Name of the student Class Subject Topic Date Time Duration Group Place M method of teaching A.V.

AIDS

D.Reddamma : M.SC Nursing 1 year

; Obstetrics and gynecology nursing : Third and forth stages of labor : 18.04.2011 : 2pm to 4pm : 2 hours : Peer group : ; Lecturer cum discussion : flash cards :diet and vital signs Charts :management of third stage of labour

Power point:third stage of labour. HOD Supervised by : Mrs.Rafathrazia Professor , Principal : Mrs.sujatha Manjari , Lecturer

Student teacher objectives

     By the end of the seminar student will be able Introduce the topic from general specific D develop skills in organization of content Develop skills in explaining the content Acquire skills in selecting preparing and presenting appropriate A.V.AIDS

Behavioral objectives
By the end of the seminar the group will be able to gain in depth knowledge regarding management of third and fourth stage of labor

SPECIFIC

OBJECTIVES

 Introduce normal labor and stages of labor  Define third stage of labor and explain the mechanism of third stage of labor  Describe the two methods of expulsion of placenta and

mechanism of control bleeding  Assess the clinical course of third stage of labor

 Explain medical and nursing management of third stage of Labor  Enumerate complications of third management stage of labor and

and prevention of complications

 Define fourth stage of labor

 Discuss the management of fourth stage of labor and nursing management of fourth stage of labor  Research studies  Summary  Conclusion  Bibliography

INTRODUCTION

The first stage of labor usually starts with the onset of regular uterine contractions and culminates in the complete dilatation of the cervix .There are number of premonitory signs and symptoms that may alert a midwife to a women s approaching labor ,so that appropriate counseling ,guidance and care can be given

The second stage of labor begins with complete dilatation of the cervix and ends with birth complete dilatation of cervix and can be definitely confirmed only by vaginal examination .However the experienced nurse is often able to suspect complete dilatation by observing changes in the client behavior .These findings are correlated with parity the speed of any previous labor and the present labor and anticipated size of the new born.

During the third stage separation and expulsion of the placenta and membranes occur as the result of an inter play of an mechanical and haemostatic factors .This is a time when the activity and excitement accompanying the birth of the baby are replaced by the parents quiet and wondrous contemplation of their offspring

NORMAL LABOR (EUTOCIA);

Labor is called normal if it is fulfilling the following criteria: 1).Spontaneous is onset at term 2).With vertex presentation 3).Without under prolongation 4).Natural termination with minimal aids 5).Without having any complications affecting the health of the mother and for the baby DC Dutta (2004)

Normal labor occurs at term and is spontaneous is onset with the fetus presenting by the vertex the process is completed within 18 hours and no complications arise _Classidy 1999

STAGES OF LABOUR
Labor is divided into four stages FIRST S TAGE : It starts from the onset of true labor pain and ends with full dilatation of the cervix . It is in other words cervical stage of labor .Its average duration 12 hours in prime gravid and 6 hours in multi pare

SECOND STAGE: It starts from the full dilatation of the cervix not rupture of membranes and ends with expulsion of the fetus from the birth canal .It has got two phases y The propulsive phase; Starts from full dilatation up to the descent of the presenting part to the pelvic floor y The expulsive phase; Distinguished by maternal bearing down and ends with delivery of the baby . its average duration in 2 hours in prime gravid and 30 minutes in multi Para THIRD STAGE: . It begins after expulsion of the fetus and ends with expulsion of the placenta and membranes (after birth) .It average duration is about 15 minutes in both prime gravid and multi Para FOURTH STAGE; It is the stage of observation for at least one hour after expulsion of the placenta . During this period general condition of the patient and the behavior of the uterus are to be carefully watched

THIRD

STAGE OF LABOR
of

The third stage of labor begins upon completion The birth known as averages one hour

of the baby and ends with the birth of the placenta. It is the placental stage of labor .The third stage of labor between five and fifteen minutes but any period up to may be considered with in normal limits

Third stage of labor comprises the phases of placental separation ,its decent to the lower segment and finally its expulsion with the membranes.

MECHANISM

OF THIRD STAGE OF LABOR

The third stage of labor consists of two phases .The first phase is the placental separation and the second phase is that of placental expulsion. Both separation and expulsion brought about by contractions, which begin again after brief pause at birth. The contraction must have been approximately every 2 to 21/2 minutes a part during the second stage of labor. After birth of the baby ,the next contraction may not occur for 3 to 5 minutes until there has been separation and expulsion of the placenta and membranes .

PLACENTAL SEPARATION
Placental separation is the result of the abrupt decrease in size of uterine cavity during and following delivery of the baby , as the uterine cavity empties progressively ,the retraction process accelerates.

This decrease in uterine size necessarily means a concomitant decreases in the area of placental attachment .The placenta however remains the same size and at the site of attachment ,it is unable to withstand the stress and buckles. The result is a separation of the placenta from the uterine wall ,which takes place in the spongiosa layer of the deciduas. Separation usually begins at the center so that a retro placental clot is formed .This may further aid separation by exerting pressure at the midpoint of placental attachment so that the increased weight helps to strip the adherent lateral borders .This increased weight also helps to peel the membranes of the uterine wall. While the formation of the retro placental clot is the result rather than the cause of placental separation ,it does facilitate the completion of placental separation

Descent of the placenta

After the placenta has separated ,it descends into the lower uterine segment or into the upper vaginal vault ,causing the clinical signs of placental separation to become evident. These are as follows: 1) Sudden trickle or gush of blood. 2) Lengthening of the amount of the umbilical cord visible at the vaginal introitus 3) Change in the shape of the uterus from a discoid (circular) to globular ,as the uterus now contracts itself. 4) Change in the position of the uterus as it rises in the abdomen, because the bulk of the placenta is in the lower uterine segment or upper vaginal vault. .

METHODS OF EXPULSION OF PLACENTA

Placental expulsion begins with descent of the placenta into the lower uterine segment .It then passes through the cervix into the upper vaginal vault from where it is expelled .Expulsion of the placenta is by one of two mechanisms .

SCHULTZ METHOD
The Schultz mechanism of placental expulsion is delivery of the placenta with the fetal side presenting .This is brought to occur when separation begins centrally with corresponding formation of a central retro placental clot .which weights the placenta so the central portion descends first.  This in effects inverts the placenta and amniotic sac and causes the membranes to peel off the deciduas and trial behind the placenta.  The majority of the bleeding occurring with this mechanism of placental separation is not visualized until the placenta and membranes are delivered ,since the inverted membranes catch and hold the blood .This method is more common of the two.

MATTHEW ,S DUNCAN METHOD

The Duncan mechanism of placental expulsion is delivery of the placenta with the maternal side presenting .this is thought to occur when separation first takes place at the margin or periphery of the placenta .

 Blood escapes between the membranes and uterine wall and is visualized externally .The placenta descends side ways and the amniotic sac ,therefore , is not inverted but The trials behind the placenta for delivery.  The memory aid for correctly identifying the mechanisms of placental expulsion is based on the appearance of two different sides of the placenta .The fetal side is shiny and glistering , because it is covering the fetal membranes , while the maternal side is rough and red looking ,hence the saying shiny Schultz and dirty Duncan .

MECHANISM OF CONTROL OF BLEEDING

After placental separation innumerable torn sinuses which have free circulation of blood from uterine and ovarian vessels have to be obliterated . The occlusions is effected by complete retraction where by the arterioles .As they pass interlacing intermediate layer of the myometrium are literally clamped . y It is the principle mechanism to prevent bleeding ,however a phenomenon which is facilitated by a position of the walls of the uterus following expulsion of the placenta myotamponode also contributes to minimize blood loss .

CLIBICAL COURSE OF THIRD STAGE OF LABOR

y Third stage includes separation, descent and expulsion placenta with its membranes

of the

y Pains for a short time the patient experiences , no pain however intermittent discomfort in the lower abdomen re appears , corresponding with the uterine contractions.

BEFORE

SEPARATION

y Per abdomen; Uterus becomes discoid in shape firm in feel non ballot able ,fundal height reaches slightly below the umbilicus . y PER VAGINUM: There may be slight trickling of blood ,length of the umbilical card as visible from outside remain static.

AFTER

SEPARATION

y It starts about 5minute in conventional management for the placenta to separate per vaginum .There may be 1).Slight gush of vaginal bleeding . 2).Permanent lengthening of the cord

3).Per abdomen change in the shape of the uterus from a discoid (circular) to a globular ,as the uterus now contracts upon it self firm & ballot able. 4).Change in the position of the uterus as it raises in he abdomen ,because the bulk of the placenta is in the lower uterine segment or upper vaginal vault.

y Fundal height is slightly raised as the separated placenta comes down in the lower segment and the contracted uterus rest on to pot it.

EXPULSION

OF PLACENTA &MEMBRANES

y The expulsion is activated either by voluntary bearing down efforts or more commonly aided by manipulative procedure .The after birth delivery is soon followed by slight to moderate bleeding amounting to 100- 250 ml y Maternal sign ; There may be chills and occasional shivering slight transient hypotension is unusual.

MANAGE MENT OF THIRD STAGE OF LABOR

y This stage is most crucial stage of labor previously uneventful first and second stage can become abnormal with in a minute with disastrous consequences. y Care of the mother in the third stage of labor should be based on an understanding of the normal physiological processes at work. y Prompt nursing actions can reduce the risk of hemorrhage ,infection, retained placenta, and shock.

y Management of third stage can make considerable difference for blood loss by the mother. Mismanagement of third stage is the largest single cause of third stage hemorrhage

Scheme of management of third stage delivery of the baby

Clamp ,divide and ligate the cord

STEPS OF MANAGEMENT

Two methods of management

are currently in practice

y Expectant management y Active management

EXPECTANT MANAGEMENT
y This management In the placental separation and its descent into the vagina are allowed to occur spontaneously minimal assistance may be given for the placental expulsion if it needed. y Constant watch is mandatory and the patient should not be left alone y In the mother is delivered in the lateral position .she should be changed to dorsal position to note features 0f placental separation and to assess the amount of blood loss . y A hand is placed placed over the fundus. a).To recognize the signs of separation of placenta b).To note the state of uterine activity contraction& relaxation.

c).To detect through care cupping of the fundus which is an early evidence of inversion of the uterus desire to fiddle with the fundus or massage the uterus is strongly to be condemned .Placenta is separated with in minutes following the birth of the baby.

y A watchful expectancy can be extended up to 15-20 minutes .In some institutions no touch or hard off policy is employed .The patient is expected to expel the placenta with in 20mts with the aid of gravity.

EXPULSIOS OF THE

PLACENTA

Only when fetus of placental separation and its descent into the lower segment are confirmed, the patient is asked to bear down simultaneously with the hardening of the uterus the raised intra abdominal pressure is often adequate to expel the placenta ,if the patient fails to expel one can wait safely up to 10 minutes , if there is no bleeding ,as soon as placenta passes through the introits . It is gasped by hands and twisted round and round with gentle traction so the membranes are striped intact .if the membranes tract to tear ,they are cautch hold by sponging holding forceps and is similar twisting movements the rest of the membranes are delivered. Gentleness ,patience and care are prerequisites of the membranes . for complete delivery

If spontaneous expulsion fails or is not practicable because of delivery under anesthetics ,any one of the following methods can be used to expedite expulsion.

ASSISTED EXPULSION

Controlled card traction (modified brand Andrews method) the palmer surface of the fingers of the left hand is placed (above the symphysis pubis) approximately at the junction of the upper and lower uterine segment . The body of the uterus is pushed up words ,towards the umbilicus while by the right hand not too strong traction) is given down ward direction ,holding the clamp until the placenta introits and back wards steadily tension 9out and back ward comes outside the

If is thus more an uterine elevation which facilitates expulsion the placenta .the procedure is to be adopted only when the uterus is hard and contracted.

of

FUNDAL

PRESSURE

The fundus is pushed downwards and back wards after placing four fingers behind the fundus and thumb in front using the uterus as a sort of portion .The pressure must be given only when the uterus becomes hard. If it is not then make it hard by gentle rubbing the pressure is to be with drawn as soon as placenta passes through the introits .If body is maturated or premature this method is preferable to cord traction as the tensile strength of the cord is much reduced in both the instances. The cord may be accidently torn which is not likely to cause any problem. The sterile gloved hand should be introduced and the placenta is to be grasped and extracted .

THE UTERUS IS TO BE

MASSAGE

To make it hard which facilitates expulsion of retained clots if any inj: oxytocin (5-10units) i.v or methergine o.2mg is given ,intramuscular oxytocin is more stable and has lesser side effects (nausea and vomiting ,risk of BP)compared to ergometrine .

EXAMINATION OF THE

PLACENTA MEMBRANES AND CORD

The placenta is placed on tray and is washed out in running tap water to remove the blood clots .The surfaced is first inspected for its completion and anomalies .The maternal surfaced is covered with grayish deciduas (spongy layer of the deciduas basis). Normally the cotyledons are placed approximation any gap indicates a missing cotyledons .The membranes chorine and amnion are to be examined carefully for completion and presence of abnormal vessels indicate succenturiate lobe .The amnion is shiny but the chorion is shaggy . the cut end of the cord is inspected for number of blood vessels. Normally ,an oval running demands there are two umbilical arteries and one umbilical vein gap in the chorion with torn end of the blood vessels up to the margin of the gap indicates a missing membranes exploration of the uterus.

Vulva ,vagina, and perineum are inspected carefully for injuries and to be repaired if any .The episiotomy wound is now sutured .The vulva and adjoining part are cleaned with cotton swabs ,soaked in antiseptic solution .A sterile pad is placed over the vulva.

ASSESSMENT OF THE PLACENTA

y Any clot from maternal surface must be removed and kept for measuring .Broken fragments of cotyledons must be carefully replaced before an accurate assessment is done. y Infractions that are recent or old: These areas on the placental surface indicate deprivation of blood supply recent infractions appear bright red and old infractions are gray patches. y Localized calcifications : These are seen as a flattened white plaques that feel gritty ( as a small hard particles card) to the touch . y Lobes: The lobes of complete placenta fit neatly together without any gaps ,the edges forming a uniform circle. y Blood vessels: They should not radiate beyond the placental edge .If they do this denotes a succenturiate lobe ,if the lobes has been retained the vessel will be and abruptly at the hole in the membrane. y Insertion of the card :Normal insertion is normal ,lateral insertion insertion is abnormal y Umbilical vessels: Two umbilical arteries and one vein should be present. The absence of one artery may be associated with congenital abnormalities particularly renal agenesis.

y Card length : Average length is 50cm y Weight of the placenta: Approximately one sixth of the baby s weight.

DISPOSAL OF THE PLACENTA:

y It is an important that the placenta is the properly of the mothers and her wishes to regarding its disposal must be solicited and respected. y Disposal of burial is not recommended because of the risk of preying animals. y Up on completion of the examination the midwife should return her attention to the mothers.

ACTIVE MANAGEMENT OF THIRD STAGE

The underling principle is active management is to excite powerful uterine contractions following birth of anterior shoulder by prenateral oxytocin which facilitates but produces effective uterine contractions following its separation.

ADVANTAGES :
a).To minimize blood loss in third stage . b).To shorten the duration of third stage.

DISADVANTAGES :The disadvantage is increased

incidence of retained placenta (1-2%)and consequent increased incidence of manual removal of course,accidental administration during

delivery of the first baby is undiagnosed twins procedure grave danger to the unborn , second baby caused by asphyxia due to titanic contractions of uterus .Thus it is imperative to limits use in twins only during delivery of the second baby.

PROCEDURE

Inj:Ergometrine 0.25 mg or Inj: methergine:0.2 mg is given intravenously following birth of anterior shoulder .If administer prior to this ,there is chance of imprisonment of the shoulder behind the symphysis pubis .This is followed by slow delivery of the baby taking at least 2-3 minutes .The placenta is expected to be delivered following the delivery of the buttocks. If the placenta is not delivered instantaneously ,it should be delivered forth with bycontrolled cord traction technique after clamping the cord while the uterus still remains contracted .If first attempt fails another attempt is made after 2-3 minutes .If this is still fails removal is to be done. If the administration is miss time as might happened in a busy labour room .One should not be panickly but conduct the third stage with conventional watchful expectancy.

LIMITATIONS :
To be effective it should be administered in proper time followed by slow delivery of the baby and followed by rapid delivery of the placenta .Thus it may be an ideal procedure while conducting delivery in an equipped surrounding and the attached is conversant with the management .Even if

it is certainly of value hemorrhage

for cases

likely to develop post partum

These are cases .delivered vaginally under anesthesia ,anemia ,hydramnions ,twins and grad multi purpose and previous history of PPH. It should not be used in cardiac cases or severe pre eclampsia for fear of precipitating cardiac over load in the form or and aggravation of blood pressure in the latter.

FUNDAL HEIGHT DURING THE

THIRD STAGE

At the beginning of the third stage fundus is palpable below the umbilicus .If feels broad as the placenta is still in the upper segment .As the placenta separates and fall into the lower uterine segment ,there is a small fresh blood loss ,the cord lengthens and the fundus becomes rounder. Smaller and more mobile as it raises in the abdomen to the level of the umbilicus or just above the umbilicus .At the end of this stage following the expulsion of the placenta the fundus is about 4 cm below the umbilicus .

CARE OF MOTHER AND BABY :

Careful observation of mother and baby is very important Maternal comfort and safety :Some women feel cold and shiver which is transient warmth may be provided by covering with clean dry linen a blanket and a warm drink.

Care of the baby and mother : y The baby should be dried and kept warm with pre warmed linen. y The baby can be cuddled by the mother. y Initiate breast feeding as early as possible. y Observe general skin colour ,respirations ,and temperature. y The mother should receive cleaning body wash ,mouth wash and perineal care .She should be encouraged to empty her bladder and a bed pan offered .Blood pressure ,uterine contractions and bleeding should be checked every 15 minutes. y The baby s general wellbeing and security of the card clamp needs to be checked .As the baby will quickly chill after birth it is important to thoroughly dry and wrap the baby in a clean dry towel or blanket .A full neonatal examination is done at any early stage and baby is kept in a warm crib or cuddled close to the mother. y Mother intending to breast feed may be encouraged to put their babies to the beast during early contact .Babies are usually alert and their sucking reflex strong at this time .For the mother early breast feeding causes a reflex release of oxytocine from the posterior lobe of the pituitary gland that stimulates the uterus to contract. The mother may experience a sudden fresh blood loss as the uterus empties and she should be reassured.

COMPLICATIONS OF THIRD STAGE

POST PARTUM HEMORRHAGE

Post partum hemorrhage is defined as excessive bleeding from the genital tract at any time following baby birth to six weeks after delivery .If it occurs during the third stage of labour or with in 24 hours of delivery it is termed as primary post partum hemorrhage.

If bleeding occurs subsequently to the first 24 hours following birth until sixth week post partum it is termed as secondary post partum hemorrhage.

PRIMARY POST PARTUM HEMORRHAGE

During the first hour or two after birth when blood loss is excessive it is difficulty to measure it accurately especially when the fluid has soaked into dressings and linen. The measurable solidified clots only represent about half the fluid loss .If measured blood loss reaches 500 ml . If it is treated as post partum hemorrhage and another yardstick maternal condition and states that any blood loss ,however small which adversely affects the mother condition constitutes a post partum hemorrhage causes of primary post partum hemorrhage are atonic uterus ,retained placenta ,trauma and coagulation disorder.

ATONIC UTERUS

This is a failure of the myometrium at the placental site to contract and retract and to compress torn blood vessels and control blood loss by a living ligature action .The volume of blood flow at the placental site ,when the placenta is attached approximately 500-800 ml per minute up on separation the efficient contraction and retraction of the uterine muscles stops the flow of blood and prevents hemorrhage.

Factors that interfere with this phenomenon and cause bleeding are listed below:

1. Incomplete placental separation :If placental tissue remains partially embedded in the spongy deciduas efficient contraction and retraction are interrupted .If the placenta remains fully adherent to the uterine wall it is unlikely causing bleeding once separation has begun maternal vessels are torn open. 2. Retained cotyledons placental fragments or membranes. 3. Precipitate labour 4. Uterine inertia due to prolonged labour . 5. Uterine over distension due to polyhydramnios ,multiple pregnancy or large baby 6. Placenta previa ; The placental site is partially or wholly in the lower uterine segment .Where the muscle layer contains few oblique fibers .This results in poor control of bleeding 7. Mismanagement of third stage of labour .A full bladder may interfere with uterine action this is also considered as mismanagement.

8. Grand multiparty 9. Uterine fibroids: These may impede efficient uterine contraction 10. Anemia :Woman who enter labour with reduced hemoglobin concentration are more prone to bleed more. 11. Abruptio placenta. 12. Traumatic condition :These includes perineal tears , vaginal tears, cervical tears ,lower segment tears , and uterine rupture. 13. Previous history of post partum hemorrhage or retained placenta. 14. Coagulopathy:Conditions such as disseminated intravascular coagulation ,excessive fibrinolysis inherited coagulation disorders and idiopathic thrombocytopenic purpura.

CLINICAL FEATURES

Visible bleeding per vagina Enlarged uterus Pallor Rising pulse rate Falling blood pressure Altered level of consciousness may become restlessness or drowsy y Metabolic acidosis and shock y y y y y y

PROPHY LAXIS
1. Women who are identified as having risk factors should be instructed to have delivery in a unit where facilities for dealing with emergencies are available. 2. Anemia should be corrected and detected 3. During labour good management practices should be followed to prevent prolonged labour and keto acidosis 4. A women should not enter the second or third stage of labour with a full bladder. 5. Prophylactic administration of oxtocic agents is administered . 6. Two units of cross matched blood should be kept available for any women known to have a placentaprevia.

MANAGEMENT OF POST PARTUM HEMORRHAGE

Primary post partum hemorrhage is an emergency which requires prompt and efficient management .As soon as midwife recognizes the occurrence .She must call he physician. She must call the physician.

1. STOP BLEEDING: Feel the fundus with the finger tips if it is soft and relaxed (atonic)massage the fundus with a smooth circular motion to make it contract .when contraction occurs the hand is to be held still.

2. GIVE OXYTOCIC TO SUSTAIN THE CONTRACTIONS: In many cases syntocinon 10 units must have already been administered and this may be repeated .Alternatively ergometrine o.25-o.5mg may be given intravenously which will be effective in 45 seconds. 3. RESUSCITATE THE MOTHER: An intravenous line must be commenced while peripheral veins are easily negotiated fluid replacement and administration of oxytocin are done. Ringer lactate and blood may be administrated. 4. EMPTY THE UTERUS: Once midwife is satisfied that the uterus is well contracted .She should ensure that it is emptied .With firm gentle pressure on the fundus expel the residual clots.If placenta is still in the uterus it should be delivered by applying supra pubic pressure and controlled cord traction . If this fails placenta is removed manually. 5. BIMANNUAL COMPRESSION: If bleeding continues bimanual bi - manual compression of the uterus may be necessary in order to apply pressure to the placental site . The left hand is placed behind the uterus abdominally the fingers pointing towards the cervix. The uterus is brought forwards and compressed between the palm of the left hand and the fist in the vagina.

6. REMOVAL OF THE RETAINED PLACENTA: If the placenta is retained by a constriction ring it is removed manually after relaxing the ring with general anesthesia .placenta acreta ,increta, and precreta requires total abdominal hystectomy. 7. GENITAL TRACT INJURIES AND TRAUMA:

If bleeding continuous despite a well contracted uterus it may be due to trauma .In order to identify the source of bleeding .The mother placed in a lithotomy position under good directional light .Any torn vessel identified must be clamped and ligated . No evidence of trauma can be found and uterine rupture must be suspected.This needs repair following laporatomy or hysterectomy. 8. BLLOD COAGULATION DISORDER: Post partum hemorrhage may be result of coagulation failure .It can occur severe pre eclampsia ,ante partum hemorrhage. Amniotic fluid embolism ,intra uterine death or sepsis. Transfusion of fresh blood are usually the best treatment as thi will contain platelets and coagulation factor .fresh frozen plasma and fibrinogen are also transfused. 9. Pulse and blood pressure must be recorded every 15-30 minutes and temperature every 4 hours. y The uterus must be palpated frequently to ensure that remains well contracted. y Intravenous fluid replacement must be carefully monitoring of central venous pressure ,fluid intake and out put are

done hourly and recorded .care full observation will be required for 24-48 hours.

SECONDARY POST PARTUM HEMORRHAGE

Secondary post partum hemorrhage is bleeding from genital tract more than 2 4 hours after delivery of the placenta and may occur between up to 6weeks later .It is most likely occur between 10 to 14 days after delivery .Bleeding is usually due to retentions of fragments of the placenta or membranes or the pressure of blood clots .sub involution and infection. CLINICAL MANIFESTATIONS: y The lochia are heavier than normal and recurrence of bright red flow. y Offensive lochia if infection is a contributory factor y Sub involution of uterus. y Pyrexia and tachycardia. MANAGEMENT Massage the uterus if it is still palpable to bright out a contraction Express any clots Encourage the mother to empty her bladder. Give oxytocic drug such as ergometrine iv or im. Save all pads and linen to assess the volume of blood loss. If retained products of conception and are not seen on an ultra sound scan ,the mother may be treated consesvatively with antibiotic therapy and oral ergometrine. y Anemia is treat with iron supplements ,severe cases blood is transfused. y y y y y y

HEMATOMA FORMATION
Post partum hemorrhage may also be concealed because of hematoma formation these form at sites such as the perineum ,lower vagina the blood ligament or vault of the vagina a large volume of blood up to 1 liter may collect insidiously y Involution of the uterus and lochia are usually normal . y The main symptom is increasingly severe pain y The hematoma has to be drained in the operating room under general anesthesia .Secondary infection is a high possibility and broad spectrum antibiotics are generally administered.

MANAGEMENT OF FOURTH STAGE OF LABOUR

FOURTH STAGE: The fourth stage of labor begins with birth of the placenta and ends with one hour later.This stages marks the completion of the tasks associated with the three stage of labour .The mother may expression of relief and accomplishment ,intermingled with excitement.

EVALUATION AND INSPECTION

The first post partal hour is a critical time of initial recovery from the stress of labour and delivery and requires close observation of the mother .The activities may include the following: y Evaluation of the uterus y Inspection and evaluation of the perineum ,vagina ,and cervix. y Inspection and evaluation of the placenta ,membranes and umbilical cord. y Repair of episiotomy and laceration ,if any. EVALUATION OF THE UTERUS y After delivery of the placenta ,the uterus is normally found in the midline of the abdomen approximately two third to three fourth of the way up between the symphysis pubis and umbilicus . y A uterus is found above the umbilicus is indicative of blood clots inside ,which needs to be expressed and expelled.A uterus is found above the umbilicus and to one side usually the right side indicates a full bladder , the bladder must be emptied .Afull bladder displaces the uterus from its position and prevents its contracting. y The uterus should firm to touch a soft boggy uterus is hypotonic uterus .not contracting and post partum hemorrhage may occur.

HEMOSTASIS Uterine homeostasis occur as a result of interplay of certain physiological processes. y Retraction of oblique uterine muscle fibers in the upper uterine segment through which the tortuous blood vessels intertwine . y When contracted the entwining muscle fibers in the myometrium serve as a ligatures to the open blood vessels at the placental site and bleedind is controlled is the absence of oblique fibers in the lower uterine segment that contributes to increased blood loss following placental separation in placenta previa. y The vigorous uterine contractions that occurs following separation of the placenta brings the walls into apposition exerting further pressure on the placental site. y The third mechanism that contributes to the achievement of hemostasis is the transitory activation of the coagulation and fibrinolytic system during and immediately following placental separation .This protective responsive is especially active at the placental site so that clot formation in torn vessels is intensified. INSPCETION OF THE CERVIX AND UPPER VAGINAL VAULT The cervix and upper vaginal vault must be inspected in the presence of any following indications. y The uterus is well contracted but there continues to be a steady trickle or flow of blood from the vagina. y The mother was pushing prior to complete dilatation of the vagina. y The labour and delivery were rapid and precipitous y There was maniputation of the cervix during labour ,such as manually pushing back an edematous anterior lip of the cervix . y Traumatic procedures were necessary such as forceps application .

y Traumatic second stage of delivery such as prolonged shoulder dystocia or large baby. y Following normal spontaneous vaginal deliveries if none of this indications is present ,it is not necessary to do a cervical and upper vaginal vault inspection REPAIRS y The repair of any lacerations or an episiotomy is done after the examination of the placenta and membranes .Inspection and evaluation of the placenta ,membranes and umbilical cord are done before repairing any lacerations or an episiotomy . PERINEAL CLEANING AND POSITION OF LEGS y After the episiotomy or lacerations repair the midwife has to see or watch for uterus consistency watch for effect of uterine massage on the amount of vaginal blood flow express any blood clots y Wash of the entire perineal area including perineum vulva,inner thighs buttocks and the rectal areas . y Perineal pad placed against the perineum.If the women is still in lithotomy position if one leg is up or one leg is down the mother may get back strain .So keep both legs in resting position ,tis stimulates circulation of the legs and makes the transition of position less abrupt and more comfortable. VITAL SIGNS The mother blood pressure ,pulse and respirations are evaluated every 15 minutes until stable at pre labour levels.

y The temperature is taken at least once during the fourth stage of labour .The temperature continues to be elevated normal being less than 2f increases or below 100.4(38c) y In assessing the blood pressure and pulse rate it must be remembered that ,the excitement after delivery may cause an elevation in some mothers .Injection of oxytocic drugs may also cause some women to experience elevated blood pressure and pulse rate. PALPATION OF THE FUNDUS OF UTERUS FOR CONTRACTIBILITY The fundus of the uterus is palpated by placing the side of one hand on top of and slightly cupped above the fundus .while the other hand is placed supra pubically with the exertion of slight pressure ideally ,the fundus should lie on the mid plane of the pelvis at or below the umbilicus. MEASUREMENT OF THE FUNDUS A measurement of the height of the fundus is taken after the fundus is expressed ,measuring from the top of the fundus to the umbilicus using finger breadths .the fundus of the uterus tends to lie closer to the umbilicus in mother who are multiparas. INSPECTION OF PERINEUM While inspecting the perineal area during the post partum check the nurse have to observe swelling or echymosis this is an indicative of the formation of a perineal or vaginal haematoma. INSPECTION OF THE BLADDER The bladder must be evaluated and emptied the utreus. if it is full and displacing

I n the event that the bladder is filling or full a bladder bulge will be evident.it feels and appears as a spongy fluid filled marks below the uterus and above the symphysis pubis CONTINUING CARE AND MONITORING Through out the remainder of the fourth stage of labour the mother vital signs ,bladder ,lochia,and perineum are monitored and evaluated. INSPECTION AND CHANGE IN PERINEAL PAD y It is not necessary to perform any particular type of perineal care during the first hour post partum except to keep the area as clean and dry as possible. y Regular change of perineal pad and lies under buttocks is required in order to keep the lochia from becoming dry and adhering to mothers baby. y It is necessary to wash perineal area and buttocks with mild soap and water to remove lochia not absorbed by the perineal pa. y When checking perineal pad for lochia the mother is rolled on her side so that the midwife can better determine the lochia. y The colour(lochia rubra) amount ,odour, presence of clots and number of pads. FLUIDS AND FOOD y Any previous nausea and vomiting should have subsided and the mother feel thirsty .So encouraged to take water juices and tea or coffee with sugar. y After stabilize condition ,solid foods also can take and encouraged to eat small amount first and to eat slowly. y Allow warm fluids by mouth unless contraindicated.

COMFORT MEASURES Comfort measures should be supplied include warm blankets ,gown. RECORDS AND REPORTS y A complete and accurate documentation of all observation is the responsibility of the midwife.the records should include. y Progress of the labour. y Duration of labour. y Drug administration. y Reason for episitomy, type of episiotomy. y Perineal repair y Date and time of delivery. y Type of delivery y Sex ,weight condition and apgar of the baby.This should include details of examination of the placenta ,membranes and cord ,with attention drawn to any abnormalities. y The volume of blood loss is particularly important y Condition of mother y Presence of any complication with mother and baby. y It is usually the midwife who completes the birth notification form ,this must be sent with in 36 hours to the medical officer of the health district in which the baby was born. TRANFER FROM THE LABOUR WARD The midwife is responsible for seeing that all observation are made and record. Prior to transfer of mother and baby to the postnatal ward.

SUMMARY Today we have discussed third and fourth stage of labour ,mechanism of placental separation ,expulsion of placenta ,control of bleeding medical management and nursing management and complications. CONCLUSION The labour process is a an exciting and anxious time for the laboring women and her significant others ,comprehensive knowledge of certain essential factors is necessary for ensuring that the labour women and competent management of third and fourth of labour is necessary .Careful observation of mother and baby is very important this helps to preserve the women sense of control and participation in her own child birth experience. BIBLIOGRAPHY y D.C dutta text book of obstetrics edited by hiralal konar ,seventh edition page no:122, 131, 139. y V.ruth Bennett linda .k. brown Myles text book for midwives 15th edition page no:216-232. y Annamma Jacob a comprehensive text book of midwifery published by jaypee brothers medical publishers p(LTD) page no; 205-219. y B.T. basavanthappa text book of midwifery and reproductive health nursing .jaypee brothers medical publishers p(ltd) first edition page no;334-342. y Internet referrencs.www. google.com.

GOVERNMENT COLLEGE OF NURSING, HYDERABAD ZIST ON THIRD AND FOURTH STAGE OF LABOUR D Reddamma M.SC.Nursing 1st year INTRODUCTION .