On January 26, 2010, The Joint Commission issued Sentinel Event Alert Issue 44 drawing attention to data indicating that maternal death may be rising in the United States. Despite this trend, maternal death remains a rare event.1 For professionals who witness a maternal death, however, the experience can be enduring. Questions are often asked: "How did this happen?" "Were there signs that we missed?" "Could we have prevented this?" and "Is there anything we should have done differently?" Answers to these questions should be sought in a thorough and objective manner following each maternal death. In this issue, the authors explore answers to questions of how to train and respond to maternal cardiac arrest and which women are most susceptible.

Jones, McMurtry Baird, Thurman, and Gaskin review the physiologic changes of pregnancy that impact basic and advanced life support. Critical technical events such as displacing the uterus and hand placement during compressions are included along with perimortem cesarean birth, a crucial intervention if the pregnancy is more than 20 weeks' gestation. A key feature of advanced life support is determining why the arrest happened to this patient at this time. The most common causes associated with maternal death are discussed.

Incorporating pregnancy-specific interventions with traditional tasks of basic and advanced cardiac life support can be difficult for healthcare professionals. The first 5 to 7 minutes of the response to maternal arrest require a blend of traditional resuscitation practices with pregnancy considerations that range from determining gestation to preparing for emergent birth. Schimmelpfennig and Stanfill describe how a traditional American Heart Association advanced cardiac life support program can be enhanced to include pregnancy-specific knowledge and tasks.

A completely different approach to training for this important time period is illustrated in the article by Puck, Oakeson, Morales-Clark, and Druzin. In this program, basic life support is emphasized. A simplified cognitive aid covering key actions is paired with simulation-based training. Emphasis on collaboration with a code team and other professionals with expertise in resuscitation occurs during simulation training and debriefing.

Each facility that provides obstetric care will need to address how staff will be trained to respond to maternal arrest. The individual strengths and weaknesses of the facility need to be closely examined to determine how they can best care for this unique group of patients. Regardless of the training method chosen, a system for early recognition of deterioration in maternal condition, rapid and effective initial response to arrest including consideration of perimortem birth, and collaboration with experts in resuscitation and intensive care is required. If not already detailed or under development, we trust that the articles in this issue will provide a forum for discussion about this rare but devastating event.

This issue on Neonatal Resuscitation is an exciting one, with a lineup providing updates on state of the art and science. Two articles focus on updates of 2 critical neonatal programs used when resuscitating neonates: The Neonatal Resuscitation Program (NRP) and The S.T.A.B.L.E.(R) Program. In addition, there are 2 research articles reporting on studies of the 5-minute Apgar score and outcome and clinical performance of pulse oximetry monitors with extremely low-birth-weight (ELBW) infants.

McGowan describes the evidence and review process that led to a number of significant changes in practice for the 2010 NRP update. The NRP has been part of the American Academy of Pediatrics for almost 25 years, providing educational tools that are used in the United States and throughout the world to teach neonatal resuscitation. Over time the guidelines for resuscitation have been increasingly evidence-based, and a formal system has been established for determining which steps should be updated on the basis of available information.

The CE article by Kendall, Scott, and Karlsen focuses on The S.T.A.B.L.E(R) Program. S.T.A.B.L.E. is an acronym for the 6 essential assessment parameters taught in the program: Sugar and Safe care, Temperature, Airway, Blood pressure, Lab work, and Emotional support. The program aims to prevent leading causes of neonatal mortality. It has been the subject of published peer-reviewed research and is periodically updated to ensure relevancy and inclusion of current best evidence. The sixth edition of the program is scheduled for release in 2012 and will reflect the latest in stabilization guidelines throughout the 6 modules and supplemental content. The article describes international research and current recommendations of the most current evidence to date.

Phalen, Kirkby, and Dysart report on the relationship between the 5-minute Apgar score of ELBW infants, as it relates to survival and morbidities associated with prematurity and length of hospital stay. This interprofessional research team conducted a retrospective query of the Alere neonatal database from 2001 to 2011, including 3898 infants less than 32 weeks' gestation and less than 1000-g birth weight. Comparative analyses of the 5-minute Apgar score were performed on 2 groups: those with score 4 or greater or those with score less than 4. The findings conclude that infants with a low 5-minute Apgar score have greater risk for mortality and morbidities associated with prematurity.

van der Eijk et al. report on a study of the performance of new-generation pulse oximeters in the ELBW infants. The prospective crossover observational study evaluated the performance of 3 brands of pulse oximeters by dual SpO₂ measurement in ELBW infants via foot probes. Absolute differences in SpO₂ values ([DELTA]SpO₂) and the bias between brands were studied. Results suggest that the handling of the pulse oximeter in clinical practice, such as the place and positioning of the probe, influences performance the most. Improvement in the accuracy of oxygen monitoring techniques for ELBW infants is required.

-Julie M. R. Arafeh, MSN, RN

Perinatal Guest Editor

Obstetric Simulation Specialist

Center for Advanced Pediatric and Perinatal Education

Division of Neonatal and Developmental Medicine

Department of Pediatrics

Stanford University School of Medicine

Palo Alto, California

-Ksenia Zukowsky, PhD, CRNP, BC-NNP

Neonatal Guest Editor

Associate Professor

Jefferson School of Nursing

Thomas Jefferson University

Philadelphia, Pennsylvania

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