1055/a-1815-2000
SMFM Fellowship Series Article

Patient Decisions Regarding Fetal Monitoring in the Periviable Period and Perinatal and Maternal Outcomes

Kate Swanson 
1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
2   Division of Medical Genetics, Department of Pediatrics, University of California, San Francisco
,
Katelin Kramer
3   Division of Neonatology, Department of Pediatrics, University of California, San Francisco
,
Samhita Jain
3   Division of Neonatology, Department of Pediatrics, University of California, San Francisco
,
Elizabeth E. Rogers
3   Division of Neonatology, Department of Pediatrics, University of California, San Francisco
,
Melissa G. Rosenstein
1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
› Author Affiliations Funding None.
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Abstract

Objective Management of delivery at periviable gestation requires complex counseling and decision making, including difficult choices about monitoring and potential cesarean delivery (CD) for fetal benefit. Our objective was to characterize decisions that patients make regarding fetal monitoring and potential CD for fetal benefit when delivering in the periviable period, and associations with perinatal and obstetric outcomes. We hypothesize that a significant number of patients forgo monitoring and potential CD for fetal benefit in the periviable period when offered the opportunity to do so.

Study Design Retrospective cohort study of nonanomalous singleton pregnancies delivering between 230/7 and 256/7 weeks at a tertiary care center from 2015 to 2020 as based on our institutional clinical practice. Since 2015, these patients are offered the ability to accept or decline fetal monitoring, potential CD for fetal benefit, and active resuscitation of a liveborn neonate. The frequency of patients desiring potential CD for fetal benefit was identified, and associations with CD and intrapartum demise were analyzed.

Results Fifty subjects were included. Seventy-eight percent (n = 39) desired monitoring and potential CD for fetal benefit, and 84% (n = 42) desired resuscitation if the neonate was born alive. This varied by gestational age: 55% (6/11) of patients delivering between 230/7 and 236/7 weeks desired fetal monitoring and potential CD for fetal benefit, while 90% (19/21) of patients delivering between 250/7 and 256/7 weeks desired fetal monitoring and potential CD for fetal benefit (p = 0.02). Sixty-nine percent of pregnancies in which potential CD for fetal benefit was desired resulted in CD (27/39), of which 85% were classical (23/27). Intrapartum fetal demise occurred in 45% (5/11) of pregnancies in which monitoring was not performed.

Conclusion While a majority of patients delivering between 230/7 and 256/7 weeks desired monitoring and potential CD for fetal benefit, this varied significantly by gestational age. The decision to perform monitoring and potential CD for fetal benefit was associated with a high frequency of CD, while the decision to forgo monitoring was associated with high frequency of intrapartum demise.

Key Points

  • Patients desires vary in the setting of periviable delivery.

  • Periviable monitoring is associated with cesarean delivery.

  • Forgoing monitoring is associated with intrapartum demise.

Keywords

periviable delivery - periviability counseling - fetal monitoring - cesarean delivery - intrapartum fetal demise

Note

This paper was presented in poster format at the 41st Annual Pregnancy Meeting of the Society of Maternal-Fetal Medicine in January 2021.




Publication History

Received: 18 June 2021

Accepted: 28 March 2022

Accepted Manuscript online:
01 April 2022

Article published online:
06 June 2022

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