Antenatal counselling before a preterm delivery has many benefits for parents: reducing anxiety, increasing knowledge, facilitating informed decision-making and providing a good starting point for what may be a long and critically important relationship with the neonatal clinicians. However, information recall is poor, especially in highly stressful situations such as labour, where distracting factors such as pain and anxiety may lead to discordance between parental and clinician recall of the conversation.[3, 4] Post-counselling documentation is therefore critical in providing a record to which future health-care professionals can refer; for instance acting as a starting point for later discussions or as a form of legal document if advance treatment preferences are being decided. Despite this there has been little research into what is documented by clinicians after such discussions.
We looked at all antenatal counselling sessions given within 3 days of delivery (gestational age 28–35 weeks) over a 4-month period in our hospital (n = 24). Parental views and recall were obtained via a semi-structured questionnaire, and clinical notes were reviewed for documented evidence of counselling (n = 18 available).
There was wide variation in the information that parents recalled, but this was difficult to interpret as documentation of the consultation and what was discussed was universally poor (Table 1), with 44% (n = 8) of counselled mothers having no written evidence of the discussion at all. Certain important topics were both poorly recalled and documented, including neurological and cardiac complications. These sensitive areas may be more challenging for junior clinicians to discuss, leading to a failure to convey the information thoroughly or to topic avoidance, or parents may subconsciously choose not to acknowledge or remember this difficult information.
|Discussion topic||Parental recall (total n = 18)||Documentation (total n = 18)||Cases with both recall and documentation|
|Respiratory (e.g. need for ventilation, long term oxygen)||17||94||7||39||7||39|
|Neurological (e.g. intraventricular haemorrhage, cranial imaging)||6||33||6||33||4||22|
|Gastrointestinal (e.g. necrotising enterocolitis)||8||44||3||17||3||17|
|Cardiac (e.g. patent ductus arteriosus)||3||17||2||11||1||6|
|Immunity (e.g. infection risk, antibiotic use)||12||67||6||33||4||22|
|Feeding and nutrition (e.g. parenteral feeds, hypoglycaemia)||10||56||7||39||4||22|
|Homeostasis (e.g. body temperature, need for incubator)||14||78||3||17||1||6|
Documentation may not be the highest priority when faced with an imminent preterm delivery but the majority of women in our study (72%) were counselled at least 4 h before delivery, allowing ample time for adequate documentation. Inadequate documentation results in uncertainty for subsequent clinicians who will not know what has been discussed and therefore overwhelm parents in subsequent consultations with repeated information or conversely fail to cover essential topics, assuming they were already discussed. This becomes increasingly important as more neonates are born at the edge of viability and challenging decisions need to be made regarding levels of care, ideally with full parental understanding and involvement. The introduction of a counselling checklist, alongside clinician education, could help improve documentation rates.