Aggressive intrapartum management of lethal fetal anomalies: beyond fetal beneficence.
OBJECTIVE
To evaluate management recommendations from the current literature for patients whose fetuses are certain to have lethal anomalies or absent (or virtually absent) cognitive function. These recommendations include termination of pregnancy or, for cases in the third trimester, nonaggressive intrapartum management, avoiding cesarean delivery for fetal indications.


METHODS
We report our experience with several patients who voiced opposition to nonaggressive intrapartum care and present a rationale for selectively aggressive, intrapartum management for some of these cases.


RESULTS
Four women whose fetuses had lethal anomalies requested aggressive intrapartum management. For three of the four, standard aggressive management of labor resulted in vaginal delivery of live-born infants who died shortly thereafter. The patients found comfort in the live births. The fourth patient accepted a recommendation to avoid fetal monitoring during labor, and the fetus was stillborn. This patient found the intrapartum experience to be very stressful.


CONCLUSIONS
When a patient's desire to avoid an intrapartum stillbirth is strong enough that substantial psychological harm might result from one, the physician's beneficence-based obligation to her and respect for maternal autonomy justify selectively aggressive intrapartum therapy, even if no beneficence-based obligation to the fetus exists.
Spinnato
J A
JA
Department of Obstetrics and Gynecology, University of Louisville School of Medicine, Kentucky.
Cook
V D
VD
Cook
C R
CR
Voss
D H
DH
D000328:Adult; D002985:Clinical Protocols; D036861:Delivery, Obstetric / Q000379:methods*; D005260:Female; D005313:Fetal Death; D005315:Fetal Diseases / Q000000981:diagnostic imaging*; D005317:Fetal Growth Retardation / Q000000981:diagnostic imaging; D006345:Heart Septal Defects, Ventricular / Q000000981:diagnostic imaging*; D006554:Hernia, Umbilical / Q000000981:diagnostic imaging*; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D016104:Oligohydramnios / Q000000981:diagnostic imaging*; D011247:Pregnancy; D016216:Ultrasonography, Prenatal