Neonatal perinatal fellows complete 13 months of inpatient clinical service during their 36 months of fellowship training. Clinical training in neonatal perinatal medicine takes place in the 150-bed neonatal intensive care unit (NICU) at St. Louis Children’s Hospital (SLCH) and on the labor and delivery service at the adjacent Woman and Infant’s Pavilion at Barnes-Jewish Hospital’s Parkview Tower.
The SLCH NICU has more than 1,300 admissions per year. Approximately half of these newborns are born at Parkview Tower and the other half are transported to SLCH from hospitals throughout Missouri and Illinois, as well as from national and international referrals for the highly specialized care available at St. Louis Children’s Hospital.
Diagnoses range from extreme prematurity to complex genetic syndromes giving fellows a wide-breadth of experience in caring for critically ill newborns. All major therapies, including NICU-based extracorporeal membrane oxygenation, renal replacement therapies and solid organ transplantation are available. All pediatric and surgical sub-specialists are readily available to care for complex patients and enhance the learning environment.
Fellows partner with the St. Louis Children’s Hospital critical care transport team, serving as medical control, providing in-the-field expertise in neonatal stabilization and assisting in transferring critically ill newborns by air and ground from referring hospitals.
Fellows on the clinical services lead the evaluation and management of patients under the guidance of more than 35 faculty members. This provides an excellent environment for the development of outstanding clinical, procedural, teaching and leadership skills.
Five fellows are on service in the NICU each month, each one covering one of the seven teams in the NICU. These teams include the team covering all NICU ECMO patients and the Labor and Delivery team. A clinical team typically consists of an attending neonatologist, a clinical fellow, pediatric residents and neonatal nurse practitioners. The SLCH NICU values a multidisciplinary approach to patient care, and neonatal pharmacists, dietitians, lactation consultants, respiratory therapists, occupational and physical therapists, speech-language pathologists, family partners, and social workers are integral members of each team.
On service fellows take in-house calls approximately every fifth night during their service blocks, and one fellow rotates on an in-house, two-week night float rotation. An attending neonatologist provides in-house back-up to both on-call fellows and the medical teams. Off-service fellows take calls either Saturday or Sunday for approximately 8-10 calls per year to allow focused attention on their scholarly work.
First year fellows are given time off clinical service to prepare for the initial General Pediatrics Certifying Examination offered by the American Board of Pediatrics in October. The second and third year fellows cover during this time period which is reciprocated by the first year fellows later in their fellowship.
The labor and delivery service at the Woman and Infant’s Pavilion at Barnes-Jewish Hospital’s Parkview Tower is a high-risk obstetrical service with approximately 4,000 deliveries per year, providing fellows considerable experience in resuscitating and stabilizing the most critically ill newborns. Fellows work closely with the maternal-fetal medicine specialists in providing antenatal consultation to women with high-risk pregnancies. Mothers are transported from outside St. Louis to Parkview Tower by the maternal – fetal transport team. Fellows have many opportunities to plan for complex deliveries, consult with obstetricians and families and resuscitate neonates born at extremely preterm gestations with complex anomalies, or as part of multiple gestations.
The two-week cardiac intensive care unit rotation takes place in the SLCH CICU. This rotation provides fellows an excellent opportunity to learn the physiology of pre- and post-operative care of neonates with complex congenital heart disease on a team led by cardiac intensivists and cardiothoracic surgeons.
Fellows rotate with in Fetal Care Center, a multidisciplinary clinic providing antenatal care to mothers with fetal anomalies, and they develop expertise in antenatal counseling, resuscitation planning and coordination of multispecialty care. Fellows on the fetal care rotation develop expertise in fetal evaluation of and treatment for a variety of congenital anomalies. The two-week rotation allows fellows to participate in a multidisciplinary approach to counseling and care for families referred to the Fetal Care Center. During this two-week rotation, neonatal-perinatal medicine fellows participate in OB ultrasound clinic, Fetal Heart Center echocardiography, antenatal counseling, bimonthly conferences and any fetal procedures that may occur during the rotation.
The NICU follow-up clinic meets once every week and allows fellows to provide ongoing care of infants after discharge from the NICU. The clinic provides an opportunity to evaluate NICU graduates for growth, neurodevelopmental progress and impairment, provide appropriate intervention and counsel families about ongoing and new medical problems. Fellows attend clinic 1-2 times per month when they are not on clinical service. We offer three specialty follow-up clinics in which second and third year fellows can participate: neonatal opiod withdrawl syndrome, congenital heart disease and congenital diaphragmatic hernia.
Fellows in their third year have the opportunity to utilize their accumulated clinical knowledge, teaching and leadership skills in the pre-attending rotation, where they spend two weeks in the NICU serving in an attending role. The fellow leads rounds, coordinates the team, makes decisions and documents in the medical record with NICU faculty clinical supervision.