Management of 4 stage of

th

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 don’t 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 0 1 2
Heart rate absent <100bpm >100bpm
Respiratory rate No repiration slow spontaneous
Muscle tone limp Minimal flexion Flexed bodily
posture
Reflex response No response grimace Responds
properly
Color Pallor Bluish hand &feet 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