Chapter 55: 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? What language do they speak? Is an interpreter needed? Discuss the situation with the obstetric staff, and call for an interpreter if needed. Avoid using family members to translate because they need to be listening, may not have the expertise to provide appropriate translation of medical details, and may at times dominate questioning during the counseling session.

2. Is the mother too sick or uncomfortable to be able to adequately participate in the discussion? In this situation, time is critical; be sure 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. Some practitioners ask parents to repeat what they have heard at the end of the session.

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 and planning the discussion.

III. DIFFERENTIAL DIAGNOSIS

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

1. Preterm birth

2. Fetal growth restriction (FGR) (also known as intrauterine growth restriction [IUGR])

3. Maternal substance use disorder (SUDS)

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, keep in mind that most people cannot think in percentages, acknowledge uncertainties, and try to give the parents an idea of what to expect. 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 neonatal intensive care unit (NICU).

3. Content of discussion. As appropriate, discuss the infant’s chances of survival, possible complications, and the range of long-term outcomes. ...