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Delivery of a high-risk fetus requires multidisciplinary prenatal decision making to ensure the best outcome for the newborn and mother. Obstetricians, neonatologists, and, in appropriate cases, pediatric medical and/or surgical subspecialists must work together to determine an appropriate plan of care for the fetus and delivery of the newborn and provide counseling for the family. Discovery of a significant complication during pregnancy often warrants referral of the mother to a perinatologist for further evaluation and possible treatment. When circumstances allow, the mother of a high-risk fetus should be transferred to a tertiary care center with experience in high-risk obstetric and neonatal care prior to delivery. Numerous studies have shown improved outcomes for low-birth-weight (LBW) infants (<2500 g) who are delivered at a center with a higher level of neonatal care.


Successful transition from fetal to ex utero life involves a complex series of hormonal and physiologic changes, many of which occur or begin before birth. Events such as cord compression, placental abruption, meconium aspiration, and premature delivery or the presence of infection or major congenital malformations may alter or prevent the essential postnatal transition. Any process that prevents or hinders the newborn from inflating the lungs with air and establishing effective ventilation, oxygenation, and/or circulation will result in a depressed newborn in need of resuscitation for survival.


The American Academy of Pediatrics (AAP) guidelines mandate that at least 1 skilled person capable of carrying out resuscitation of a newborn be present at every delivery. When a delivery is identified as high risk, 2 or more skilled people may be required to provide adequate care. Often it is useful to assign roles to the resuscitation staff to ensure that the resuscitation flows as smoothly as possible. The equipment required for resuscitation, such as the bag and mask used for ventilation, the blender for oxygen and air delivery, the suction equipment, the radiant warmer, and the monitors, should be checked prior to the delivery. Communication between the obstetric and neonatal staff about the maternal medical and obstetric history as well as the prenatal history of the fetus is essential to ensure that the neonatal team can anticipate and interpret the problems the newborn may have in the delivery room.


Delivery Room Management


Although the expectations may be different and the need for resuscitation more common, the same principles apply to a high-risk delivery as to a routine delivery: The newborn should be kept warm and rapidly assessed to determine the need for intervention.


The initial evaluation and resuscitation may take place in the delivery room or, in centers with a high-risk delivery service, preferentially in an adjacent room specifically designed for high-risk resuscitations. Typically the newborn is brought immediately to a radiant warmer, although some institutions weigh extremely premature infants prior to transfer to the warmer bed in order to determine the birth weight if viability is in question. The infant is dried with prewarmed towels to prevent heat loss. At some centers, LBW newborns are put ...

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