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  1. Problem. The nurse calls to notify you of a pending high-risk delivery. You are on delivery room duty, and are asked to speak with the parents.

  2. Immediate questions

      1. Are both parents and other important family members available? Is a translator needed?

      1. Is the mother too sick or uncomfortable to be able to participate adequately in the discussion? In this situation, it is essential to include other family members in the discussion.

      1. How well do they understand their current situation? Review the chart.

      1. What do they know about neonatal intensive care units (NICUs), pregnancy and neonatal complications, chronic health problems, and neurodevelopmental disability?

  3. Differential diagnosis. Although a neonatologist can be called on to counsel expectant parents in a variety of circumstances, the following are common problems that are discussed with parents before delivery.

      1. Preterm delivery.

      1. Intrauterine growth restriction (IUGR).

      1. Maternal drug use.

      1. Fetal distress.

      1. Congenital anomaly.

  4. Database

      1. Maternal/paternal data. Obtain the following information: age of both parents, obstetric history, history of the current pregnancy, medication history, pertinent laboratory and sonographic data, family history, social background and supports, and communication ability.

      1. Fetal. Review current fetal information with the obstetrician: findings on prenatal ultrasounds, accuracy of gestational age dating, abnormalities of fetal heart rate tracing, biophysical profile, fetal scalp pH (if done), and any other pertinent tests.

  5. Plan

      1. General approach to parent counseling. Parent counseling before delivery is often performed under less than ideal circumstances. Every effort should be made to communicate effectively, explaining all medical terms and avoiding abbreviations and percentages as much as possible. Expectations for what will happen at delivery, possible complications, and the range of possible outcomes should be covered in addition to the infant's chances of survival. Uncertainties regarding outcome should be acknowledged. Most important, repetition may be necessary for parents to comprehend all this information, and an opportunity to review the information should be provided. If NICU admission is anticipated, an opportunity to tour the NICU (and to see other infants hooked up to monitoring and life support equipment) should be offered. Specific and detailed survival and outcome statistics are beyond the scope of this book but are contained in neonatal and obstetric textbooks.

      1. Specific counseling issues

          1. Preterm delivery. The more immature the infant, the greater the risk of death, complications of prematurity, health sequelae, and neurodevelopmental disability. Current data, drawn from many published outcome studies, are presented in Table 44–1, although quoting percentages to parents should be avoided (because it is confusing to many people).

              1. Immediate questions

                  1. What is the infant's gestational age? This is the most important question because morbidity and mortality are so closely tied to maturity. Both gestational age and birthweight have been used as proxies for maturity in predicting survival and outcome. However, only gestational age is available when counseling parents in labor and delivery.

                  1. What is the reason for the preterm delivery? The reason for preterm delivery affects infant outcome and the likelihood of delaying delivery (eg, delay is contraindicated with suspected chorioamnionitis).

                  1. Are there signs of ...

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