This issue of the Journal of Perinatal & Neonatal Nursing focuses on complications that can occur during pregnancy. Although the vast majority of pregnancies progress in a routine fashion and result in a term uncomplicated delivery of a healthy infant, perinatal nurses certainly know that a variety of high-risk conditions may complicate pregnancy putting the mother and/or infant at risk of a less than optimal outcome. According to the US Vital Statistics the maternal mortality rate remains far above the Healthy People 2010 and 2020 national target of less than 3.3 maternal deaths per 100000 live births.1 The current maternal mortality rate in the United States is 13.3 deaths per 100000 live births, well above the targeted rate and thought to be underreported because of inconsistent state reporting systems.2 Racial disparities related to maternal mortality also exist. Black women are 3.7 times more likely to die from pregnancy complications than white women.3 In addition, studies also demonstrate that maternal death is just one component of this alarming data. Pregnancies complicated by preexisting medical conditions have increased.4 In another recent study, severe morbidity was shown to be 50 times more common than maternal death.5

We, the guest editors of this issue, have a combined 50 years of experience in perinatal nursing with a large focus of our practice in the area of high-risk obstetrics. The topics included in this issue are some of the most common and, in our opinion, the most important for perinatal nurses to understand.

The incidence of type 2 diabetes among children and adolescents is increasing in the United States and is occurring in parallel with an increasing prevalence of obesity in children.6 The increased incidence in this population will lead to an increased number of women entering pregnancy with preexisting diabetes. In 2010, The International Association of Diabetes and Pregnancy Study Group (IADPSG), recommended a change to the traditional terminology used to classify diabetes in pregnancy.7 In 2011, the American Diabetes Association (ADA) endorsed this recommendation,8 whereas the American College of Obstetricians and Gynecologists (ACOG) has not yet taken a position on the proposed change. If IADSPG criteria for diagnosing overt and gestational diabetes were used, about 18% of women would be diagnosed with diabetes during pregnancy.7 With the potential complications to the mother and the fetus that can occur with undiagnosed or poorly controlled diabetes in pregnancy, it is imperative that patients are correctly diagnosed and managed.

Although recent research has revealed much more information regarding the pathogenesis of preeclampsia than was previously known, mysteries about this syndrome continue. What influence do maternal and fetal genes have? Why do visible symptoms develop at different times in gestation and in varying degrees of severity? Will an ideal screening test for preeclampsia be developed? These issues as well as nursing implications for assessment and management are addressed.

Hemorrhage remains one of the top causes of pregnancy related mortality.9 Identifying patients at risk for obstetric hemorrhage, developing guidelines for management, instituting standardized education including simulation drills and forming obstetric emergency response teams are ways that many hospitals are working to improve outcomes for their obstetric patients. This issue includes information on those at risk for obstetric hemorrhage as well as principles of acute volume resuscitation.

Normal physiologic changes cause the pregnant woman to be at increased risk of critical illness from pulmonary complications, such as influenza. Five percent of all US H1N1 deaths in 2009 occurred in women who were pregnant. In addition, preterm labor and birth risks are increased in women with influenza.10 Many women do not receive influenza vaccination during pregnancy and postpartum because of a lack of knowledge, awareness, and concerns related to vaccine safety. Vaccination in any trimester is safe and recommended during influenza season (October through May) to prevent morbidity and mortality.10

Improvement of maternal and infant health has long been a national concern. Even though pregnancy and birth are physiologic events, complications that occur often cause hemodynamic instability and jeopardize the health and outcomes of the mother. Also, when the mother experiences compromise, there is increased risk of preterm labor, birth, and profound effects on fetal oxygen status. We hope that all perinatal nurses will use this information in their daily practice to impact the outcomes of mothers, families and babies.

The complicated neonate tests every facet of cognitive and emotional attributes of the high-risk nursery healthcare provider. Despite common disease processes and family dynamics, no 1 patient and family is really like another. The manuscripts presented here focus on a range of topics encountered on a daily basis.

Amentrout tackles the sensitive area of "Informing Parents about the Actual or Impending Death of Their Infant in a Newborn Intensive Care Unit." Very little training is provided academically or clinically on how to approach the parents at such a vulnerable time. Simulation laboratories may provide scenarios to help both the novice and experienced nurse become more comfortable in discussing delicate information to help the family cope with the possible death of their baby.

There continues to be much controversy over the use of oxygen in the preterm population as well as the parameters of saturations that are the safest to target. Deuber has provided a systematic review of the literature with respect to hyperoxia in the preterm infant less than 28 weeks postmenstrual age. She describes the association between hyperoxia and chronic sequelae such as retinopathy of prematurity, chronic lung disease, and brain injury, and suggests avenues that have potential to improve outcomes for this population.

Administration of steroids for neonates with chronic lung disease that are ventilator dependent has been associated with adverse neurodevelopmental development. However, there is still a small fraction of neonates who, after weighing the potential risks of the medication, may benefit from the treatment. The CE article by Forest presents a case study of just such a neonate, historical information regarding postnatal steroid treatment, and the dilemmas involved when deciding to administer steroids in this population. Ethical considerations related to the medical treatment, the family's autonomy, and quality of life issues are also highlighted in "Postnatal Steroids for the Treatment of Bronchopulmonary dysplasia: A Complex Case Presentation."

A relatively new topic in perinatal literature, failure to rescue, is just beginning to make its way into neonatal circles. Gephart conceptualizes that failure to rescue is the end result of a series of events, some of which may be linked to nursing actions, and thus, preventable. Because the nurse is the healthcare provider that is the constant at the bedside, nursing is in an ideal position to recognize signs of danger and promptly take action. The article "Failure to Rescue in Neonatal Care" defines failure to rescue and describes opportunities in the neonatal intensive care unit for improving failure to rescue by outlining both nursing and system strategies.

-Susan Drummond, RN, MSN, C-EFM

Perinatal Guest Editor

Assistant in Obstetrics

Department of OBGYN

Vanderbilt University Medical Center

Nashville, Tennessee

-Suzanne McMurtry Baird, DNPc, RN

Perinatal Guest Editor

Assistant Director, Clinical Practice

Texas Children's Hospital

Houston, Texas

-M. Terese Verklan, PhD, CCNS, RNC

Neonatal Guest Editor

Adjunct faculty

Neonatal Clinical Nurse Specialist

Texas Woman's University

Houston, Texas

References