Fourth stage of labor

Prepared by: Mr,s Raheegeh Awni

04/19/23

Fourth Stage

• Lasts from delivery of the placenta until the postpartum condition of the woman has become stabilized (usually 1-2 hours after delivery).

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uterus

• Return of uterus to nonpregnant state is known as Involution process.

• This process begins immediately after expulsion of placenta.

• At the end of the third stage, the uterus in midline approximately 2 cm below the level of umbilicus.

• At this time, the uterus weights about 1000 gm

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lochia

• Vsoconstriction in the overall blood supply to the uterus results in tissue deoxygenation and a state of ischemia arise.

• Coagulation takes place through platelet aggregation and the release of fibrinogen and fibrin.

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lochia

• Is a latin word.• Three phases of lochia.• Lochia rubra is the first discharge, red in color

because of the large amount of blood it contains.

• It typically lasts no longer than 3 to 5 days after birth.

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• Lochia serosa: lochia which has thinned and turned brownish or pink in color. It contains serous exudate, erythrocytes, leukocytes, and cervical mucus.

• This stage continues until around the tenth day after delivery.

Lochia alba: lochia once it has turned whitish or yellowish-white. It typically lasts from the second through the third to sixth week after delivery. It contains fewer red blood cells and is mainly made up of leukocytes, epithelial cells, cholesterol, fat, and mucus.

Preventing Hemorrhage

• Ensure accurate measurement of intake and output maintained throughout labor and delivery.

• Immediately after delivery of the placenta, administer oxytocin (Pitocin 10 to 40 units/L at 100 mU/min) either I.V. piggyback or I.M. as directed by facility policy and provider.

• Infuse as bolus initially, then titrate to uterus (ie, if uterus is firm, decrease the infusion; if boggy, leave as bolus).

• Pitocin should never be administered I.V. push as it can cause cardiac dysrhythmia and death.

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• Immediately after initiating Pitocin, massage uterine fundus until firm.

• Uterine massage is done with two hands, one anchored at the lower uterine segment above the symphysis pubis and the other hand gently massages the fundus.

• Check to see that the placenta and membranes are complete.

• Evaluate and massage the uterine fundus until firm.• Evaluate vaginal bleeding. If bleeding continuously

and uterus is boggy, prepare Methergine I.M. (0.2 mg every 2 to 4 hours), Hemabate (Prostaglandin F2 Alpha) I.M. (0.25 mg I.M. every 15 to 90 minutes ≤ 8 doses), Dinoprostone (Prostin E2) 20 mg per rectum (PR), or Misoprostol (Cytotec) 400 to 1,000 mcg PR.– Increase I.V. fluids.– Monitor vital signs, especially pulse and blood

pressure.

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IMMEDIATE CARE OF THE NEONATE

• Nursing Diagnoses• Ineffective Airway Clearance related to nasal

and oral secretions from delivery• Ineffective Thermoregulation related to

environment and immature ability for adaptation

• Risk for Injury related to immaturity

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Promoting Thermoregulation

• Dry the neonate immediately after delivery, remove wet towels, and place infant on warm dry towels.

• A wet, small neonate loses up to 200 cal/kg/min in the delivery room through evaporation, convection, conduction, and radiation.

• Drying the infant cuts this heat loss in half.• Cover the neonate's head with a cotton stocking cap

to prevent heat loss.• Wrap the neonate in warm blankets.

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• Place the neonate under a radiant heat warmer, or place the neonate on the mother's abdomen with skin-to-skin contact.

• Provide a warm, draft-free environment for the neonate.

• Take the neonate's axillary temperature: a normal temperature is between(36.4 and 37.2° C).

Preventing Injury and Infection

• Administer prophylactic treatment against ophthalmia neonatorum (gonorrheal or chlamydial).

– Treatment may be with of sterile ointment of tetracycline (1%) or erythromycin (0.5%) ophthalmic ointment or ophthalmic solution of povidone-iodine (2.5%).

– This treatment can be delayed up to 1 hour after birth and usually delayed until after the first breast-feeding.

– If the mother has a positive gonococcal or chlamydial culture, the neonate will require further treatment.

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– Treatment is mandatory in all states.• Administer a single parental prophylactic

injection of vitamin K within 1 hour of birth.– This is done to prevent a vitamin K-dependent

hemorrhagic disease of the neonate.– If the parents do not want the vitamin K

administered, inform the parents that circumcision may not be performed. –However, inform parents that the Vitamin K

levels will reach their peak (without neonatal injection) at 8 days after birth.

identification bracelets

• While in the delivery room (DR), place identical identification bracelets on the mother and the neonate. The nurse in the DR should be responsible for preparing and securely fastening the bands on the neonate.– Information includes the mother's name,

hospital/admission number, neonate's sex, race, and date and time of birth and other information specified in your facility's policy.

– The father or significant other may also wear a bracelet matching the mother's.

– Footprinting and fingerprinting the neonate are not adequate methods of patient identification.

– Complete all identification procedures before the infant is taken from the delivery room.

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• Weigh and measure the infant shortly after birth.– Normal neonate weight is 6 to 9 lb (2,700 to 4,000 g).– Normal neonate length is 19 to 21 inches (48 to 53 cm).

• No later than 2 hours after birth, nursery/mother-baby personnel should evaluate the neonate's status and assess risks.

• Administer hepatitis B vaccine according to your facility's policy.– Vaccination of all infants born in the United States is

recommended regardless of mother's hepatitis status. If the mother's HBsAg status is negative, the vaccine is given at birth (before discharge) to age 2 months and then again at 1 to 2 months after the initial dose with the

– If mother is hepatitis B positive, infant will receive hepatitis B immunoglobulin (HBIG) and the HBV vaccine at birth to within 12 hours.

– Additionally, infants of hepatitis-positive mothers will receive HBV at age 1 to 2 months and age 6 months.

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– Neonates born to nonscreened mothers will receive the HBV at birth within 12 hours of birth.

– If the mother later proves to be hepatitis B positive, the neonate will also receive HBIG (0.5 ml) I.M. as soon as possible, but no later than 1 week after birth.

– The infant will also receive HBV at 1 to 2 months and another injection at 6 to 18 months.

• Evaluation: Expected Outcomes• Neonate transitions appropriately as

evidenced by Apgar score between 7 and 10• Temperature remains between (36.4 and 37.2

C)• Identification bracelets on neonate and initial

neonate care complete

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Nursing Diagnoses

• Risk for Injury related to uterine atony and hemorrhage

• Deficient Fluid Volume related to decreased oral intake, bleeding, and diaphoresis

• Acute Pain related to tissue trauma and birth process, intensified by fatigue

• Impaired Urinary Elimination related to epidural or spinal anesthesia and tissue trauma

• Disturbed Sensory Perception (tactile) related to effects of regional anesthesia

• Risk for Impaired Parenting related to inexperience

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• Promoting Uterine Contraction and Controlling Bleeding

• Monitor blood pressure, pulse, and respirations every 15 minutes for 1 hour, then every ½ hour to 1 hour until stable or transferred to the postpartum unit.

• Vital signs are taken more frequently if complications encountered.

• Take temperature every 4 hours unless elevated, then every 1 to 2 hours.

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• Evaluate the following at the time vital signs are taken initially then every 4 hours or more frequently as indicated for 12 to 24 hours or according to your facility's policy:– Uterine fundal tone, height, and position. – The uterus should be firm around the level of the

umbilicus, at the midline. If deviated to the side (usually the right side), it is indicative of a full bladder; have the mother empty her bladder and the uterus should return to midline.

– Amount of vaginal bleeding.

• Scant blood: only on tissue when wiped or less than 1-inch (2.5-cm) stain on perineal pad within 1 hour.• Small/light: less than 4-inch (10-cm) stain on perineal

pad within 1 hour.• Moderate: less than 6-inch (15.2-cm) stain on perineal

pad within 1 hour.• Heavy: saturated perineal pad within 1 hour.

– Perineum for edema, discoloration, bleeding, or hematoma formation.

– Episiotomy for intactness and bleeding.

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• Maintaining Fluid Volume• Maintain I.V. fluids as indicated.• Provide oral fluids and a snack or meal as

tolerated.• Encourage drink and food before assisting the

woman out of bed.

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Relieving Discomfort and Fatigue

• Apply a covered ice pack to the perineum during the first 24 hours for an episiotomy, perineal laceration, or edema.

• Administer analgesics as indicated.• Assure that epidural catheter has been removed.• Assist the woman in finding comfortable positions.• Assist the woman with a partial bath and perineal care, and

change linens and pads as necessary.• Allow for privacy and rest periods between postpartum

checks.• Provide warm blankets, and reassure the woman that

tremors are common during this period.

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Encouraging Bladder Emptying

• Evaluate the bladder for distention.• Encourage the woman to void.

– Provide adequate time and privacy.

– The sound from a running faucet may stimulate voiding.

– Gently squirting tepid water against the perineum in a perineal bottle may help.

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• Catheterize the woman (in and out) if the bladder is full and she is unable to void.

– Birth trauma, anesthesia, and pain from lacerations and episiotomy may reduce or alter the voiding reflex.

– Bladder distention may displace the uterus upward and to the side.

Assessing return of sensation

• Evaluate mobility and sensation of the lower extremities.

• Evaluate vital signs.• Remain with the woman, and assist her out of bed

for the first time. • Evaluate her ability to support her weight and

ambulate.• Do not provide hot fluids if sensation is decreased.

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Promoting Parenting

• Show the neonate to the mother and father or support person immediately after birth when possible.

• Encourage the mother and father to hold the infant as soon as possible.

• Teach the mother or parents to hold the neonate close to their faces, about 8 to 12 inches (20.5 to 30.5 cm), when talking to the baby.

• Have the mother or parents look at and inspect the infant's body to familiarize themselves with their child.

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• Assist the mother with breast-feeding during the first 30 minutes, then 2 hours, after birth.

• This is typically a period of quiet alert time for the neonate, and he or she will usually take to the breast.

• Provide quiet alone time in a low-lighted room for the family to become acquainted.

• Observe and record the reaction of the mother or parents to the neonate.

Evaluation: Expected Outcomes

• Vital signs remain stable, • vaginal bleeding remains light to moderate,• uterus remains firm at the midline• Tolerates fluids well after delivery• Verbalizes decreased perineal pain and feeling more

rested• Voids greater than 100 mL within 6 hours of delivery• Ambulates without problems• Interacts with the neonate

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documentation

• Demographic data• LMP• EDD• GA• TYPE OF DELIVERY• NEW BORN INFORMATION• sex, weight, A/S, vaccination • V/S

• Perineal tear• Epsiotomy type, suture type, local infiltration• Type of pain relief• Stages of labor• ROM,liqour, augmentation, induction of labor• Birth attendant• Birth certificate• Vaccination card

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