A 26 yr-old woman has been admitted and assessed following identification of sever IUGR. After appropriate investigations and treatment, the decision was taken to deliver by Caesarean Section at 27 weeks gestation. How would you counsel her?
A decision to deliver a fetus at 27 weeks gestation means that there is a high risk of fetal demise if the pregnancy is allowed to continue. The mother and her partner will have many questions and anxieties. An understanding attitude and enough time and privacy to address all their concerns must be provided.
She will be reassured that this is the best choice for the baby at this time. She will be advised that fetal lung maturity will be enhanced by the administration of maternal steroids and suitable arrangement made for expert neonatal care in a neonatal intensive care unit. Surfactant administration after delivery will further improve lung function.
I will also advise her that Caesarean Section at this time may necessitate a classical or modified classical incision or a J- or U-shaped incision. This is associated with increased blood loss. However, arrangements for the consultant anaesthetist and senior obstetrician to perform or supervise anaethesia and the operation will be made.
If the above incision becomes necessary, I would explain to her the implications for a future pregnancy, especially ruptured uterus, if labour is allowed to take place.
She will be advised that the baby will most likely not withstand the stress of labour .If this is her first pregnancy, induction of labour is likely to be a prolonged process and failure of induction is quite possible. Both these situations will then necessitate an emergency Caesarean Section at a time when all senior personnel may not be available. There is also increased maternal morbidity as well as a worse prognosis for the baby. It will thus be better for a planned delivery by elective caesarean Section.
She will be advised that although the baby may gain normal weight in the neonatal period, there is an increased risk of hypertension, ischaemic heart disease and atheromatous vascular disease in later life.
I will arrange a consultation with neonatologist to discuss risks and prognosis for the baby. She will be encouraged to visit the neonatal unit and view premature babies being ventilated in order to prepare her to deal with her situation.
Arrangement with the anaesthetist will also be made to discuss type of anaethesia employed for surgery.
I will also advise and arrange for a visit with a haemotologist or physician after the puerperiun. This is to identify with factors for IUGR especially thrombophilias, if the cause of IUGR was not established or if it was not pregnancy related, for example, pre-eclampsia. She will be advised that the risk of severe morbidity and even mortality is high even though the baby is delivered.
However, if all facilities and expert personnel are involved in her management she will feel reassured that her baby’s best interest is being pursued at this time.
