Management of 4th stage of labour

Blessy solomon

LABOUR
DEFINITION A series of event that take place in the genital organ in an effort to expell the viable products of conception out of the womb through the vagina into the outer world is called as labour.

STAGES OF LABOUR

FIRST STAGE OF LABOUR(cervical

stage)
It starts with the onset of true labour pain and ends with full dilation of cervix.

Second stage of labour

It starts with full dilatation of cervix and ends with the expulsion of the fetus from the birth canal.

Third stage of labour

It begins after the expulsion of the fetus and ends with expulsion of placenta.

FOURTH STAGE OF LABOUR

Fourth stage labour

This is the period from the delivery of the afterbirth to the time when the woman is examined and then transferred to her room. It is the stage of observartion for atleast one two hour after expulsion of the afterbirth.

ASSESSMENTS

what to assess ?
INITIAL ASSESSMENTS VITAL SIGNS PAIN LOCATION AND FIRMNESS OF THE FUNDUS AMOUNT AND COLOUR OF LOCHIA PERINIUM INTRAVENOUS INFUSION URINARY OUTPUT

VITAL SIGNS
BLOOD PRESSURE HYPERTENSION (BP >140/90mmHg)indicates PREECLAMPSIA HYPOTENSION may indicate DEHYDRATION or HYPOVOLEMIA

PULSE TACHYCARDIA may indicate PAIN,ANXIETY,DEHYDRATION, HYPOVOLEMIA, ANEMIA or INFECTION. RESPIRATION CHECK for abnormal breath sounds in high risk cases.

TEMPERATURE TEMPERATURE more than 38 degree celsius is normal during 1st 24 hrs.

PAIN
ASSESS THE TYPE,LOCATION AND INTENSITY OF PAIN. LOOK FOR SIGNS OF DISCOMFORT

FUNDUS
The fundus remains firm and at or near the umbilical level.. A boggy uterus many indicate uterine atony or retained placental fragments. Boggy refers to being inadequately contracted and having a spongy rather than firm feeling.

LOCHIA
Excessive Lochia in presence of contracted uterus indicates laceration of birth canal. A constant trickle,dribble or oozing of lochia indicates excessive bleeding.

perinium
The acronym REEDA is used as a reminder to assess the episiotomy or a perineal site. R-redness E-edema E-ecchymosis D-discharge A-approximation

Urinary output
Look for bladder distention as the mother usually dont feel the urge to void.

Intravenous infusion
Type of fluid rate of fluid administration Type and amount of medication added. Patency of IV lines.

Neonatal observation

Apgar score
Assessment Heart rate Respiratory rate Muscle tone Reflex response Color 0 absent No repiration limp No response Pallor 1 <100bpm slow Minimal flexion grimace Bluish hand &feet 2 >100bpm spontaneous Flexed bodily posture Responds properly Pink

 Taken at 1 and 5 minutes after birth Heart rate, Respiratory rate, and Color are used as the basis for resuscitation need Totals: 0-2 = severe distress 3-6 = moderate distress 7-10 = minimal distress

Vital Signs and General Measurements

 General Appearance Well-flexed, full range of motion, spontaneous movement

General Measurements
Head Circumference - 33 to 35 cm Chest circumference - 30.5 to 33 cm

Skin
Skin reddish in color, smooth and puffy at birth Turgor good with quick recoil Vernix caseosa - The white, cheesy substance covering the newborn's body. Lanugo - Fine downy body hair

other findings
ACROCYANOSIS The result of sluggish peripheral circulation.

PHYSIOLOGICAL JAUNDICE

Head
Anterior fontanel diamond shaped 2-3 3-4 cms Posterior fontanel triangular 0.5 - 1 cm Fontanels soft, firm and flat Sutures palpable with small separation between each

Eyes
Slate gray , BLACK,BROWNor blue eye color No tears Fixation at times - with ability to follow objects to midline Blink reflex Distinct eyebrows Cornea bright and shiny Pupils equal and reactive to light

Ears
Loud noise elicits Startle Reflex Flexible pinna with cartilage present Pinna top on horizontal line with outer canthus of eye

Nose
Expected findings: Nostrils patent bilaterally Obligate nose breathers No nasal discharge

Mouth and Throat

Expected findings: Uvula midline Minimal or absent salivation Tongue moves freely and does not protrude Well developed fat pads bilateral cheeks

Neck
Expected findings: Short and thick Turns easily side to side Clavicles intact Some head control

Chest
Expected findings: Evident xiphoid process Equal anteroposterior and lateral diameter Bilateral synchronous chest movement Symmetrical nipples

Abdomen
Expected findings: Dome-shaped abdomen Abdominal respirations Soft to palpation Well formed umbilical cord Three vessels in cord Cord dry at base

 Liver papable 2 - 3 cms below right costal margin Bowel sounds auscultated within two hours of birth Voiding within 24 hours of birth Meconium within 24 - 48 hours of birth

Female Genitalia
Expected findings: Edematous labia and clitoris Labia majora are larger and surrounding labia minora Vernix between labia

Male Genitalia
Expected findings: Urinary meatus at tip of glans penis Palpable testes in scrotum Large, edematous, pendulous scrotum, with rugae Smegma beneath prepuce Stream adequate on voiding

Extremities
Expected findings: Maintains posture of flexion Equal and bilateral movement and tone Full range of motion all joints Ten fingers and ten toes Grasp reflex present Legs appear bowed Palmar creases present

reflexes

Sucking reflex

Crawling reflex

 BABINSKIS REFLEX

 GRASPING REFLEX

ROOTING REFLEX

 GALANTS REFLEX

 Moros reflex

Nursing management
Transfer the patient from the delivery table. Remove the drapes and soiled linen. Assist the patient to move from the table to the bed. Provide care of the perineum. An ice pack may be applied to the perineum to reduce swelling from episiotomy . Apply a clean perineal pad between the legs

 Monitor the patient's vital signs and general condition. Take BP, P, and R every 15 minutes for an hour, then every 30 minutes for an hour, and then every hour as long as the patient is stable

 Document thick, foul-smelling lochia. Document lochia flow when the fundus is massaged Observe for uterine atony or hemorrhage. Observe for any untoward effects from anesthesia. Orient the patient to the surroundings (bathroom, call bell, lights, etc.). Allow the patient time to rest.

Encourage the patient to drink fluids. Observe patient's urinary bladder for distention. Bulging of the lower abdomen .

Full bladders may actually cause postpartum hemorrhage because it prevents the uterus from contracting Ambulate the patient to the bathroom. Urine output less than 300cc on initial void after delivery may suggest urinary retention.

 Evaluate the perineal area for signs of develop edema Apply an ice pack to the perineum decrease the amount of developing edema. Stress the importance of perineal-care and use of "sitz-baths Assessment for perineal hematoma. Look for discoloration of the perineum. Listen for the patient's complaints or expression of severe perineal pain.

 Assess for ambulatory stability. The patient is at risk of fainting on initial ambulation after delivery due to hypovolemia from blood loss at delivery and hypoglycemia from prolonged nothing by mouth (NPO) status. The patient should be accompanied on the first ambulation and observed for stability.

 Carry out neonatal assessment Administer vit K inj Maintain warmth and initiate breast feeding.

ASSIGNMENT