Comprehensive Labor, Delivery & Infection Risks – Study Notes

Neonatal Complications of Maternal Diabetes

• Undiagnosed/poorly-controlled maternal diabetes → chronic fetal hyperglycemia in utero → abrupt cessation of high-glucose supply once cord is clamped.

  • Mechanism: placenta removed → no exogenous glucose → infant’s endogenous insulin keeps working → rapid fall in serum glucose.

  • Result: neonatal hypoglycemia (critical in first hrs of life).

  • Signs/risks: jitteriness, lethargy, poor feeding, apnea, seizures, respiratory distress (↓ energy to intercostals).

• Macrosomia ("big body")

  • High in-utero glucose stimulates fetal insulin (growth hormone-like) → 9–11 lb infants.

  • Birth trauma: shoulder dystocia, clavicle fractures, head/neck bruising, emergent C-section after failed passage.

• Post-delivery glucose protocol

  • ALL infants feed within 1 h of birth (breast or formula).

  • For diabetic/gestational-diabetic mothers:
    • Check BG 45 min after first feed.
    • For 24 h, check BG immediately before each feed.
    • ≥2–3 pre-feed BG < 40\,mg/dL → admit to NICU, start 10 % dextrose IV.

Maternal Heart Disease in Pregnancy

• Pregnancy stresses CV system: ↑ blood volume, ↑ clotting factors → ↑ workload & thrombosis risk.

• If heart cannot meet demand → congestive heart failure (CHF).

  • Fetal risk: ↓ placental perfusion.

• Classic CHF signs (know for exam!):

  • Persistent cough, crackles, orthopnea.

  • Fatigue/fainting on exertion.

  • Severe dependent or generalized pitting edema (NOT automatically pre-eclampsia; need proteinuria).

  • Palpitations; non-reassuring FHR patterns.

• Management

  • Refer to OB + cardiology.

  • Limit physical activity; beta-blocker of choice = labetalol (least fetal effect).

  • Anticoagulants, diuretics as indicated.

  • Vaginal delivery preferred (less infection/resp. risk) unless OB reason for C-section.

Anemia in Pregnancy

• ↓ O₂-carrying capacity → fatigue, pallor, SOB, palpitations, tachycardia.

• Four significant types

  1. Iron-deficiency (microcytic): treat with oral iron + vitamin C (orange juice ↑ absorption); avoid milk/antacids ≥2 h.

  2. Folic-acid deficiency: supplement pre-conception & during gestation.

  3. Sickle cell disease.

  4. Thalassemia.

• Iron therapy continues ≥3 mo after Hgb normalizes.

TORCH & Other Key Infections

• TORCH = Toxoplasmosis, Other, Rubella, Cytomegalovirus (CMV), Herpes (HSV).

Cytomegalovirus (CMV)

• Fetal effects: intellectual disability, seizures, blindness, deafness, petechiae, dental defects.

• No effective treatment; early infection → therapeutic abortion often discussed.

Rubella (German measles)

• Mild in adults; devastating in fetus (microcephaly, cataracts, deafness, heart defects, IUGR).

• Live-virus vaccine contra-indicated in pregnancy; avoid conception ≥1 mo post-vaccine.

Herpes Simplex Virus (HSV)

• Type I: oral cold sores; Type II: genital.

• Lifelong latency; active lesions contraindicate vaginal delivery.

  • Oral lesions at delivery: NO kissing newborn skin; family education.

  • Active genital lesions: elective C-section.

Hepatitis B

• Transmitted via blood, saliva, semen, breast milk; vertical & intrapartum.

• Newborn protocol: HBIG + first Hep-B vaccine dose within birth admission.

Sexually Transmitted Infections (syphilis, gonorrhea, chlamydia, trichomonas, condylomata)

• Screen early & near term; active infection → treat or schedule C-section.

HIV

• Crosses placenta (≈100 % transmission without treatment).

• Maternal ARVs during pregnancy; infant ARVs within 12 h of birth.

• Strict NO breast-feeding.

Toxoplasmosis

• Protozoan via cat feces & raw meat.

• Fetal effects: low birth weight, hepatosplenomegaly, jaundice, eye inflammation, neuro damage.

• Prevention: no litter boxes, gloves w/ raw meat.

Group B Streptococcus (GBS)

• ~40 % women colonized; asymptomatic for mother, lethal to neonate.

• Vaginal/rectal culture 35–37 wks.

  • Positive → IV penicillin q4 h in labor (cephalosporin/macrolide if PCN-allergic).

  • Refusal = reportable to Child Protective Services due to preventable risk.

Urinary Tract Infection (UTI)

• Hormonal changes, pelvic pressure predispose.

• Can trigger pre-term contractions; treat promptly.

Pre-Labor (“Premonitory”) Signs

• Fetal lung maturation & surfactant surge late term.

• Loose stools 24–48 h pre-labor.

• Nesting (energy spurt: cleaning, shopping).

• “Bloody show” – small pink/brown mucus plug loss (NOT heavy bleeding).

• Pelvic ligament softening; cervix softening/dilation; “lightening” (baby drops into pelvis).

• Braxton-Hicks vs. true labor:

  • BH cease with walking/rest/wine; true labor persists & intensifies.

The 4 P’s of Labor

1. Power – uterine contractions.

2. Passage – maternal bony pelvis & soft tissues.

3. Passenger – fetus (size, lie, presentation, attitude, position).

4. Psyche – maternal emotional state (pain relief can improve dilation).

Contraction Characteristics

• Frequency: start-to-start; ideal every 2–3 min.

• Duration: 45–60 s desirable for effective labor.

• Intensity (palpation, or monitor):
  • Mild = chin, Moderate = nose, Strong/Firm = forehead.

Cervical Assessment & Station

• Dilation: 0–10 cm; Effacement: 0–100 %.

• Station: relationship of presenting part to ischial spines.

  • 0 = level with spines; –1/–2/–3 above (negative → not imminent); +1/+2/+3 below (positive → imminent birth).

Fetal Position & Leopold’s Maneuvers (F-B-I-Head mnemonic)

1. Fundus (feel what’s at top).

2. Back (palpate smooth vs. small parts along sides).

3. Inlet (locate presenting part at pelvic brim).

4. Head (identify cephalic prominence to know flexion).

• Best positions: LOA, ROA (occiput anterior).

• Monitor transducer placed over fetal back for clean FHR.

Electronic Fetal Monitoring (EFM)

• Baseline FHR: 110\text{–}160\,bpm.

• Variability

  • Moderate = 6–25 bpm fluctuation (reassuring).

  • Marked or absent = non-reassuring.

• Accelerations = ≥15 bpm ↑ for ≥15 s → healthy.

• Decelerations (VEAL-CHOP):
  • Variable = Cord compression → reposition mother, O₂ 10 L mask.
  • Early = Head compression → benign, no action.
  • Acceleration = OK, often with movement.
  • Late = Placental insufficiency → O₂, IV fluid bolus, side-lie, call provider; prep OR.

Amniotic Membrane & Fluid Evaluation

• Spontaneous vs. Artificial Rupture of Membranes (AROM).

  • Priority after ANY ROM: auscultate FHR immediately.

• Tests for ruptured membranes

  • Fern test: dried fluid on slide → crystalline “ferns”.

  • Nitrazine paper: pH > 6 (turns blue) → likely amniotic fluid.

• Prolonged ROM ≥24 h ↑ infection risk for mother & neonate.

• Meconium-stained fluid (green) = fetal stress; anticipate neonatal airway management.

Stages & Phases of Labor

1. First Stage – onset of true labor → full dilation/effacement.

   • Latent: 0–3 cm; talkative, mild pain.

   • Active: 4–7 cm; ↑ pain, stronger contractions.

   • Transition: 7–10 cm; most intense, NV, “can’t do this.”

2. Second Stage – 10 cm → birth; pushing with contractions only.

3. Third Stage – birth → placental delivery (5–30 min).

4. Fourth Stage – first 2 h postpartum; highest PPH risk, fundal checks.

Pushing & Delivery Mechanics

• Begin ONLY at 10 cm/100 % effaced to prevent cervical edema.

• Use contraction cycle: deep breath, hold, bear down 6–8 s ×3 per contraction.

• Positions: dorsal lithotomy, side-lying, all-fours, squatting (opens pelvis by ≈1 cm).

Standard L&D Admission Orders

• Diet: clear liquids or light snacks (early labor only).

• Labs: CBC, VDRL, HIV, type & Rh, urinalysis.

• IV: LR maintenance (D5LR if diabetic & insulin-dependent).

• Continuous or intermittent EFM as per stage.

Pain Management & Special Considerations

• Cultural/individual variability.

• Analgesics (IV narcotics) avoided if birth expected <1 h (risk neonatal resp. depression).

• General anesthesia reserved for crash C-section; ketamine/ketorolac discussed as adjuncts.

• Non-pharm: breathing, position changes, hydrotherapy, partner support.

Ethical & Practical Implications

• Informed refusal of prophylaxis (e.g., GBS) has legal/CPS implications.

• Counseling on no-kissing newborn policy to prevent HSV.

• Public-health value of routine prenatal care: undiagnosed diabetes → universal NICU admission in observed practice.

These notes incorporate every substantive point, example, clinical pearl, and exam tip from the transcript, organized for rapid study and reference.