50: Counseling Parents Before High-Risk Delivery

I. PROBLEM

The nurse calls to notify you of a pending high-risk delivery. You are on delivery room duty, and you are asked to counsel the parents before their infant is delivered.

II. IMMEDIATE QUESTIONS

1. Are both parents and other important family members available? Is a translator needed? Discuss the situation with the obstetric staff. A family member is often too emotionally involved to accurately translate.

2. Is the mother too sick or uncomfortable to be able to adequately participate in the discussion? In this situation, it is essential to include other family members.

3. How well do the parents understand their current situation? Discuss the circumstances with the obstetric staff, and ask the parents what they understand.

4. What do they know about neonatal intensive care units (NICUs), pregnancy and neonatal complications, chronic health problems, and neurodevelopmental disability? This helps you in beginning the discussion.

III. DIFFERENTIAL DIAGNOSIS

Neonatologists are called to counsel expectant parents in a variety of circumstances. These include:

1. Preterm birth

2. Intrauterine growth restriction (IUGR)

3. Maternal drug use

4. Signs of fetal distress

5. Congenital anomalies

IV. DATABASE

1. Maternal/paternal data. Obtain information regarding the age of both parents; mother's obstetric, past medical, and social history; history of the pregnancy, medications, and pertinent laboratory data; and family history.

2. Fetal data. Review fetal information with the obstetric staff, including accuracy of pregnancy dating, findings on prenatal ultrasounds, and signs of fetal distress.

V. PLAN

1. General approach to parent counseling. Although circumstances are often less than ideal, it is important to communicate as effectively and empathetically as possible. Sit down, communicate at eye level, take time to introduce yourself and your role, and talk in a clear and unhurried manner. Explain all medical terms, avoid using abbreviations and percentages (many people cannot comprehend them), and acknowledge uncertainties. Ask if they understand, and summarize the most important points. Ask if they have any questions and offer to follow-up with them if they have more questions.

2. Goal of counseling session. Because a complete discussion is often unrealistic, your goal is to help parents anticipate and to provide a framework for understanding what happens during delivery and in the NICU.

3. Content of discussion. Discuss the infant's chances of survival, possible complications, and the range of long-term outcomes. Review appropriate references and other chapters in this book and textbooks for more information. Describe the anticipated activity during delivery. Giving them the opportunity to tour the NICU allows them to see the monitoring and life support equipment, so that they can better see their own baby underneath it all.

4. Bedside manner. For many, the shock and anxiety of facing difficult circumstances challenges their ability to process. Avoid overloading the family with information. Your communication is most effective if conveyed in a caring, empathetic, and unhurried manner. Understand that hope ...