Antenatal Neonatology Consultation Note

Date/Time: [Date and time of consultation]

Gestational Age / EDD: [Gestational age in weeks+days] / [EDD] (Include dating method: LMP, US, or IVF.)

Fetus: [Singleton / Multiple gestation: Fetus A, Fetus B, etc.] (For multiples, maintain consistent labeling across all sections and future notes.)

Participants Present: [Patient, partner/support persons, interpreter if used, neonatology team members, other team members present]

Referring Service / Reason for Consultation: [Referring service and clinician] — [Clinical question/indication] [anticipatory / urgent]

Chief Concern

[Brief statement of the specific clinical question being addressed] (Limit to 1–3 lines. State the focus of counseling and planning.)

History and Context

[Information sources: patient report, chart review, outside records] (Note any limitations or missing data.)

[Gravida/para and relevant obstetric history] (Include only details impacting neonatal risk: prior preterm birth, anomalies, fetal/neonatal losses, relevant cesarean history.)

[Pertinent maternal medical conditions affecting delivery or NICU course] (Include only if relevant: diabetes, hypertension, infections, autoimmune disease, substance exposure.)

[Pregnancy complications to date] (Include timing and current status: PPROM, preterm labor, growth restriction, fluid abnormalities, placental issues.)

[Antenatal therapies relevant to neonatal planning] (Include medication and dates: corticosteroids, magnesium sulfate, antibiotics, tocolytics.)

[Genetic testing performed or pending with key results] (Summarize high-impact findings only. Note pending tests and expected availability.)

[Social and decision-making context] (Include only if relevant: primary decision-makers, interpreter needs, logistical considerations affecting care coordination.)

Fetal Assessment

(Summarize the most recent and highest-impact studies with dates. Prioritize findings affecting delivery room stabilization and immediate postnatal management.)

Dating and Growth: [Most recent EFW and percentile, amniotic fluid status, umbilical/MCA Dopplers if relevant, growth trend] (Include dates.)

Key Imaging and Diagnostic Findings:

• [Ultrasound findings impacting airway, respiratory status, hemodynamics, or need for surgery]
• [Fetal echocardiogram findings: structure, function, ductal dependence risk, rhythm]
• [Fetal MRI findings relevant to delivery or NICU plan]
• [Subspecialist conclusions: surgery, cardiology, genetics]
• [Pending or planned studies with expected timing and how results may alter plans]

Fetal Problem List: (List in descending clinical impact.)

• [Problem] [confirmed / suspected / consistent with / pending confirmation]
• [Additional problems as applicable]
• [Pregnancy-level considerations: placental or cord issues impacting delivery]

(For multiple gestation, duplicate the above for each fetus under labeled subheadings: Fetus A, Fetus B, etc.)

Assessment

[Clinical synthesis integrating fetal findings and gestational age with operational implications for delivery and immediate neonatal care] (1–2 paragraphs. Use probabilistic language and acknowledge uncertainty.)

• Airway/Respiratory: [Risk level for immediate intubation, likely support mode, difficult or surgical airway concerns]
• Cardiovascular: [Hemodynamic instability risk, ductal dependence, anticipated need for prostaglandin]
• Surgical Needs: [Immediate surgical evaluation vs deferred]
• Prematurity-related risks: [RDS, IVH, NEC, sepsis considerations] (Include if applicable.)
• Other: [Metabolic, infectious, or neurologic concerns impacting early management]

Counseling and Shared Decision-Making

[Overview of topics covered: diagnosis, uncertainties, prognosis, intervention options, expected NICU trajectory, potential long-term outcomes]

Information Shared

• Knowns vs Unknowns: [What is established vs uncertain about the diagnosis and prognosis]
• Prognosis framing: [Survival ranges, morbidity risks, neurodevelopmental outcomes, quality of life considerations] (Acknowledge uncertainty; avoid guarantees.)
• Delivery room expectations: [Anticipated interventions tailored to diagnosis]
• Anticipated NICU course: [Major interventions, evaluations, monitoring, estimated length of stay] (Use ranges and contingencies.)

Options Discussed

• [Full resuscitation and intensive care]
• [Time-limited trial with reassessment triggers]
• [Selected limitations if requested]
• [Comfort-focused care]
• [Other family-requested options]

(Use neutral language; present risks, benefits, and reasonable alternatives.)

Values and Goals

[Family's stated hopes, worries, and priorities] (Use patient-centered language. Include brief direct quotes when they capture key values. Note cultural or spiritual considerations only if shared by family and relevant to planning.)

Decisions and Current Plan

• Resuscitation intent: [Full / Limited (specify) / Comfort-focused] (Include contingencies, e.g., reassess if postnatal findings differ.)
• Disposition plan: [NICU admission / Comfort care with mother / OR transfer]
• Specifically requested or declined interventions: [List if applicable]
• Requested supports: [Palliative care, chaplaincy, social work, memory-making, lactation]
• Decision status: [Confirmed today / Deferred with follow-up plan and timing]

Delivery Room Management Plan

(Executable quick-reference for delivery team. For multiple gestation with different needs, create separate labeled subsections per fetus.)

• Team Presence: [NICU team level, RT, nursing, OB anesthesia, subspecialists needed: surgery, ENT, cardiology, palliative care] (Specify in-room vs on-call.)
• Initial Steps: [Thermoregulation approach, airway management plan, positioning, monitoring setup]
• Vascular Access and Medications: [UVC/UAC vs peripheral, fluids, prostaglandin if ductal-dependent, antibiotics, glucose management]
• Contingencies and Triggers: [Criteria for escalation, response to inadequate resuscitation response per counseling, difficult airway algorithm triggers]
• Immediate Disposition: [NICU / OR / Remain with mother for comfort care] (Include transport logistics.)

Postnatal Evaluation and NICU Course

• Immediate Stabilization: [Respiratory support, vascular access, antibiotics if indicated, thermal management, glucose monitoring, initial labs and imaging]
• Confirmatory Diagnostics and Consults: [Echo timing, imaging studies, surgical evaluation, genetics samples, other subspecialty consults]
• Anticipated Procedures: [Procedures with timing and criteria for intervention vs observation]
• Feeding and Nutrition: [Colostrum collection, lactation support, enteral feeding plan, TPN if needed, aspiration precautions]
• Discharge Planning: [Anticipated equipment, home services, follow-up clinics, screening completion] (Include if applicable.)

Follow-up and Coordination

• Next Counseling Session: [Date/time if scheduled, or trigger for reconvening]
• Plan Ownership: [Service responsible for updating delivery plan if new information arises]
• Family Contact: [How family can reach the team for questions or changes]
• Notifications: [Services notified of this consultation: MFM, primary OB, subspecialists, palliative care, L&D/NICU]
• Documentation References: [Location of birth plan in EHR, linked orders]

(If information for a section is unavailable or not applicable, omit that section or note briefly what is pending. Attribute facts to sources and label uncertainty explicitly throughout.)