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Optimization of the NICU Environment

Neurobehavioral Maturation The expected physiologic environment for a preterm infant would be in utero, floating and moving in warm amniotic fluid, mostly in a flexed position, tasting the amniotic fluid, sensing their mother’s movements and circadian rhythm, hearing her voice and sounds from her body but being protected from loud noises, receiving rich amounts of nutrients for optimal growth, and performing gas exchange through the placenta.…

Thermal Environment of the Intensive Care Nursery

Thermal management of the newborn infant is a cornerstone of neonatal care: The field accommodates important advances in care provision spanning from pioneering studies on chronic cold stress and neonatal incubation to kangaroo mother care, prevention of low admission temperatures, and therapeutic hypothermia. Globally, cold stress remains a contributor to neonatal mortality and morbidity, and the potential impact of optimal thermal care provision on infant health…

Chest Compression, Medications, and Special Problems in Neonatal Resuscitation

Advanced resuscitation in the delivery room is rarely needed as long as effective ventilation is quickly established. When compressions are needed, it is critical to minimize pauses, use the most effective two-thumb method from the head of the bed position, and coordinate with breaths that inflate the lung. In rare cases of profound asphyxia, intravenous epinephrine may be needed to reestablish adequate coronary perfusion pressure. Medical…

Oxygen Therapy in Neonatal Resuscitation

Use of Oxygen in Perinatal Asphyxia and Resuscitation Oxidative Stress: Pathophysiologic Background Perinatal asphyxia is a devastating disorder that affects roughly 2% of newborn babies in industrialized countries, but constitutes one of the leading causes of early neonatal death in nonindustrialized countries. Both ischemia and hypoxia reduce oxygen and glucose supply to neurons leading to ATP depletion and inactivation of ATP-depending ion pumps, causing intracellular accumulation…

Role of Positive Pressure Ventilation in Neonatal Resuscitation

Newborn babies who do not spontaneously breathe at birth require support to safely make the transition to extra-uterine life. Over the past 20 years, guidelines for those providing care to these infants have been developed. However, the evidence available to guide initial respiratory support remains limited, reflecting the challenges associated with conducting research in the delivery room. The crucial steps in the adaption to extra-uterine life…

Overview and Initial Management of Delivery Room Resuscitation

The transition from fetus to neonate represents a series of rapid and dramatic physiologic changes during which the placenta is replaced by the lungs as the primary organ of gas exchange. Although this transition goes smoothly most of the time, in approximately 10% of births the active intervention of a skilled individual or team is necessary to ensure that the newborn receives the appropriate assistance to…

Congenital Anomalies

Major anomalies are seen in about 2% of newborns, often prompting parental worry and urgent medical intervention soon after birth. In addition, they are a common cause of long-term illness and death. This chapter reviews some of the significant etiologic and epidemiologic aspects of congenital anomalies. It provides an approach to and a framework for the evaluation of the infant with congenital anomalies, with emphasis on…

Birth Injuries

Birth injuries are those sustained during the birth process, which includes labor and delivery. They may be avoidable, or they may be unavoidable and occur despite skilled and competent obstetric care, as in an especially hard or prolonged labor or with an abnormal presentation. Fetal injuries related to amniocentesis and intrauterine transfusions and neonatal injuries after resuscitation procedures are not considered birth injuries. However, injuries related…

Physical Examination of the Newborn

Immediately after a baby is born, all parents want to know, “Is my baby all right?” A quick initial physical examination of all newborns should be performed in the delivery room to ensure that there are no major anomalies or birth injuries, that the newborn's lips and body appear pink, and that breathing is normal. This primary survey must include a brief look at the entire…

Anesthesia for Labor and Delivery

The goal of modern-day obstetric anesthesia practice is to provide the patient with analgesia as she requests it. That assumes her choice is appropriate to the labor process and to the current conditions as evaluated by her obstetric provider, and has as little impact on the fetus as possible. Depending on the patient's predilections, labor might be approached with prepared responses to modify pain perception, a…

Placental Pathology

The placenta has two opposing functions. It is the sole source of sustenance for the fetus and its sole protection against noxious external influences. It can be argued that no evaluation of a sick neonate is complete without knowing the status of the organ that has accompanied it through the preceding gestation. The specific “value added” by placental examination can be summarized under five overlapping headings:…

Perinatal Infections and Chorioamnionitis

Definitions and Epidemiology Chorioamnionitis (or intra-amniotic infection) is a major cause of fetal, neonatal, and maternal morbidity and mortality. There are strong associations between chorioamnionitis and maternal morbidity, preterm birth, early-onset neonatal sepsis, bronchopulmonary dysplasia, retinopathy of prematurity, and diffuse white matter injury. The literature supporting these associations has been inconsistent, largely because of lack of precision in the diagnosis of chorioamnionitis. Potential sites of microbial…

Amniotic Fluid Volume

Amniotic fluid surrounds the developing embryo throughout gestation, protecting the fetus and umbilical cord from trauma while allowing mobility to facilitate structural growth and development. The underlying forces that regulate amniotic fluid are exceedingly complex and dynamic, synchronizing volumes within relatively narrow ranges and providing an indirect measure of fetal well-being. Understanding the pathways of water and solute exchange provides the physiologic basis of the pathologic…

Immune and Nonimmune Hydrops Fetalis

Hydrops fetalis (HF) is defined as the presence of excessive fetal fluid in two or more of the following spaces: abdominal ascites, pleural effusion, pericardial effusion, skin edema, polyhydramnios, or placentomegaly. The diagnosis is made by ultrasound imaging evaluating body cavities, the placenta, and the amniotic fluid volume. Classically, HF has been classified into two categories based on etiology: Immune HF accounts for an estimated 10%-24%,…

Obstetric Management of Multiple Gestation and Birth

The human female is programmed by nature to mono-ovulate, to nurture one fetus, and to take care of one neonate at a time. This natural pattern results in the relatively rare birth of twins (about 1 per 80 to 100 births) and in the extremely rare occurrence of high-order multiple gestations. The rarity of high-order multiple gestations can be appreciated by the quasi-mathematical Hellin-Zellany rule for…

Fetal Effects of Autoimmune Disease

Placental Transfer: General Remarks The maternal-fetal interface is quite efficient in its selective exclusion of substances during the transport process from the maternal to the fetal circulation. At the same time, the placenta selectively transfers other substances, a process that is facilitated by the proximity of the respective maternal-fetal vascular systems within the placental cotyledons. Although there is no mixing of the maternal and fetal blood,…

Obstetric Management of Prematurity

Preterm birth is defined as a delivery that occurs at 20 weeks’ gestation or later but prior to 37 weeks’ gestation (from the first day of the last menstrual period). Although advancements in neonatology and obstetrical interventions have dramatically improved outcomes and reduced the burden associated with prematurity, the rate of preterm birth itself has not changed substantially over the past 40 years. From 1990-2006, the…

Pregnancy Complicated by Diabetes Mellitus

In the United States, depending on the applied diagnostic criteria, 135,000-200,000 women develop gestational diabetes mellitus (GDM) annually, adding to the number of pregnant women diagnosed with either type 1 or type 2 diabetes. Of greater concern may be the fact that approximately 80% of these mothers will develop type 2 diabetes and metabolic syndrome, both of which are associated with high mortality and morbidity. Furthermore,…

Hypertensive Disorders of Pregnancy

Hypertensive disorders of pregnancy consist of a broad spectrum of medical complications, including gestational hypertension, preeclampsia, eclampsia, and pregestational hypertension. The incidence is estimated to be between 3% and 10% of all pregnancies. Worldwide, preeclampsia and related conditions are among the leading causes of maternal mortality. Although maternal death caused by preeclampsia is less common in developed countries, maternal morbidity remains high. Hypertensive disorders of pregnancy…