AGGRESSIVE INTRAPARTUM MANAGEMENT OF LETHAL FETAL ANOMALIES - BEYOND FETAL BENEFICENCE

Objective: To evaluate management recommendations from the current lit erature for patients whose fetuses are certain to have lethal anomalie s or absent (or virtually absent) cognitive function. These recommenda tions include termination of pregnancy or, for cases in the third trim ester, nonaggressive intrapartum management, avoiding cesarean deliver y for fetal indications. Methods: We report our experience with severa l patients who voiced opposition to nonaggressive intrapartum care and present a rationale for selectively aggressive, intrapartum managemen t for some of these eases. Results: Four women whose fetuses had letha l 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 patient s found comfort in the live births. The fourth patient accepted a reco mmendation to avoid fetal monitoring during labor, and the fetus was s tillborn. This patient found the intrapartum experience to be very str essful. Conclusion: When a patient's desire to avoid an intrapartum st illbirth is strong enough that substantial psychological harm might re sult from one, the physician's beneficence-based obligation to her and respect for maternal autonomy justify selectively aggressive intrapar tum therapy, even if no beneficence-based obligation to the fetus exis ts.