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The role of Obstetric Anesthesia in the life of baby Evelyn
Abstract Number: F1D-9
Abstract Type: Case Report/Case Series
Introduction: Perinatal palliative care (PPC) is a multifactorial care model to support families of neonates with a life-limiting condition that should be activated at the time of prenatal diagnosis and continue through bereavement. PPC strives to honor parental preferences, including physical, emotional, spiritual, moral, and cultural domains. The Institute of Medicine’s report on Pediatric Palliative Care describes the need for coordination and continuity across phases of care, sites of service, and caregivers. Standards of Practice for Pediatric Hospice and Palliative Care Programs have been developed, and the Children’s Project on Hospice/Palliative Services (ChiPPS) provides strategies, research, and education for families and caregivers. This case report describes the role of the anesthesia team as part of a PPC plan for a family with anticipated Cesarean delivery (CD) of a trisomy18 infant. We aim to highlight the scope of anesthetic decision-making in these difficult circumstances, as well as introduce providers to resources.
Case Report: This patient was a 33 year old G3P2 at 37wks for repeat CD with pregnancy complicated by life-limiting anomalies. Our perinatal palliative care provider formulated a multidisciplinary care plan to meet the family’s wishes which included members from nursing, obstetrics, anesthesia and neonatology. In preoperative anesthesia consultation with the parents, we discussed their specific concerns and planned a routine spinal anesthetic with standard ASA monitors, offered the use of a clear drape during delivery and allowed for photography services throughout the birth. The neonate delivered with Apgar of 8 and 9 at 1 and 5 min. As previously decided, our anesthesia team facilitated immediate skin to skin bonding, sedation was avoided and the patient was alert to participate during the unpredictable dynamic circumstances. Accommodations were made for recovery in a private PACU with extended family including her two young children with no alteration in standard monitoring or analgesia protocols. Mom and baby were discharged home with hospice resources on POD #2. The neonate survived for 57 days.
Discussion: In this case, involvement of the anesthesia team began weeks before delivery to establish a birth plan and ended with participation in a funeral service celebrating the life of the infant. Medical care providers should be aware of the potential for their own grief and have access to support services. Anesthetic considerations should be consistent with PPC philosophy in respecting wishes of the family without compromising the safety of the maternal patient. Anesthetic management in these circumstances can be naturally aligned with broader palliative goals of reducing suffering and promoting quality of life.
References: Levang Perinatal and Neonatal Palliative/Hospice Care November 2017: 26-32.2Limbo. Resolve Through Sharing (RTS) position paper on perinatal palliative care2008-2016