Ethical Dilemma

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Scenario: Dr wants to send a patient with a 22 week gestation (nonviable) to be induced stating; the fetus has severe oligohydramnios and will not be able to breath on it's own..so let's go ahead and induce labor. Fetus is alive at this time and will probably be born alive... Some staff are viewing this as a therapeutic abortion and are ethically opposed. The other issue revolves around the period between 20 and 24 weeks, where generally less than 20 weeks is not seen in L&D and over 24 weeks needs to go to a tertiary care center for the proper level of care with delivery. Has anyone else had a similar situation, if so , how was it addressed. Appreciate your input

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Specializes in Maternal - Child Health.

In the institutions where I have worked, an elective induction of a living fetus would be considered a pregnancy termination, and would have to meet the facility's criteria for that procedure.

One hospital where I worked did elective terminations, so this patient would have been admitted to L&D (assuming that she desired to terminate her pregnancy.)

The other facilities restricted pregnancy terminations to circumstances where 2 independent physicians certified that the mother's life was endangered by the pregnancy. Assuming that this patient has intact membranes and no evidence of chorioamnionitis, she would not meet the criteria of life endangerment.

I am also terribly concerned by the doctor's assessment of fetal lung development. While oligohydramnios can certainly put a fetus at risk for hypoplastic lungs, I don't know how he can make an accurate diagnosis at this early gestation. Seems to me he risks terminating a pregnancy that may be viable, depending on future fetal development.

Is he unwilling to adopt a "wait and see" approach? If so, why?

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Thank you this is most helpful!!!!!!!

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Specializes in Community, OB, Nursery.

I agree with Jolie. (I'm agreeing w/ Jolie a lot here!)

I do believe that if baby is currently alive, then it has to be considered an elective AB (sounds like the doc is the one electing). I can see the ethical dilemma. Current NRP allow nonresuscitation for under 23 weeks with good dates, but not resuscitating a baby that's born early from PTL (which may indeed be caused by chorio) is in my mind different than inducing a labor because a problem may or may not exist.

If we have a delivery at 22 weeks and there is any sign that baby might be born alive (big teaching hospital), NICU is there to resuscitate, period, unless parents have decided beforehand not to.

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Thank you very much!!

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

totally agree w/the others.

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Specializes in ICU, PICC Nurse, Nursing Supervisor.

I don't work in OB/GYN but what does the family say?

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Some thoughts:

This is the parents call to make.

Babies with fluid levels of 0-2 do extrememly poorly. They generally spend a long time in level 3 on progressively increasing oscillator vents until their lungs blow and the suffocate and hemorrhage to death. Also, do you have an infant ECMO to attempt the save at viability ?

Also there is the question about why there is a lack of fluid. Likely, the mother's placenta is defective enough to not support the pregnancy further and/or the baby has big problems. True oligo doesn't happen in a vacuum.

I'd also like to gently point out that I think your bias is showing in how you phrased the doc's point of view when you presented the Doc as saying "so lets go ahead and induce" as thought the doc was making a flip decision and family wasn't a part of the decision process.

We have an 18 week gestation making a similar decision today. I feel quite confident that your (hypothetical?) family and my (real) family is gathering the best information they can and making the best decision they can for themselves.

If you cannot set aside your feelings about what you would choose and take care of this family in the way they need, then send them to me.

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Ouch!!!!

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

This is obviously a hot-button topic. Please don't let this turn into an unfriendly debate, that is all I ask.

Thanks!

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No debate at all..I'm actually just the intercessor in this dilemma looking for suggestions for management, quoting as it had been quoted to me. I appreciate all feedback and viewpoints..in searching for the best solution for all involved..

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

I appreciate the purpose of your thread. I just hope to keep things on track, that is all.

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