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Palliative Care

Key Points Palliative care is the total care of a patient with a life-limiting illness regardless of the disease trajectory or treatment options chosen. There is a special focus on pain/symptom management, communication, quality of life, family support, and grief support. Up to 3% of pregnancies are complicated by a life-limiting diagnosis. Roughly one-third of deaths in children's hospitals in the United States occur in neonatal…

Neonatal Pain and Stress

Key Points Pain and discomfort in infants are common occurrences in intensive care. Identification and management of neonatal pain remain challenging. Many neonatal pain scoring tools assist in classifying pain, but many were not validated in clinical practice. Neonatal pain recognition with near-infrared spectroscopy and amplitude-integrated electroencephalography does not always align with clinical manifestations of pain, raising questions about how best to define, diagnose, and treat…

Neonatal Pharmacology

Key Points The key feature of neonatal physiology is rapid maturation, resulting in extensive variability in pharmacokinetics and pharmacodynamics, further aggravated by other covariates, like pharmacogenetics or unique disease characteristics. Variability is the essence of neonatal care and neonatal pharmacology. Thorough understanding of these factors, especially developmental changes, that affect pharmacokinetics (absorption, distribution, metabolism, elimination) in neonates helps to provide accurate dose adjustments to assure effective…

Fluid, Electrolyte, and Acid-Base Balance

Key Points In the neonate, many pathologic states and/or their treatment are associated with disruptions in normal body fluid, electrolyte, and acid-base balance, which at times may in themselves become life-threatening. Conversely, many conditions may be negatively affected by disruptions of normal body fluid, electrolyte, and acid-base balance occurring independently of the condition itself. The maintenance of normal fluid, electrolyte, and acid-base balance is a cornerstone…

Neonatal Transport

Key Points Regionalization of neonatal critical care improves outcomes. Highly effective transport systems feature centralized and standardized communications, experienced medical oversight and skilled teams trained to care for sick neonates. Appropriate transport care depends on the training and competency of the transport teams. The care delivered should not decrease in sophistication during the transport process. The referring provider is responsible (per Emergency Medical Treatment and Active…

Newborn Screening

Key Points Newborn screening (NBS) provides an opportunity for early identification of newborns with disorders in which the clinical complications develop postnatally and may remain unrecognized prior to irreversible clinical damage. Since its inception nearly six decades ago, with screening for a single disorder, NBS has expanded substantially to more than 60 disorders in the current screening panels. NBS is a “screen,” and individuals should not…

Temperature Regulation

Key Points Providing an appropriate and stable thermal environment is important for newborns regardless of size or gestational age. Neutral thermal environment (NTE) refers to the ambient temperature necessary to maintain normal metabolism. Newborn (admission) hypothermia continues to be a global challenge, particularly in resource-limited settings. Radiant warmers, warm blankets, thermal mattresses, head covering, plastic wrap (without drying), delayed bathing, and skin-to-skin care have been recommended…

Care of the Newborn

Key Points Prenatal ultrasonography can diagnose multiple newborn conditions early. However, the natural history of many common ultrasound findings is variable, and the findings may or may not represent markers of serious disease. The short-term and long-term benefits of breastfeeding are clear. The effects on breastfeeding rates from interventions such as formula supplementation, frenotomy, and restriction of pacifiers remain controversial, as does breastfeeding among HIV-positive mothers.…

Perinatal Transition and Newborn Resuscitation

Key Points Preparation prior to delivery helps ensure timely and effective newborn resuscitation. Delayed umbilical cord clamping following delivery may have a significant impact on newborn outcomes. Establishing adequate ventilation is key to the perinatal transition. The laryngeal mask airway is an alternative to intubation in newborns at ≥34 weeks’ gestation and > 2000 g. Devices such as carbon dioxide detectors, pulse oximetry, electrocardiography, and respiratory…

Obstetric Analgesia and Anesthesia

Key Points Labor results in significant pain for many women that is individualized, dynamic, and unpredictable. Although the effects of obstetric analgesia and anesthesia on the fetus and neonate are typically benign, there is potential for adverse neonatal effects. During pregnancy, labor, and delivery, women undergo fundamental changes in anatomy and physiology that affect all organ systems, significantly alter pharmacokinetic and pharmacodynamics responses to many drugs…

Complicated Deliveries

Key Points Cesarean section occurs in approximately one-third of all births in the United States, with substantial variation among hospitals that cannot be entirely accounted for by preexisting maternal or fetal comorbidities. Multidisciplinary team training can reduce infant morbidity after shoulder dystocia. Operative vaginal birth with either forceps or vacuum has declined to a multi-decade low despite the low frequency of infant complications directly attributable to…

Assessment of Fetal Well-Being

Key Points Fetal assessment demands a view into the somewhat inaccessible intrauterine environment; the primary tools are ultrasound and fetal heart rate monitoring. It is important to make the distinction between intrapartum (during labor) and antepartum (before labor) fetal assessment; the latter is the focus of this chapter. Current debate centers on who should undergo sonographic examination and what type of evaluation these patients should have.…

Intrauterine Drug Exposure: Fetal and Postnatal Effects

Key Points Substance use remains at epidemic proportions, both nationally and globally. Increasing legalization of marijuana has resulted in new concerns for fetal and infant exposure, with limited understanding of the short- and long-term effects in this population. The recent focus of perinatal substance use has grown to include widely prescribed substances, including opioids and other psychotropic drugs. The importance of establishing and maintaining consistent protocols…

Hypertensive Complications of Pregnancy

Key Points Hypertensive disorders of pregnancy are classified as chronic hypertension, gestational hypertension, preeclampsia with and without severe features, and chronic hypertension with superimposed preeclampsia. Pharmacologic management of chronic hypertension should be reserved for women with sustained elevations in blood pressure at or greater than 160 mm Hg systolic or 110 mm Hg diastolic. Magnesium sulfate administration to prevent eclampsia is used for those preeclampsia cases…

Maternal Medical Disorders of Fetal Significance

Key Points Diagnostic imaging carries a risk of fetal radiation exposure. However, in most cases the actual fetal dose is low. While x-ray and computed tomography imaging should be avoided during pregnancy if possible, these studies are not contraindicated if needed. Adverse pregnancy outcomes in patients with lupus are more frequently seen in those with renal disease, antiphospholipid antibody syndrome, thrombocytopenia, and active disease. Cardiovascular disease…

Maternal Diabetes

Key Points The incidence of diabetes in pregnancy is steadily rising, likely in parallel with the rising incidence of obesity among pregnant patients. Pregnant patients with diabetes are at increased risk for fetal complications (such as congenital malformations, fetal growth abnormalities, and stillbirth) and perinatal/neonatal complications (such as prematurity, respiratory distress, and metabolic abnormalities, including hypoglycemia and electrolyte derangements). Tight maternal glycemic control, achieved preconception and…

Nonimmune Hydrops

Key Points Nonimmune hydrops fetalis results from many etiologies. Management involves correcting the underlying cause. The condition is associated with significant morbidity and mortality. Some etiologies are amenable to treatment in utero. A newborn with hydrops has an abnormal accumulation of fluid. The condition varies from mild, generalized edema to massive anasarca with effusions in multiple body cavities and with peripheral edema so severe that the…

Prematurity and Stillbirth: Causes and Prevention

Key Points Preterm birth, defined as birth prior to 37 weeks gestation, is the leading cause of under-five child mortality worldwide. Preterm birth can be spontaneous or medically indicated, in which cesarean delivery or induction of labor is performed to avoid the risks of continued pregnancy. Preterm birth and stillbirth should be considered as occurring on a spectrum rather than distinct entities, due to overlapping physiology…

Multiple Gestations and Assisted Reproductive Technology

Key Points The multiple birth rate has increased by 76% in the past three decades; however, it has recently started to stabilize or even decline. Increased utilization of assisted reproductive technologies and women delaying childbearing are the main contributors to the high rate of multiples. Multiple gestations are at high risk for both maternal and fetal morbidity and mortality, which increase as fetal number increases. Most…

Abnormalities of Fetal Growth

Key Points Normal fetal growth is determined by a number of factors. The pattern of normal fetal growth involves rapid increases in fetal weight, length, and head circumference during the last half of gestation. Year-over-year increases in birth weight for gestational age are attributed to improvements in living conditions and maternal nutrition as well as changes in obstetric management. Variations in fetal growth have been identified…