Approaching this difficult, emotional topic with long-time colleague Dr. Jessica Spiegelman, Dr. Fox discusses periviability: the period of time in which a baby is more likely than not to not survive the birth process. While clinically this period of time is somewhat well-defined, the choices, care plans, and procedures that might have to be done are anything but.
“Peri-viable birth” – with Dr. Jessica Spiegelman
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Dr. Fox: Welcome to the “Healthful Woman” podcast, the fastest-growing podcast in women’s health. Today’s Monday, December 26th, 2022. For those of you who celebrate, I hope you had a terrific Christmas yesterday, and hope everyone who’s able to is enjoying their Monday off from work today. Today, we start a series of four podcasts on the topic of periviable birth, which is a preterm birth that occurs just at the cusp of when a newborn might be able to survive, somewhere around 23 to 24 weeks.
This is one of the most difficult clinical situations in all of pregnancy, for the parents, for the baby, and for the doctors. So, we’re gonna try to spend some time on it. Two of the four podcasts will be with doctors and two of the podcasts will be stories from parents from our high-risk birth story series. Today, we start with Dr. Jessica Spiegelman, who is an MFM and was on this podcast a few weeks ago. Jessica and I give an introduction to periviable birth, what it is, why it is so problematic, and how we try to help parents make very difficult decisions during the process.
Next week, I’m gonna be joined by Dr. Annemarie Stroustrup, who is a neonatologist or a NICU doctor, and a return guest on the podcast to talk about the NICU care of babies born in the periviable time period. All right. Thanks for listening. Have a great week. We’ll see you next Monday in 2023.
Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right, Dr. Jessica Spiegelman…
Dr. Spiegelman: Hello.
Dr. Fox: …welcome to the podcast.
Dr. Spiegelman: Thank you.
Dr. Fox: This has been a long time coming.
Dr. Spiegelman: I guess so.
Dr. Fox: Amazing. It’s great to have you here for our listeners. And then we’re gonna get into this when we talk about your history, which you didn’t know I was gonna ask you about, to go and tell your personal history. I’ve known you a long time. You were a resident at Mount Sinai, you came up in the ranks, you refused to work with me the first time, and then… But here we go, as the world turns, you’re back and we’re together again.
Dr. Spiegelman: I couldn’t resist.
Dr. Fox: Amazing. How are you doing today?
Dr. Spiegelman: I’m great.
Dr. Fox: Excited to podcast?
Dr. Spiegelman: Very excited.
Dr. Fox: Is this your first experience being a guest on a podcast?
Dr. Spiegelman: This is my first experience.
Dr. Fox: But since you’re of the generation younger than me, you do listen to podcasts, right?
Dr. Spiegelman: I listen to a lot of podcasts. So I’ve heard the way people talk on them and I’ve tried to emulate it.
Dr. Fox: So you’re familiar with the podcast format?
Dr. Spiegelman: I am.
Dr. Fox: All right, good. So, tell us a little bit about yourself, where you’re from, how you got into medicine, and so forth.
Dr. Spiegelman: I grew up in Teaneck, New Jersey, just a stone’s throw over the George Washington Bridge from here. And I have wanted to be in medicine since I was in high school.
Dr. Fox: Really? Why?
Dr. Spiegelman: Really, my dad suggested it. He said, “You’re good at science.”
Dr. Fox: My daughter’s a nerd, you should go into medicine. All right, yeah.
Dr. Spiegelman: And then I kind of just explored it and liked it. I was an EMT in high school and liked the medicine and thought I was gonna be a pediatrician for most of my college life, then got into medical school and loved my OB-GYN rotation.
Dr. Fox: So just, that was it. You said, “I love OB-GYN. I’m doing it.”
Dr. Spiegelman: Yeah, took like two seconds.
Dr. Fox: Wow. And then how did you end up at Mount Sinai for residency?
Dr. Spiegelman: I did an MFM sub I, which is basically like in your fourth year of medical school, you do a rotation where you pretend to be the intern. And so, I applied to a bunch of them, I got one at Mount Sinai. And I just loved it there so much that I wanted to come and be a resident.
Dr. Fox: Wow. And then during your… For the record, everyone, Jessica was a terrific resident. And I’m not saying that to blow smoke up your butt or [inaudible 00:03:51]. We told you at the time, you’re a terrific resident…
Dr. Spiegelman: Thank you.
Dr. Fox: …and we wanted you to work with us immediately. But you decided for some strange reason to do a fellowship in MFM.
Dr. Spiegelman: Yes.
Dr. Fox: Yeah. How did that come to you?
Dr. Spiegelman: Well, so I did an MSM sub I and I came into residency wanting to do MFM, which I didn’t tell anybody my whole intern year because I wanted to, like, keep my options open, maybe I’d like something else, but I didn’t. So, I just loved high-risk pregnancy and I wanted to be better at it.
Dr. Fox: Well… But you did leave us to go to Columbia?
Dr. Spiegelman: I did. I did.
Dr. Fox: Yeah. We weren’t happy about that.
Dr. Spiegelman: I thought it’s good to kind of vary your experience and see how different places practice and kind of get a different perspective. And I had an amazing experience at Columbia.
Dr. Fox: And then you were amongst a…like a back to back to back to back Sinai residence going to Columbia for fellowship?
Dr. Spiegelman: I was the third in a row. And so, when I was a first-year fellow, there was one of us in every class and it was kind of a joke at Columbia that, like, their forceps numbers went up…
Dr. Fox: Right. The three best fellows that, yeah, all came from Sinai residency.
Dr. Spiegelman: Exactly.
Dr. Fox: If anyone out there at Colombia is listening, yeah, I said that. No, no…
Dr. Spiegelman: Everybody was great.
Dr. Fox: Yeah. And none of them are listening to this podcast, I would say that right now.
Dr. Spiegelman: Well, maybe they are.
Dr. Fox: But now they will. And so, you spent a couple of years working in New York City at NYU and then just recently, you came back for the mothership.
Dr. Spiegelman: What I’m trying to do is just, like, hop around to all the hospitals, you know, see how every single New York City hospital functions.
Dr. Fox: And if one day Mount Sinai grants you privileges back into their institution, then we will see you in the hospital. But how’s it been thus far, coming back somewhat to your roots with our practice? And you have to say good things.
Dr. Spiegelman: No, it has been really nice. It’s been very good to kind of be around people who really trained me. So I feel really comfortable asking questions when I’m not sure and, you know, bouncing ideas off of people, and I just…it feels like coming home.
Dr. Fox: Well, we feel the same way. It’s been awesome. And then when we decided to do this podcast, we really went for… We’re knee-deep on this topic, periviable birth, which is really, really tough stuff.
Dr. Spiegelman: Very.
Dr. Fox: I will just sort of preface this by saying this is a hard topic to podcast about. It’s hard to banter about it because it’s so heavy. Like, in fellowship and in MFM, this is like, whoa. It’s just…it’s a lot.
Dr. Spiegelman: This is the stuff I feel like you really need an MFM for because the counseling is so just nuanced and takes so much experience. But I think it’s important because when we deal with it in real life, we’re kind of having people expect to… We expect them to learn a lot of information that we spend years training to learn very quickly, and when they never thought they would have to deal with it. So, having some background knowledge, I think could be helpful, although, you know, hopefully not, you know, for people who are gonna find themselves in this situation.
Dr. Fox: Yeah, I mean, we’ll get into exactly what this means and what we talk about. And we were talking about before how this is our first, you know, “Healthful Woman Podcast” on this topic specifically. But we sort of, you know, circled around it several times in other podcasts and some of the high-risk birth stories, you know, people are telling their story about, they might be delivering around 23, 24, 25 weeks and like, what do you do? How do you navigate that? You know, am I losing the pregnancy? Am I having very premature babies? Do I intervene? Do I not intervene? You know, the medicine is complicated, the emotions are horrifying. It’s so hard to sort of sort out what to do. And there’s, you know, so much that goes into it.
We had a podcast with [inaudible 00:07:30], who wrote a book and she had a whole chapter on this. And we spoke about it. And so, it’s come up from time to time on the podcast but even though it’s a difficult topic, it’s really important, particularly, if there’s anyone out here listening who, unfortunately, themselves is in this predicament, in this situation, or potentially someone who has or has had a family member or friend go through this, to sort of understand what it means or what it meant for them.
And obviously, for the people listening who maybe are in medicine or even, you know, in the OB world, they just sort of get, you know, some more information on the complexities of this topic. So thanks for suggesting it. And we’ll try to give as best, I guess, a discussion as possible. So, how would you even define periviable birth? Like, what are we talking about here?
Dr. Spiegelman: So, technically, the periviable period is defined as 20 weeks and 0 days until 25 weeks and 6 days. A lot of it kind of depends on what the exact situation is. I think, in practicality, the period that we most find having the most discussions around is 22 weeks until 24 weeks and 6 days. That’s kind of the three-week period where most of the decisions become more complicated, but technically 20 and 0 to 25 and 6.
Dr. Fox: Right. And then also, just to clarify, when we, as obstetricians, talk about weeks, we have this strange system where we date pregnancies from the first day of the last period, or if that’s unknown, or if that IVF, we start two weeks prior to conception, meaning the day the egg and the sperm meet each other, you’re two weeks and zero days. And in our world…so we’d say you’re 10 weeks, you’re 12 weeks, you’re 18 weeks, you’re 20 weeks, whatever, and that’s sort of…we always think about it. But it is sort of confusing, particularly, the beginning of pregnancy, we tell someone, “You’re four weeks,” they’re like, “What are you talking about?” Like, “I had sex two weeks ago.” Like, it doesn’t make sense. And also, sometimes you’ll pull up old references, like, from embryology books or old books that talk about actual pregnancy weeks…
Dr. Spiegelman: Weeks of conception.
Dr. Fox: …right, from the date of conception. And so, sometimes there’s a little bit of confusion there. There used to be a lot of confusion in New York State law regarding sort of what was the legal limits of termination of pregnancy. What were they talking about? That’s sort of been…that law has been changed but there is discussion. So when we talk about weeks, we mean sort of what your obstetrician, what your midwife, what they will tell you, “You’re X weeks pregnant” and that means from the last period. So, okay, why is that gestational age period so complex?
Dr. Spiegelman: So, it’s a complicated period because the survival of a fetus or of a neonate after birth is really not assured if delivery occurs during that period. And the limit of viability kind of used to be, I don’t wanna say universally, but, you know, in the United States kind of generally accepted as being 24 weeks, definitely until the late ’80s and probably into the ’90s. And then, as neonatal technologies have improved, the kind of limit of viability of when baby can be resuscitated and potentially survive outside of the uterus has moved earlier and earlier. And in some places, it’s now as early as 22 weeks. And so depending on what the precise complication is that we’re dealing with, and kind of why a fetus might need to be delivered, the idea is, what do we do in that kind of period where a baby could survive, but has a pretty high chance of not surviving if delivered, and also has a very high risk of what we call morbidities, you know, really serious health complications that can be lifelong?
Dr. Fox: Yeah, I mean, if a baby’s born under 22 weeks, the likelihood the baby’s gonna survive at all is exceedingly low. It’s hard to say zero because it has been reported but we think of it as zero or close to zero.
Dr. Spiegelman: It’s as close to zero as you can kind of statistically get.
Dr. Fox: Yeah. Yeah. And if the baby’s born after, like, 26 plus weeks, the chance of survival is very, very, very high. And, you know, it’s really interesting, from a scientific standpoint, how over just the course of three or four weeks, the survival goes from 0 to like 80%. I mean, it’s just a crazy change in that very brief window, and how much development takes place. And a lot of that is because the lungs sort of develop, like, sort of, from pre-lungs to lungs at that time. Essentially, that’s one of the big reasons that happens. So that’s one area of complexity.
But also, you know, which is what makes it really hard is that a surviving baby does not mean a healthy baby, right? And so you can have a baby that survives and does very well, does relatively well, and does not well at all, and is very, very sick for a short time or a long time. And people feel differently about that. And, you know, that’s why it’s so emotional, you know, if people have to decide between, well, my baby’s not gonna survive and I’m gonna mourn the loss of a child versus my baby might survive, but then has a very high chance of being very sick for a very long time.
I mean, how do you make that decision? Right? It’s very, very difficult. Maybe for some people, it’s not difficult, and that’s okay. But it can be a very difficult decision to make. And if we have to make decisions about either, whether we should deliver the baby if it’s under our control or if the baby’s coming anyways, do we try to “save the baby?” That’s a very tough situation.
Dr. Spiegelman: Yeah, it’s really hard. And, you know, most people don’t expect to find themselves in this situation. Some people have gone through it before and have, you know, certain conditions that might predispose them to having deliveries in this time period and so may be familiar, but that’s the exception. Most people who find themselves in this situation have really…you know, they didn’t expect to be in it when they became pregnant, and it usually is a very quick…you know, we either have to deliver the baby or the baby’s coming. And there’s a lot of counseling that has to happen about what to do. And expecting people to grapple through these decisions with no background and no warning is really, really hard.
Dr. Fox: Yeah, I mean, like you were saying before, like, for us, you know, we have years and years of training. And we’ve seen this over and over, and we’ve talked it through over and over, and we’ve thought about it, and we’ve read about it. And it’s still very difficult for us to wrap our heads around what is the right decision to make, you know, for the patient, whether…if we were in the situation… Like, it’s very, very hard.
And we know as much as you can know, right? And pretty much, like, we have all the information available to us and we thought about it. But, you know, for pretty much everyone who’s in this situation, A, they have no medical training, right, and, B, they’ve never had to think about this, right? They’ve never had to grapple with it. And just on the front end, the information aspect, like, what does it mean to have a baby who has cerebral palsy or what is it… Like, what do these statistics mean, and how do I understand numbers? And then all the obviously emotional, social, religious… There’s so much baggage that comes into it, and they’ve never had to think about it. And now, like, in the throes of this, here we go, here’s, you know, 12 years condensed into 12 minutes.
Dr. Spiegelman: And then another thing I think is hard is we give a lot of statistics in these situations, but the statistics don’t really matter to an individual because your outcome is your outcome. So it doesn’t matter if 80% of babies survive, or 80% of babies don’t survive, or 80% of babies have cerebral palsy, or whatever it is, if it’s your baby that that happens to, it doesn’t matter what happens to them…
Dr. Fox: Right. One or zero. Right.
Dr. Spiegelman: Right. Exactly.
Dr. Fox: It’s really tough stuff. And the things we’re talking about, I mean, we’re talking about death, right, which is very, very heavy, obviously, medical issues like… And people don’t… What does it mean to have a baby who has chronic lung disease? I don’t know. Is it horrible? Well, okay… And it’s sort of… You can envision different situations, and you can go online, and you can find stories where you hear of these miracle babies, and my baby’s perfectly fine, or my baby has lung disease, but is great, and is healthy, and is going to Harvard, and every… Okay. And you can hear other stories, which is like, my baby has been suffering horribly for 12 years. And the reason that range is out there is because that range exists. It could be anything. And like you said, statistics only, like, lean in one direction, but they don’t tell you what’s gonna happen for you. And we just don’t have guarantees in either direction. It’s very hard.
Dr. Spiegelman: Yeah, it’s really tough. And I think our job when we’re in this situation is to try and sort of make it as clear for the patient as possible what the various different outcomes are. Because there are some risks some people are willing to take that others might not be willing to take in terms of the health of their baby long-term, and so it’s just important for them to know as much as we can tell them.
Dr. Fox: Yeah. And there’s also, unfortunately, a lot of disagreement sometimes amongst the providers. And I don’t mean disagreement in the sense that they sit around the room fighting about it, but just sort of, you know, you may have a nurse who has one angle on this, and you have a doctor has another angle, and a pediatrician has a third angle. And that’s based on their own experiences sometimes or the like, oh, you’ll get the exact same situation. And these are three professionals who’ve seen this before and one might say, “Oh, you should end the pregnancy,” one would say, “Oh, you should go for it.” And it’s just like, what? You know, because there’s so much that goes into that, and there’s value, and there’s experience, and there’s, you know, emotions. It’s
Dr. Spiegelman: Something that’s really tough in sort of talking about that is coming at it as objectively as possible. And patients often ask like, “Well, what would you do?” And I really have to say, I actually don’t know what I would do, and we need to just kind of talk through what are the possibilities of the outcomes here, and just for the providers to stay as objective as possible, and really try and help the patient come to the conclusion that’s as right as possible for them without bringing their own value systems.
Dr. Fox: Right. I think that there’s… When somebody asks, what would you do? There’s two ways that people approach that or there’s two things that that can mean. The first thing can sort of mean, I can’t sort through all of this data and I can’t figure out… Like, dude, you’re the doctor, tell me what the right thing to do is, and that happens a lot. And sometimes we should tell them, sometimes we shouldn’t. And that’s a complicated, you know, sort of process when that’s appropriate.
And I find that in this situation, sometimes it’s not that, sometimes it’s like, this decision is too much for me. Like, I can’t have this on my conscious for the rest of my life if I made the right decision, the wrong decision. I don’t want the regret of doing this and, like, so please decide for me. And sometimes people will, like, call upon their spiritual advisor, or like a family member and say, like, “I need you to tell me what to do,” just so it’s like, that burden is lifted off of me. Because it is, this is something that will weigh on you for the rest of your life in either direction, and it’s hard.
Dr. Spiegelman: Yeah. There are some situations where patients ask us for direction and we really should give it. And I think this is one where we really can’t decide for them. They really have to decide, maybe not for themselves, maybe with the help of people in their lives. But unless there’s a clear medical reason to go one way or the other, it’s very hard to be directive in that situation.
Dr. Fox: Yeah. And sometimes we can help people say, “Okay, like, if you feel A, B, C, and D, it would sort of lead you to this choice. Whereas, if you felt this, this, and this, you go to this choice” to sort of say like, you know, if you’re this kind of person, or if you believe this, or if you want this or, you know, how would you feel about this? And we try to help people make a decision. But yeah, it’s hard for me to say, “Oh, you should do this again,” unless obviously, medically, one is clearly a better option than the other. Let’s take a step back for a second. What are the situations that might place someone in this periviable delivery conundrum?
Dr. Spiegelman: So periviable birth is kind of a subset of preterm birth. And so, there’s a few different reasons why somebody might have a preterm delivery, and I like to kind of think about it as either spontaneous or kind of indicated. Spontaneous is somebody is in preterm labor or their cervix is dilating and, basically, their body is delivering the baby and, you know, we can maybe try it and slow things down but that’s just what’s probably gonna happen. They break their water or something like that. And then indicated is medical situations where we are telling someone, “Well, it’s not safe for you to be pregnant anymore.” At this gestational age, probably the most common one would be severe preeclampsia or HELLP syndrome, some, you know, hypertensive condition that is severe enough that continuing pregnancy would endanger the life of the mother. And there’s other situations like that too but I think that would probably be the most common one.
Dr. Fox: Right. There’s sometimes a third where the fetus is in trouble, right?
Dr. Spiegelman: That’s true too. Yeah.
Dr. Fox: So if the baby’s really, like, growth restricted and we say, you know, if we don’t deliver, the baby’s gonna die inside. And so, we can either deliver or not deliver, and then… Again, that sort of brings about the same situation other than… You know, it’s a little bit different.
Dr. Spiegelman: Yeah, growth restriction at that gestational age, often the fetus is too small to resuscitate. But, yeah, you could sort of get into that. And there’s a margin of error of ultrasound so maybe we’re underestimating the weight of the baby, and so we could deliver and… Yeah, so growth restriction would definitely be another one.
Dr. Fox: Yeah, let’s talk first about the one where someone’s in spontaneous preterm labor or their water breaks. And that’s sort of the one that, you know, hits people usually out of nowhere. Again, if they’ve had this before then maybe they’ve been prepped, so to speak. But for most people, it’s their first pregnancy, it’s the first time this happened to them, and they’re sort of like they’re 22, 23 weeks and suddenly, their water breaks or suddenly, they’re having contractions, they come to the hospital, and, like, you’re five centimeters dilated.
And so, there isn’t often a ton of time to sort out, number one, and number two, you don’t always know the day they’re gonna deliver. That’s the other thing you sort of like, all right, well, if you deliver today, right, and… You know, as we said before, there’s like a four-week period where survival goes from 0 to 80%, so every day you stay pregnant that number is gonna bump up and up and up and up. And so, this counseling has to sort of reinvent itself every day, every other day. I mean, whatever it is. It’s very, very… And so, we’re sort of left with three options at that point. You can either sort of say, ”Oh, I did not wanna be in this situation and I’m gonna, like, actively terminate a pregnancy,” which is obviously very complex for a lot of reasons. Some of them nowadays are just simply legal, right?
Whether that’s even an option for you, depends where you live, it depends on the rules, it depends on the laws. That’s its own discussion. But then also, you know, this is not something people wanna do, presumably, if they’re 22, 23 week. Yeah, this is not what they were, like, signing up for. And then there’s also sometimes… Technically, it can be challenging based on exactly the circumstances and what that means. If it means just letting the birth happen, that’s one option. The second option is sort of to, like, do everything humanly possible to sort of ”save’ the baby.” And there’s certain medications we might give to, like, stop the labor, or to maybe improve the outcomes like steroids, magnesium. And that’s sort of during the pregnancy, you know. And then there’s like…a subset of that is what do you do if the baby’s born? So, explain where that comes in as a complicated decision.
Dr. Spiegelman: Yeah. So I usually break it down exactly like that for patients. So the first kind of decision point is…I actually do it backwards. So first, if the baby comes out today, would you want the neonatologist to resuscitate the baby? Because you do have that choice about resuscitation versus non-resuscitation.
Dr. Fox: Sometimes.
Dr. Spiegelman: Sometimes.
Dr. Fox: Right.
Dr. Spiegelman: Yeah, it depends on the exact situation.
Dr. Fox: Right. I think that’s important. Let’s talk about it for a second. Once the baby… The baby’s inside the mother… Well, again, we’ll take out some of the laws that are current, but if the baby’s inside the mother, she has the decision about whether to take medications, not take medications, things that…you know, the steroids, not steroid, this is… Fine. Once the baby is outside, right, and this baby is born, the parents have the majority of decision-making, but there’s some things that they can’t…they’re not allowed to decide…
Dr. Spiegelman: Right. That’s true.
Dr. Fox: …for their child. And that’s a gray zone of exactly when it flips that the pediatrician’s like… If a baby’s born and is, you know, eight pounds and the parents say like, “Don’t resuscitate…” They saw the baby… Neonatologist’s like, ”No, we’re not listening to you” like, “We’re doing this.” Right? Whereas if the baby is, you know, like, you know, half a pound then, yeah, they’ll typically listen. And exactly where that cut-off is is very complicated and gray.
Dr. Spiegelman: And it’s a little bit NICU dependent also. Depends on the exact place where you are. I think, you know, 25 weeks, most neonatologists will say, “We’re gonna resuscitate no matter what,” but before that… Depending on the NICU.
Dr. Fox: Right, so let’s say we’re in that zone, the parents…so you ask them the question, “Would you wanna resuscitate the baby?”
Dr. Spiegelman: And so, that decision really is dependent on talking through the range of outcomes that might happen if we resuscitate. So, what are the chances of survival? What are the chances of what we call intact survival? Which is a term I actually don’t really like, but basically is, you know, survival without really serious health consequences, which could be things like chronic lung disease, blindness, deafness, cerebral palsy, really serious neurodevelopmental delays.
And I think that conversation is really useful to have with the neonatologist because they are the people who take care of the babies long-term. And so, they can give a little bit more insight into what a prolonged NICU stay really looks like and what they see in their follow-up clinic with these kids. And, you know, the very, you know, up-to-date data…the most recent data is just kind of useful to have them around. I think that’s a good joint conversation to have.
Dr. Fox: And it also depends on the NICU. It depends where you’re about to deliver.
Dr. Spiegelman: Totaly depends on the NICU. Every NICU is gonna be a little bit different and have different gestational age cut-offs and different outcomes.
Dr. Fox: And is your baby gonna be sort of born here and stay here in our NICU or does your baby need to be…
Dr. Spiegelman: Right. Get transferred. Yeah.
Dr. Fox: …stabilized and transferred? Again, that depends where you find yourself.
Dr. Spiegelman: Well, you do need to be transferred because [inaudible 00:25:59] to transfer with the mom to a higher-level NICU. So, sort of talking through what the range of outcomes might be is helpful, I think, to do along with the neonatologist. And that is, I think, kind of step one. If the baby comes out…let’s say the baby’s coming out… If the baby comes out, what do you want us to do with the baby?
The options are not resuscitate or nothing, the options are really resuscitation or sort of comfort care, basically giving medications and whatever is needed to make the baby comfortable, keep the baby warm, and give the baby as much time as possible with the family, and the family as much time as possible with the baby. So it’s not like, oh, you don’t want resuscitation, we’re just gonna abandon you, it’s really trying to maximize that time. And that’s kind of the first decision point patients need to think about.
Dr. Fox: That’s a hard decision point. And I think, you know, when I was speaking to Javi on this, she had a really good take, that it’s almost, like, we’re asking this woman or this family, what do you want this story to be? Right. Is this the story of a very premature birth which has a whole range of possible outcomes, it’s very scary and may end horribly, may end very well, everything in between. Like, it’s sort of that. Or is this a story of a pregnancy loss, that I’m miscarrying, essentially? And it could go either way, based on what we do afterwards. And if it’s a story of a very premature birth, then we’re gonna behave in a certain way.
It’s gonna be very medicalized, we’re gonna give a ton of interventions, we’re gonna have 16 people there when you deliver, they’re gonna resuscitate and do all these things. Or if it’s a story of a pregnancy loss, we’re gonna dim the lights, we’re gonna keep you comfortable, the baby’s gonna deliver, we’re gonna wrap the baby up, keep the baby, you know, warm, and again, comfort care, you’re gonna hold the baby, and the baby’s gonna pass away. Right? And neither of those stories are what anyone wanted, right, but it’s gonna be one of those two, that’s sort of what we’re saying. And so you have to make that choice. And then that dictates a tremendous amount down the tree, like you said.
Dr. Spiegelman: And then, you know, choosing what we call full intervention, like, you know, every possible intervention for the baby doesn’t guarantee you a baby that’s gonna live.
Dr. Fox: No, yeah.
Dr. Spiegelman: And sometimes I think parents really need to know that what ultimately ends up happening is they have to make the choice to redirect care and to withdraw care from a baby that’s too sick. And that is a whole other set of decisions to make and maybe a situation people don’t wanna be in. Maybe it’s a little bit easier to make the decision now as opposed to after all these interventions have been done to say, ”Well, we’re gonna, you know, redirect our care.”
Dr. Fox: Right. Right. Okay. So they’ve made that decision and what is… You said you’re going backward, so what are the next things?
Dr. Spiegelman: So presuming parents want kind of everything done after the baby is born, then we start talking about obstetric intervention. So, what can we do while you’re still pregnant to try and maximize the outcome, optimize the outcome? So, we have medications that we can give, steroids to help with lung maturity, it also reduces the risk of brain damage, magnesium to reduce the risk of cerebral palsy. We have…if someone’s in preterm labor, medications that can stop contractions and potentially buy us some time to give some of these medications. And then for somebody who’s broken their water, we have antibiotics that we can give to try and prolong pregnancy. So that’s kind of one set of obstetric interventions to try and optimize outcomes and the other set…
Dr. Fox: And that set almost always is a yes. Like, there’s…
Dr. Spiegelman: Yeah, it depends on gestational age, but yeah.
Dr. Fox: There’s very little downside.
Dr. Spiegelman: There’s very little downside. Unless parents are saying, at this gestational age I wouldn’t want intervention but this next week I do, and then we hold those things hoping they make it to that next week because, you know, the closer you give them to delivery the better they are.
Dr. Fox: Right. But essentially, if the decision is we’re gonna be resuscitating the baby after birth, almost always, it makes sense to do those things because why not make it easier resuscitation, potentially?
Dr. Spiegelman: Exactly. And the outcomes are going to be much better if you give these medications.
Dr. Fox: And I know where you’re going next with the next decision. That’s hard.
Dr. Spiegelman: So the next decision is really mode of delivery. And that’s really tough because the medications they don’t really have a downside for the mom but the mode of delivery really can. And that is a really tough decision. So, babies at this gestational age are more likely to be breech, are more likely to be butt down instead of head down. And it’s not the safest mode of delivery and [inaudible 00:30:29] a breech baby, especially in the second trimester to deliver vaginally because there can be some complications with delivery. So, if we are going to do the ”safest delivery” for the fetus, that’s a C-section.
And at that gestational age, C-sections are more complicated, the uterus isn’t fully developed. And so, often, we have to make a vertical incision on the uterus, which is called the classical C-section. It goes through the very muscular, what we call contractile portion of uterus. It can have really serious implications during that delivery and in future deliveries, higher bleeding risk during that C-section, and then in future deliveries, you will always need a C-section, higher risk of uterine rupture, which is the uterus kind of opening up at the scar. And so, that has very serious implications for the mother. And so, after we’ve kind of established, okay, well, we wanna do everything for the baby after birth, the question is, but do you want us to do a C-section if the baby’s breech or if there’s some fetal distress, right?
Dr. Fox: And the same…so the link question is, do we want to even check for fetal distress during the birth because if we’re not gonna do a C-section for it, do we wanna know? Do we not wanna know? That’s a really…I find that’s a really tough one for people because people are like, all right, you know, I guess I’ll resuscitate the baby and I guess I’m on board for all those medications but, whoa, you’re talking about like a C-section at 23 weeks, it’s like, I don’t know if I’m gonna sign up for that if I’m, you know, young, and I plan on having a lot of kids. This is a big, big change to my future, you know, pregnancies.
Dr. Spiegelman: And there’s a difference between C-section just for breech and a C-section for fetal distress. Because if you’re monitoring the fetus and you are noticing fetal distress, and then you’re doing like an emergency C-section, those outcomes are gonna be even worse. That baby’s already not doing well. Whereas if it’s just labor, then maybe a little bit better of an outcome compared to if you’re doing it for fetal distress. So should we monitor or should we not monitor is the other question.
Dr. Fox: And it’s also hard to know, in any given situation, how much is the C-section gonna improve outcomes for the baby? Because it could improve it zero and it could improve it a lot, potentially. Because we don’t know what it’s gonna be like, necessarily, during the birth. Like, there could be a breech delivery that goes fine for the baby. And so, it’s pretty hard to make that decision. I agree.
Dr. Spiegelman: And I think where people get confused is that choosing full intervention postnatally does not mean that you need to have a C-section. And I think people kind of conflate those a little bit. But it really…each decision is a decision. You know, every angle of this has its own decision point.
Dr. Fox: Yeah. And then probably the last question that they must answer is, after hearing all this, are we continuing the pregnancy or not?
Dr. Spiegelman: Right. So then kind of working backward, the question is, well, do you wanna be in this situation at all? Nobody does. But is it worse…you know, for you and your own value system, do you wanna go through any of this as we’ve described it or do you wanna just end the pregnancy now. And there’s now a lot of, unfortunately, legal issues around this but…?
Dr. Fox: There are always a lot of legal issues around this based on what state you’re in. And it’s just a little more highlighted now and more complicated now in several of those places. But, yes, that was always a very complicated one.
Dr. Spiegelman: Always complicated.
Dr. Fox: I mean, in New York, less complicated, obviously. Legally. I mean, it’s complicated socially, emotionally, for a lot of people, obviously, across the board. But yeah, legally, we can leave that aside for a different podcast.
Dr. Spiegelman: Yes.
Dr. Fox: You know, I’ve always found that… And I think you just described it really, really well, sort of the framework of how we make these decisions. I think one of the important points, like when I’m training the residents and the fellows and talking about this is, you know, what you just went through is really… That’s hard stuff. And this is not something that can just be discussed with someone at the bedside, standing there holding your clipboard for five minutes and then expect them to make a decision. This is one of those like, ”All right, we need to sit down.” Like, “I need this chair.”
Dr. Spiegelman: Yeah, this is pull up a chair. Yeah, I always pull up a chair.
Dr. Fox: Yeah, I need a chair, or this is something where, you know what, I’m gonna come back with the NICU doctor, with your nurse, with your doctor, like, and the five of us, or whatever it is, are gonna sit down together and talk through all of this at the same time. We’re gonna schedule an hour. Like, this is not gonna be a short conversation. Again, sometimes you don’t have that time if someone’s, like, in the throes of labor, but often there’s enough time to get an hour or two or whatever it is.
And I think that it’s a really important point on the patient side. If you find yourself or know someone who’s in a situation like this, and they haven’t had a very long conversation with someone, you need to, right? This is something that absolutely needs a lot of time to discuss, or at least you should be offered a lot of time to discuss. Sometimes people know immediately what they wanna do, and that’s fine. Like, you don’t have to talk for an hour. But this is legitimately complicated and confusing. And I would say that’s a really important lesson for listeners that you need to have a long conversation with someone about this to really try to make this decision, and they should be having this with you. And if it hasn’t happened, you should ask for it.
Dr. Spiegelman: Yeah, exactly. I mean, I think that whenever I had these conversations, like you said, I literally pull up a chair, I sit there for a long time, I come back with the NICU, I come back with her nurse. You know, we have a very extended conversation. And a lot of the time it’s very circular, like, going back… Because how could it not be, you’re talking about issues that somebody never thought they would have to discuss, that they don’t understand yet? And so, just repeating yourself as much as possible, as much as the patient needs you to is really important, and really making sure that you’ve given them all the information that they need to make the best decision that they can.
Dr. Fox: Yeah, I think what ends up happening, practically, is under 22 weeks, it’s unusual to have a successful resuscitation of a newborn, which would make it very unusual to do a C-section. People might choose to do magnesium or steroids, you know, whatever. Again, if they’re not so sure what the gestational age with this… Because, again, the harm isn’t so great but under 22 is very tough. Twenty two to 23 is very sort of hospital NICU situation dependent. I’m not so happy positive about 22 to 23 weeks, the outcomes are really not so great. And so, it ends up being more practically in that 23 to 25-week window and sort of, at what point are we gonna flip from the, you know, this is really not gonna work to this might really work.
And some people want to flip at 23 weeks, others 23.5, others 24, you know, sort of… And it sort of goes… Because by the time we get to 25 plus weeks at a, you know, high-quality NICU, pretty much everyone’s [inaudible 00:37:26] you’re doing all these things. And under 23, it’s kind of iffy, and it’s really in that two-week window. So, it’s not that kind… But like you said, there are situations, like if someone’s water breaks at 22 weeks, you might not do all these things today but I don’t know when she’s gonna deliver. She could be pregnant for two and a half more weeks, in which case… Yeah.
Dr. Spiegelman: Or even in 20 weeks.
Dr. Fox: Yeah.
Dr. Spiegelman: There are people who break their water at 20 weeks, and that’s, you know, the earliest point where we would give antibiotics to prolong the latency of the pregnancy, because we don’t… I mean, some people will deliver within the first 48 hours or the first seven days, but others will last several weeks then even months. So, that’s a earlier gestational age where we would have these conversations as opposed to somebody in full-blown preterm labor at 20 weeks, you know, there’s not much that we can do.
Dr. Fox: Exactly. And so, for people listening, again, if you’re, unfortunately, in this situation, or you’ve been in this situation, or you know someone’s situation has been this situation, I think some of the takeaway points are, it’s legitimately very complex and very confusing medically, emotionally, like, intellectually. It’s hard. It’s very hard to sort of know what to do. And so if you’re feeling a lot of ambivalence, that’s normal. I would say number two, absolutely positively this is not a simple decision, especially if you’re between like 23 and 25 weeks. And so if someone came in and said, ”Here’s what’s happening, here’s what needs to be done,” probably you need to like raise your hand and ask a question and say, ”Hey, can we, like, talk about this further?” That sometimes happens.
Sometimes people say, yeah, I walked in and doctor said, ”Well, you’re 23 weeks and, you know, game over.” And I said, ”Okay, game over.” And like, that’s it. But I think it depends. I think that requires some more conversation. And I think if you’re fortunate enough to have a lot of resources and support, yeah, bring them in. Bring everyone in. This is hard.
Dr. Spiegelman: Yeah. It’s a really, really tough decision. And that’s why it just requires so much counseling and discussion.
Dr. Fox: Yeah. And often, you know, where we practice…we’re fortunate to practice in a place that has all these resources available, but the majority of people are gonna deliver or present to hospitals that don’t have these resources. And so it might mean, am I better off being transferred?
Dr. Spiegelman: Yeah. You can ask to be transferred.
Dr. Fox: Yeah. Like, am I in the wrong hospital? Like, is this something you’re not dealing with on a regular basis and maybe I should be transferred if there’s time, or where’s my baby going after birth if we’re trying to do everything?
Dr. Spiegelman: If there’s time, it’s always better to transfer mom. There isn’t always time but outcomes for neonates are better if they are born in the place where they’re going to be resuscitated.
Dr. Fox: Right. Well, Spiegelman, way to really start our day off with some heavy stuff. But, again, it’s really important, and when these situations do come up, it is crucial. And, frankly, this is why we have a job. I mean, this is the real… You know, this is the big leagues of MFM, unfortunately. But, hopefully, as we continue to improve with neonatal care and prevention of preterm birth, this will be less common. But I think, unfortunately, these situations will always exist, and hopefully this podcast will have been helpful for people out there.
Dr. Spiegelman: I hope so.
Dr. Fox: Thanks for coming, Spiegs.
Dr. Spiegelman: Thanks for having me.
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