Is it time to end the use of base deficit for fetal well-being assessment?

Authors have expressed reservations regarding the use of base deficit measured in umbilical artery blood samples to assess fetal well-being during the course of labor and to predict neonatal neurologic morbidity. Despite its integration into clinical practice for more than 50 years, obstetricians and maternal-fetal medicine specialists may not realize that this marker has significant limitations in accurately identifying neonatal metabolic acidosis as a proxy for fetal well-being. In brief, there are 2 large families of base deficit, namely whole blood and extracellular fluid. Both rely on equations that use normal adult acid-base characteristics (pH 7.40 and partial CO2 pressure of 40 mm Hg) that overlook the specificity of the normal in utero acid-base status of pH 7.27 and partial CO2 pressure of 54 mm Hg. In addition, it ignores the unique characteristic of the in utero fetal response to acute hypoxia. The dependence on placental circulation for CO2 elimination may lead to extremely high values (up to 130 to 150 mm Hg) during hypoxic events, a phenomenon that is absent in adults with acute metabolic acidosis who can hyperventilate. The dispute over if to include a correction for high partial CO2 pressure in the bicarbonate estimation, as presented in the Great Trans-Atlantic Debates, remains unresolved. The key constants computed for adult acid-base physiology in the current base deficit algorithms, without accounting for the impact of high partial CO2 pressure or other fetal characteristics of buffering capacity (eg, differences in body water content composition, plasma protein, and hemoglobin attributes), may lead to an overestimation of metabolic acidosis, especially in newborns who are experiencing hypercarbia during the early stages of the hypoxic response. These unrecognized limitations impact the base deficit results and may mislead clinicians on fetal well-being assessments when discussing the management of fetal heart rate monitoring and neonatal outcomes. Based on our arguments, we believe that it is prudent to consider an alternative to base deficit for drawing conclusions regarding fetal well-being during the course of birth management. We propose a marker specifically related to the newborn acid-base physiology--the neonatal eucapnic pH correction. This marker can be added to arterial cord blood gas analysis, and we have described how to interpret it as a marker of neonatal metabolic acidosis.

Umbilical artery eucapnic pH to assess fetal well-being.

BACKGROUND: Umbilical artery gas results help obstetricians assess fetal well-being during labor and guide screening decisions on eligibility for therapeutic hypothermia (ie, whole-body or head cooling). The accuracy of results, especially for the base deficit on arterial cord gas analysis, in predicting brain injury is questioned. A novel biomarker specifically calculated for fetal acid-base physiology and response to asphyxia-neonatal eucapnic pH as a marker of neonatal metabolic acidosis-has the potential to be an accurate predictor of hypoxic-ischemic encephalopathy. OBJECTIVE: We aimed to compare false-negative rates of hypoxic-ischemic encephalopathy for umbilical artery pH, base deficit, and neonatal eucapnic pH in assessing fetal acid-base balance as a marker of fetal well-being and predicting acute brain injury. STUDY DESIGN: This is a retrospective single-center cohort study of newborns ≥ 35 weeks of gestation diagnosed with hypoxic-ischemic encephalopathy. We compared false-negative rates for any grade of hypoxic-ischemic encephalopathy using unilateral paired chi-square statistical analysis based on cutoff values for umbilical artery pH ≤7.00, base deficit ≥16 mmol/L, base deficit ≥12 mmol/L and neonatal eucapnic pH ≤7.14. We performed an analysis of variance between umbilical artery pH, base deficit, and neonatal eucapnic pH for each hypoxic-ischemic encephalopathy grade. RESULTS: We included 113 newborns. False-negative rate for hypoxic-ischemic encephalopathy was significantly higher for base deficit <16 mmol/L (n=78/113; 69.0%) than <12 mmol/L (n=46/113; 40.7%), pH >7.00 (n=41/113; 36.3%), or neonatal eucpanic pH >7.14 (n=35/113; 31.0%) (P<.0001). All true-positive cases were identified using only umbilical artery pH and neonatal eucapnic pH. Base deficit ≥16 or ≥12 mmol/L did not add any value in identifying newborns with hypoxic-ischemic encephalopathy when using umbilical artery pH and neonatal eucapnic pH. No association emerged between any marker and hypoxic-ischemic encephalopathy severity grading. CONCLUSION: Our findings support the accuracy of neonatal eucapnic pH to assess fetal well-being during labor and to improve predictive performance for acute brain injury. Neonatal eucpanic pH, in addition to umbilical artery pH, may be a viable alternative in identifying newborns at risk for hypoxic-ischemic encephalopathy.

Outcomes of infants with hypoxic-ischemic encephalopathy during COVID-19 pandemic lockdown in Canada: a cohort study.

PURPOSE: To evaluate change in the severity of hypoxic-ischemic encephalopathy (HIE) and associated morbidities between pre- and during COVID-19 pandemic periods in Canada. METHODS: We conducted a retrospective cohort study extracting the data from level-3 NICUs participating in Canadian Neonatal Network (CNN). The primary outcome was a composite of death in the first week after birth and/or stage 3 HIE (Sarnat and Sarnat). Secondary outcomes included rate and severity of HIE among admitted neonates, overall mortality, brain injury on magnetic resonance imaging (MRI), neonates requiring resuscitation, organ dysfunction, and therapeutic hypothermia (TH) usage. We included 1591 neonates with gestational age ≥ 36 weeks with HIE during the specified periods: pandemic cohort from April 1st to December 31st of 2020; pre-pandemic cohort between April 1st and December 31st of 2017, 2018, and 2019. We calculated the odds ratio (OR) and confidence intervals (CI). RESULTS: We observed no significant difference in the primary outcome (15% vs. 16%; OR 1.08; 95%CI 0.78-1.48), mortality in the first week after birth (6% vs. 6%; OR 1.10, 95%CI 0.69-1.75), neonates requiring resuscitation, organ dysfunction, TH usage, or rate of brain injury. In the ad hoc analysis, per 1000 live births, there was an increase in the rate of infants with HIE and TH use. CONCLUSIONS: Severity of HIE, associated morbidities, and mortality were not significantly different during the pandemic lockdown compared to a pre-pandemic period in Canada. Anticipated risks and difficulties in accessing healthcare have not increased the mortality and morbidities in neonates with HIE in Canada.

Extremely low gestational age infants: Developing a multidisciplinary care bundle.

BACKGROUND: Clinical experience in managing extremely low gestational age infants, particularly those born <24 weeks' gestation, is limited in Canada. Our goal was to develop a bedside care bundle for infants born <26 weeks' gestation, with special considerations for infants of <24 weeks, to harmonize and improve quality of care. METHODS: We created a multidisciplinary working group with experience in caring for preterm infants, searched the literature from 2000 to 2019 to identify best practices for the care of extremely preterm infants and consulted colleagues across Canada and internationally. Iterative improvements were made following the Plan-Do-Study-Act methodology. RESULTS: A care bundle, created in October 2015, was divided into three time periods: initial resuscitation/stabilization, the first 72 hours and days 4 to 7, with each period subdivided in 8 to 12 care themes. Revisions and practice changes were implemented to improve skin integrity, admission temperature, timing of initiation of feeds, reliability of transcutaneous CO2 monitoring and ventilation. Of 127 infants <26 weeks admitted between implementation and end of 2019, 78 survived to discharge (61%). CONCLUSION: It will be important to determine, with ongoing auditing and further evaluation, whether our care bundle led to improvements of short- and long-term outcomes in this population. Our experience may be useful to others caring for extremely low gestational age infants.

Risk factors for re-hospitalization following neonatal discharge of extremely preterm infants in Canada.

OBJECTIVE: Survivors of extremely preterm birth are at risk of re-hospitalization but risk factors in the Canadian population are unknown. Our objective is to identify neonatal, sociodemographic, and geographic characteristics that predict re-hospitalization in Canadian extremely preterm neonates. METHODS: This is a retrospective analysis of a prospective observational cohort study that included preterm infants born 22 to 28 weeks' gestational age from April 1, 2009 to September 30, 2011 and seen at 18 to 24 months corrected gestational age in a Canadian Neonatal Follow-Up Network clinic. Characteristics of infants re-hospitalized versus not re-hospitalized are compared. The potential neonatal, sociodemographic, and geographic factors with significant association in the univariate analysis are included in a multivariate model. RESULTS: From a total of 2,275 preterm infants born at 22 to 28 weeks gestation included, 838 (36.8%) were re-hospitalized at least once. There were significant disparities between Canadian provincial regions, ranging from 25.9% to 49.4%. In the multivariate logistic regression analysis, factors associated with an increased risk for re-hospitalization were region of residence, male sex, bronchopulmonary dysplasia, necrotizing enterocolitis, prolonged neonatal intensive care unit (NICU) stay, ethnicity, Indigenous ethnicity, and sibling(s) in the home. CONCLUSION: Various neonatal, sociodemographic, and geographic factors predict re-hospitalization of extremely preterm infants born in Canada. The risk factors of re-hospitalization provide insights to help health care leaders explore potential preventative approaches to improve child health and reduce health care system costs.

Umbilical artery carbon dioxide decreases the risk for hypoxic-ischaemic encephalopathy.

AIM: An accurate biomarker for metabolic acidosis at birth is needed. Our aims were to investigate the link between umbilical artery pCO2 and the risk for hypoxic-ischaemic encephalopathy (HIE) and to compare false-negative screen results in newborn infants with HIE using three umbilical artery blood gas biomarkers. METHODS: From a cohort of newborn infants ≥35 weeks born in Ottawa, Canada, between January 2007 and December 2016, we highlighted those with HIE or who died. We compared the umbilical artery pCO2 for matched pH >mean versus matched pH ≤mean. We compared false-negative rates for three umbilical artery biomarkers-pH <7.0, base deficit ≥16 mmol/L and neonatal eucapnic pH ≤7.14. RESULTS: This study included 51 286 newborn infants, 51% male and a mean gestational age of 38.9 ± 1.5 weeks. The rate for HIE or death with umbilical artery pCO2 for matched pH >mean was 22%, compared to 78% for matched pH ≤mean. In 60 HIE or deaths, the false-negative rate for umbilical artery neonatal eucapnic pH ≤7.14 was 8%; compared to 31% for pH <7.00 and 36% for base deficit ≥16 mmol/L. CONCLUSION: The rate of HIE or death is lower in newborn infants with higher pCO2 . Using neonatal eucapnic pH decreases the risk of missing newborn infants with HIE.

A meta-analysis of neurodevelopmental outcomes at 4-10 years in children born at 22-25 weeks gestation.

AIM: To update our meta-analysis on neurodevelopmental disability rates in children born at 22-25 weeks gestation. The main outcome measure was rates of neurodevelopmental disability in survivors at age 4-10 years. METHODS: We used a peer-reviewed electronic and grey search to identify articles. Two authors independently reviewed cohorts published after May 2012 with: born ≥1995 in a developed nation; assessed at 4-10 years; prospective; >65% follow-up; definitions for neurodevelopmental disability as per the EPICure cohort; results reported by gestation. We contacted authors for clarification. Random effects meta-analysis was used to estimate pooled proportions of neurodevelopmental disability. Within each study, the absolute change in proportions with each week was estimated and then pooled. RESULTS: We reviewed 3980 records; 21 articles were assessed and six were included. With the previous 9 cohorts, the meta-analysis now contains 15. Rates of moderate-to-severe neurodevelopmental disability were as follows: 42% (95% CI 23,64%; I2 0%) at 22; 41% (95% CI 31,52%; I2 20%) at 23; 32% (95% CI 25,39%; I2 45%) at 24; 23% (95% CI 18,29%; I2 60%) at 25 weeks. The analysis shows a significant decrease in risk of moderate-to-severe neurodevelopmental disability between each week (8.1% (95% CI -11.8, -4.5%); I2 0%; p < 0.001). CONCLUSION: Physicians can use this high-quality data to support parents during decision-making.

Catch the moment: The power of turning mistakes into 'precious' learning opportunities.

We developed a series of small group workshops that aim to facilitate communication during very challenging ethically sensitive scenarios within a Neonatal-Perinatal Medicine (NPM) postgraduate curriculum at the University of Ottawa. These workshops are called Scenario-Oriented Learning in Ethics (SOLE). This educational intervention aims to focus attention on the learner's needs and to help them recognize, define, and view each communicative or behavioural mistake as an occasion to achieve a personal-defined learning goal in a controlled environment free of judgement. The goal of this commentary is to describe the importance of timely interruptions during the scenarios allowing mini concurrent-guided debriefing-feedback by focusing upon trainees' communication mistakes, utilizing them as valuable learning opportunities.

Shared decision making during antenatal counselling for anticipated extremely preterm birth.

OBJECTIVES: To explore health care providers' (HCPs) perceptions of using shared decision making (SDM) and to identify facilitators of and barriers to its use with families facing the anticipated birth of an extremely preterm infant at 22+0 to 25+6 weeks gestational age. STUDY DESIGN: Qualitative descriptive study design: we conducted interviews with 25 HCPs involved in five cases at a tertiary care centre and completed qualitative content analysis of their responses. RESULTS: Nine facilitators and 16 barriers were identified. Facilitators included: a correct understanding of this process and how to apply it, a belief that parents should be the decision makers in these situations, and a positive outlook toward using SDM during antenatal counselling. Barriers included: HCPs' misunderstandings of how and when to apply SDM during antenatal counselling, challenges using the process for cases at the lower end of the gestational age range, fear of the negative emotions and stress parents face when making decisions, and HCPs' uncertainty about their ability to properly apply SDM. CONCLUSIONS: This study identified facilitators and barriers to use of SDM during antenatal counselling for anticipated birth of extremely preterm infants that can be used to inform development of tailored strategies to facilitate future implementation of shared decision making in this area.

Needs assessment of ethics and communication teaching for neonatal perinatal medicine programs in Canada.

OBJECTIVE: To explore ethics education needs in Canadian Neonatal Perinatal Medicine (NPM) training programs. METHODS: A retrospective review of NPM trainees' performance at the National NPM Objective Structured Clinical Examination (OSCE) was undertaken for 2012 to 2017 and two distinct cross-sectional online surveys were carried out. One survey targeted recently graduated neonatologists (RGNs) who completed 2 years' training in a Canadian NPM program between 2010 and 2015; the other survey was sent to Canadian NPM training program directors (PDs). The domains of interest were: perception of education, ethics and communication topics, educational strategies, assessment of trainees' competencies, and barriers to neonatal ethics education. RESULTS: NPM trainees generally performed less well in stations involving ethics and communication relative to other domains on the National OSCE. Forty-seven RGNs (44.3%) and 12 PDs (92.3%) completed the survey. Over 90% of PDs and RGNs agreed on the importance of training in ethics and communication. Both groups highly valued training on topics related to communication. Preferred teaching strategies were experiential: observation and feedback. PDs mentioned the importance of using validated tools to regularly and formally assess trainees. They recognized challenges in regard to financial resources, physical space, and faculty training in patient-physician communication. CONCLUSIONS: National OSCE results indicate the need to improve neonatal ethics and communication training in Canadian NPM programs. RGNs and PDs identified important topics, as well as teaching and evaluation strategies. These results can be used to develop a training program for ethics and communication in NPM.

Antenatal Consultations at Extreme Prematurity: A Systematic Review of Parent Communication Needs.

OBJECTIVE: To synthesize and describe parental expectations on how healthcare professionals should interact with them during a peripartum, antenatal consultation for extremely preterm infants. STUDY DESIGN: For this systematic literature review with textual narrative synthesis, we included studies that explored parental perspectives regarding the antenatal consultation for an extremely preterm infant. Electronic searches of Medline, CINAHL, PsycInfo, and Embase were conducted, along with a search of the grey literature. Quality appraisal was conducted using the guide by Walsh and Downe. Two independent reviewers reviewed 783 titles, of which 130 abstracts then 40 full-text articles were reviewed. Final data abstraction includes 19 studies. We predetermined 6 topics of interest (setting, timing, preferred healthcare professional, information, resources, and parents-physician interaction) to facilitate thematic analysis. RESULTS: In consideration of the variability of parents' specific desires, six predetermined topics and additional overarching themes such as perception of support, degree of understanding, hope, spirituality, and decision-making influences emerged. Studies suggest the quality of the antenatal consultation is not purely about information content, but also the manner in which it is provided. Limitations include thematic analysis that can potentially lead to the exclusion of important nuances. Relevant studies may have been missed if published outside the healthcare literature. CONCLUSIONS: The findings may inform clinical practice guidelines. This paper includes suggested strategies related to parents' perspectives that may facilitate communication during antenatal consultation for an extremely preterm infant. These strategies may also support parental engagement and satisfaction.

Effect of an Educational Presentation about Extremely Preterm Infants on Knowledge and Attitudes of Health Care Providers.

Objective To determine healthcare providers' knowledge (HCP) about survival rates of extremely preterm infants (EPI) and attitudes toward resuscitation before and after an educational presentation and, to examine the relationship between knowledge and attitudes toward resuscitation. Study Design Participants completed a survey before and after attending a presentation detailing evidence-based estimates of survival rates and surrounding ethical issues. Respondents included neonatologists, obstetricians, pediatricians, maternal-fetal medicine specialists, trainees in pediatrics, obstetrics, neonatal-perinatal medicine and neonatal and obstetrical nurses. Results In total, 166 participants attended an educational presentation and 130 participants completed both pre- and postsurveys (response rate 78%). Prepresentation, for all gestations, ≤ 50% of respondents correctly identified survival/intact survival rates. Postpresentation, correct responses regarding survival/intact survival rates ranged from 49 to 86% (p < 0.001) and attitudes shifted toward being more likely to resuscitate at all gestations regardless of parental wishes. There was a weak-to-modest relationship (Spearman's coefficient 0.24-0.40, p < 0.001-0.004) between knowledge responses and attitudes. Conclusion Attendance at an educational presentation did improve HCP knowledge about survival and long term outcomes for EPI, but HCP still underestimated survival and were not always willing to resuscitate in accordance with parental wishes. These findings may represent barriers to some experts' recommendation to use shared decision-making with parents when considering the resuscitation options for their EPI.

Assessing neonatal heat balance and physiological strain in newborn infants nursed under radiant warmers in intensive care with fentanyl sedation.

PURPOSE: To assess heat balance status of newborn infants nursed under radiant warmers (RWs) during intensive care. METHODS: Heat balance, thermal status and primary indicators of physiological strain were concurrently measured in 14 newborns nursed under RWs for 105 min. Metabolic heat production (M), evaporative heat loss (E), convective (C) and conductive heat flow (K), rectal temperature (T re) and mean skin temperatures (T sk) were measured continuously. The rate of radiant heat required for heat balance (R req) and the rate of radiant heat provided (R prov) were derived. The rate of body heat storage (S) was calculated using a two-compartment model of 'core' (T re) and 'shell' (T sk) temperatures. RESULTS: Mean M, E, C and K were 10.5 ± 2.7 W, 5.8 ± 1.1 W, 6.2 ± 0.8 W and 0.1 ± 0.1 W, respectively. Mean R prov (1.7 ± 2.6 W) and R req (1.7 ± 2.7 W) were similar (p > 0.05). However, while the resultant mean change in body heat content after 105 min was negligible (-0.1 ± 3.7 kJ), acute time-dependent changes in S were evidenced by a mean positive heat storage component of +6.4 ± 2.6 kJ and a mean negative heat storage component of -6.5 ± 3.7 kJ. Accordingly, large fluctuations in both T re and T sk occurred that were actively induced by changes in RW output. Nonetheless, no active physiological responses (heart rate, breathing frequency and mean arterial pressure) to these bouts of heating and cooling were observed. CONCLUSIONS: RWs maintain net heat balance over a prolonged period, but actively induce acute bouts of heat imbalance that cause rapid changes in T re and T sk. Transient bouts of heat storage do not exacerbate physiological strain, but could in the longer term.

Teaching ethics in neonatal and perinatal medicine: What is happening in Canada?

Ethically challenging clinical situations are frequently encountered in neonatal and perinatal medicine (NPM), resulting in a complex environment for trainees and a need for ethics training during NPM residency. In the present study, the authors conducted a brief environmental scan to investigate the ethics teaching strategies in Canadian NPM programs. Ten of 13 (77%) accredited Canadian NPM residency programs participated in a survey investigating teaching strategies, content and assessment mechanisms. Although informal ethics teaching was more frequently reported, there was significant variability among programs in terms of content and logistics, with the most common topics being 'The medical decision making process: Ethical considerations' and 'Review of bioethics principles' (88.9% each); lectures by staff or visiting staff was the most commonly reported formal strategy (100%); and evaluation was primarily considered to be part of their overall trainee rotation (89%). This variability indicates the need for agreement and standardization among program directors regarding these aspects, and warrants further investigation.

On affronte souvent des situations cliniques difficiles sur le plan éthique en médecine néonatale et périnatale (MNP), qui se traduisent par un milieu complexe pour les stagiaires et par la nécessité de donner une formation en éthique pendant la résidence en MNP. Dans la présente étude, les auteurs ont mené un bref examen du milieu pour examiner les stratégies d'enseignement de l'éthique au sein des programmes de MNP canadiens. Dix des 13 programmes de résidence canadiens agréés en MNP (77 %) ont participé à un sondage sur les stratégies d'enseignement, le contenu et les mécanismes d'évaluation. Même si l'enseignement informel de l'éthique était signalé davantage, on constatait une importante variabilité entre les programmes en matière de contenu et de logistique, les sujets les plus fréquents étant « Le processus de prise de décision médicale : des considérations éthiques ¼ et « Examen des principes bioéthiques ¼ (88,9 % chacun), les conférences données par le personnel ou du personnel en visite étaient la stratégie officielle la plus courante (100 %) et l'évaluation était principalement considérée comme un élément de la rotation globale des stagiaires (89 %). Cette variabilité démontre que les directeurs de programmes doivent s'entendre et standardiser ces aspects de l'éthique, et elle justifie des examens plus approfondis.

Eucapnic pH coupled with arterial cord pH improves hypoxic-ischemic encephalopathy prediction.

OBJECTIVE: To consider the classical use of "pH < 7.0 and/or a base deficiency ≥12 mmol/L" as markers of the risk of neonatal hypoxic-ischemic encephalopathy (HIE), recalling various criticisms of the use of these markers in favor of that of neonatal eucapnic pH, which appears to be a better marker of this risk. METHODS: Fifty-five cases of acidemia with pH < 7.00 were collected from a cohort from the Nice University Hospital with eight cases of HIE. We compared the receiver operating characteristics curves established from the positive likelihood ratio (+LR) for each case of: umbilical cord artery pH (pHa), neonatal eucapnic pH (pH euc-n) in isolation (not matched to pHa), and matched pHa to its own pH euc-n. RESULTS: The areas under the curve (AUC) are identical for pHa and pH euc-n, but AUC for the matched pair pHa-pH euc-n appears superior but non-significant because of the small number in our cohort. However, using the bootstrap method, the partial AUC for a sensitivity greater than 75% indicates the significant superiority (P < 0.01) of the matched pair pHa-pH euc-n approach. CONCLUSION: The originality of this study lies in the use of two methodologic approaches: (1) standardized partial analysis of the AUCs of the pHa curve and that of pHa matched to its own pH euc-n, and (2) bootstrap statistical technique, that allowed us to conclude (P < 0.01) that the combined use of pH measured at the cord coupled with its eucapnic correction is better for diagnosing metabolic acidosis and best predicting the risk of HIE.

How we teach ethics and communication during a Canadian neonatal perinatal medicine residency: an interactive experience.

BACKGROUND: Ethically challenging clinical situations frequently confront health care professionals in neonatology. These situations require neonatologists to exercise professionalism by communicating effectively throughout evolving physician-parent relationships in order to arrive at shared decisions for care that are in the best interest of the neonate and grounded solidly in ethical precepts. AIM: This article describes the process by which a well-delineated, interactive program to teach ethical reasoning and skillful communication with parents was implemented at the University of Ottawa, Canada. METHODS: A revised ethics program implemented in 2009 identified competencies that should be demonstrated at the end of the Neonatal-Perinatal Medicine (NPM) residency. Several seminars were refined while new workshops, problem-based learning in ethics, and a personal portfolio were added. RESULTS: All teaching strategies were well received based on the average level of satisfaction (5.8 out of 7, SD 0.4). We are now moving forward by formally assessing our program including the impact on knowledge acquisition and behavior. CONCLUSION: A dedicated, interactive competency-based neonatal ethics teaching program is vital to support NPM trainees in learning how to integrate ethical thinking with competencies in communication.

Vulnerabilities in clinician-parent exchanges and the cascade of communication traps: a review.

This review considers parent-clinician interactions that are associated with vulnerabilities in communication and what we refer to as 'communication traps'. Communication traps are defined by high-stress situations with affect-laden subject matter that can lead to progressively dysfunctional communications/exchanges that are avoidable. While this framework was developed in neonatology, it can be applied to other clinical practices.Communication competencies in paediatrics require the rapid development of a therapeutic alliance between parents and clinicians to ensure the provision of best care to their infants. In order to facilitate parent-clinician communication, our framework focuses clinicians' attention on the affective, behavioural and cognitive (ABC) cues that are indicative of real, apparent or potential communication traps. Strategies are provided to slow down clinicians' responses to more effectively consider ABC cues that suggest if patients/parents have failed to engage or disengage from a situation. This framework is illustrated by presenting a narrative synthesised from a number of experiences that clinicians have encountered. This review identifies key decision points in the communication process that, if left unaddressed, can cascade into communication traps which may be difficult to escape.Using results from communication studies and psychological research, our framework was developed to identify key decision points for ABC cues that can be used to prevent falling into communication traps.

Assessing shared decision making during antenatal consultations regarding extreme prematurity.

OBJECTIVE: To assess whether antenatal decisions regarding the neonatal care at birth for extremely preterm infants are more likely to be made when using shared decision-making (SDM)-style consultations compared to standard consultations. STUDY DESIGN: In 2015, we implemented a clinical practice guideline promoting SDM use within antenatal consultations in our single-centre university-based perinatal unit. We conducted a prospective cohort study with a retrospective chart review based on data collected from all pregnant women presenting to obstetrical triage between 22 + 0 and 25 + 6 weeks gestation between September 2015 and June 2018. RESULT: Two-hundred-and-seventeen cases presented; 137 received antenatal consultations with 82 (60%) being SDM-style. Decisions were frequently made (88%; 120/137) after the consultations, with no significant difference between consultation style (RR 1.08, 95% CI [0.95-1.26], p = 0.28). CONCLUSION: The provision of either an SDM-style or a standard antenatal consultation seemed to comparably facilitate the reaching of a care decision.

Development of a Bedside Tool to Predict the Diagnosis of Cerebral Palsy in Term-Born Neonates.

Importance: Cerebral palsy (CP) is the most common abnormality of motor development and causes lifelong impairment. Early diagnosis and therapy can improve outcomes, but early identification of infants at risk remains challenging. Objective: To develop a CP prognostic tool that can be applied to all term neonates to identify those at increased risk of developing CP. Design, Setting, and Participants: This case-control study used data from the Canadian Cerebral Palsy Registry (data collected from January 2003 to December 2019) for children with CP and the Alberta Pregnancy Outcomes and Nutrition study (mothers enrolled from May 2009 to September 2012; data extracted in 2020) for controls. There were 2771 children with CP and 2131 controls evaluated; 941 and 144, respectively, were removed for gestational age less than 37 weeks at birth, 565 with CP removed for incomplete data, and 2 controls removed for a diagnosis of CP. Data were analyzed from April to August 2022. Exposures: Potential risk factors were selected a priori based on the literature, including maternal, intrapartum, and infant characteristics. Main Outcomes and Measures: Diagnosis of CP, defined as a disorder of motor function due to a nonprogressive brain abnormality before age 1 year and classified by Gross Motor Function Classification System levels I to V. Results: Of 3250 included individuals, 1752 (53.9%) were male, and the median (IQR) gestational age at birth was 39 (38-40) weeks. Encephalopathy was present in 335 of 1184 infants with CP (28%) and 0 controls. The final prediction model included 12 variables and correctly classified 75% of infants, with a sensitivity of 56% (95% CI, 52-60) and specificity of 82% (95% CI, 81-84). The C statistic was 0.74 (95% CI, 71-76). Risk factors were found to be additive. A proposed threshold for screening is probability greater than 0.3, with a sensitivity of 65% (95% CI, 61-68) and specificity of 71% (95% CI, 69-73). The prognostic tool identified 2.4-fold more children with CP than would have presented with encephalopathy (odds ratio, 13.8; 95% CI, 8.87-22.65; P < .001). Conclusions and Relevance: In this case-control study, a prognostic model using 12 clinical variables improved the prediction of CP compared with clinical presentation with encephalopathy. This tool can be applied to all term newborns to help select infants for closer surveillance or further diagnostic tests, which could improve outcomes through early intervention.