Fourth Stage of Labor

Recovery Flow Record Tool

1) Baseline vital signs every 15 minutes x1h, then every 30 min x1h, then hourly til transferred to
postpartum unit; should remain within normal parameters - only minor variations
- Temp; slightly elevated related to dehydration trauma at delivery
- Pulse & Blood pressure; may both be increased r/t excitement or administration or oxytocin if
b/p decreased and pulse increased may indicate excessive bleeding
- Respirations; should be no change, monitor O2 saturation
- LOC; may be sleepy and less interested
- Warm with dry mucous membranes
- First sign of postpardum hemorrhage is tachycardia (biggest problem in first 4 hours)
2) Fundus (assessed for firmness, position, and involution)
- Firmness (contracts to stop bleeding) most crucial assessment of new mother
- Palpation detects firm or boggy (not good) fundus
- Fundus should be firm and indicates contracted muscle fibers of myometrium, firm pressure of
muscle clamps shut arteries severed by placental separation. Even slight relaxation allows
continuous bleeding
3) Position immediately post delivery fundus should be midline at level or slightly above umbilicus
- Factors which may compromise fundal position; full bladder patient may not have sensation
to void. Full bladder lifts and displaces uterus thus interfering with uterine contractions
- - signs of bladder distention; bulge over symphysis pubis fundus high above level of umbilicus
with deviation of fundus to L or R of midline
- - must empty bladder (may use catheter)
- Vaginal delivery patients usually stays for 72 hours / c-section patients 4-5 days
4) Involution (rolling or turning inward) will go faster if breastfeeding (oxytocin causes this)
- Complete involution takes 6 weeks
- If uterus feels boggy gentle massage causes myometrial muscle fibers to contract; do NOT
over massage once firm stop massage; may need meds (Pitocin) to produce contraction
(Methergine IM or PO for non-breastfeeding mother)
- Cant be as vigourous with a c-section fundus fingers on side then move upward; scants
amount of lochia because cleaned out really well
- Uterine atony without tone
5) Abdomen should have audible sounds all four quads especially important in c-section patients;
not unusual to be hungry and thirsty after delivery
6) Lochia (blood)
- Lochia rubra (red) immediately after delivery lasts 3 days
- Lochia serosa pinkish (blood and mucous) lasts 3-10 days if returns to rubra report it
- Lochia alba (white) mostly mucous clear and odorless lasts 10-14th day
- Amount 1 saturated pad = 100ml blood/hr
7) Perineum some edema/tenderness/bruising commonly seen
REEDA (acronym) used on any kind of incision
-redness (pain indicates infection)should not be redness
-edema
-ecchymosis (bruising) some is expected - not hematoma
-discharge (from incision) should be none
-approximation check suture line (usually absorbable) should be difficult to see if approximated
thats what we want
- treatment ice/cold pack 12-24 hours decrease bruising and analgesia effect
- hemorrhoids treat with sitz baths 20 min prn tucks pads topically

8) Pain use pain scale 1-10; pharmacological and non-pharmacological techniques

- Incisional pain for c-section (moderate pain) Percocet / acetaminophen / oxycodone / Tylenol
with codeine ( ie SAMS pack self administration of medication)
- Episiotomy pain; ice/cold pack / ibuprofen / acetaminophen
- Cramping; usually worse for multipara / worse for breastfeeding
- Breasts; firm fitting bra / if not breastfeeding avoid warm shower on breast tissue (stimulates
milk production)
- Legs; potential thrombophlibitis clotting factors higher during pregnancy & puerperium
stops mom from bleeding to death during birth but bad postpardum Ambulate ASAP to prevent
clots
- Flatulence; mylicon 40-80 mg after meals/hs
9) I & O
- If c-section catheter for first day; hourly outputs assess amount and color
- If vaginal encourage to void (urge to void may not be present) warm water on vulva (spray
bottle)
10) Cardiovascular fluid shift of blood from uterus and placenta returning to main circulating
producing (1) diuresis of 3000ml/day (urine) encourage shower / AC bad for baby if mother is
too hot baby takes on temp of where they are (2) diaphoresis (perspiration) need to keep dry
- If PIH prior to delivery can still develop visual disturbances and still have a seizure (use
magnesium sulfate)
Psychosocial Assessment
1) Assesses maternal mood; claiming behavior / observe father for sensitivity signals / presence of
parenting skills
2) Reva Rubins 3 phrase framework (reaction-behavior)
- Phase 1 in first day or two mother may not show great interest in baby into their own
needs
- Phase 2 taking hold phase claiming behavior BEST time for teaching
- Phase 3 - letting go (kindergarten to empty nest)
Postpartum Assessment
BUBBLEHE acronym
1)
2)
3)
4)
5)
6)
7)
8)

B breast
U uterus
B- bowel
B bladder
L lochia
E episiotomy
H Homans sign
E emotional status

1) Uterine fundus should be firm; generally not palpable by day 10

- Cramping sensation called afterpains
- Boggy uterus (bad) massage produces smooth muscle contraction and firms up uterus to
evacuate lochia
2) Breast (Mastitis inflammation of the breasts; warm shower prior to breast feeding increases
circulation and allows comfort)
- Breast feed every 2-3 hours and they should nurse 10-15 per breast; in beginning it will take 5
min of feeding to get HIND milk (leftover) Give NO water or supplemental bottles Begin nursing
on the breast they left off on.

Lactation breast size has nothing to do with ability to breast feed (only small portion of breast
is actually breast tissue producing milk Controlled by prolactin (production) and oxytocin (let
down or ejection of milk) Need 500 calories a day for breastfeeding mother (500 from prepregnant diet)
Several holds for breastfeeding; football/cradling/lying down/across the lap

3) Return of menses
- Non breast feeding mother it returns in about 2 months
- Breast feeding mother it returns 12 months or more (they are ovulating)
4) Rh Negative mother/Rh positive fetus RhoGam within 72 hours after delivery (for future fetus is
not harmed)
5) Shaken baby syndrome - think of jello brain sometimes not malicious throw baby up in air
6) Grieving mother and family emotional support and understanding needed for family
death/adoption/handicapped child
- Provide time for bereavement
- Identify room as one that holds a grieving mother
- Do not avoid patient and family

The Neonate the first four weeks of life most dangerous

First hour after birth is most critical and newborn transitions thru drastic changes in life in utero to life
outside the womb
Appearance
-

Head often mis-shapen and is of total body size

Molding head forms to birth canal (coning) usually resolves itself
Caput succedaneum head trauma (less serious) swelling of scalp (stays where it is); pressure on
head because of delivery (bruising) usually resolves itself
Cephalohematoma head trauma (more serious) swelling, bruising, bleeding (travels)longer to
resolve may have fractured skull
skin is colored and puffy

Cardiovascular system
-

cardiac by-passes anatomical openings necessary in fetal life, but then close over shortly after
birth
Foramen Ovale (opening)
1) opening between the atria of the heart
2) by-passes circulation of blood to the lungs (do not need them in utero)
3) normally closes after one minute of life
4) anatomically after two weeks
Ductus Arteriosus
1) fetal blood vessel that joins the aorta and the pulmonary artery
2) closes 15-24 hours after birth
Unstable temperature regulation system dependent on ambient room air temperature and
amount of covering
- observe facial color to gauge warmth (flushed too warm-pale or blue too cold)

Skin
-

Lanugo lost after a few months

telangiectasis or stork bites; flat red areas on nape of neck and eyelids (due to dilated small blood
vessels)
Vernix caseosa rubs off in few days
Hyperbilirubinemia excessive bilirubin in the blood
A) physiologic jaundice normal (liver is immature) occurs naturally AFTER the first 24 hours of
life
B) pathological jaundice kernicterus occurs WITHIN first 24 hours of life due to Rh or ABO
incompatibility. Emergency grave form of jaundice. Bilirubin can stain the brain and cause brain
damage
Desquamation normal peeling of neonate skin lasts 2-4 weeks
Umbilical cord dries and shrinks rapidly, drops off 6-14 days; keep open to air and look for signs of
infection (NO tub bath until cord falls off) Check 2 arteries and 1 vein

Weight/Length
-

Normal birth weight 6-9 pounds

10% lost in first few days
Steady gain begins at 1-2 weeks
Normal gain 1 -2 pounds/month
Average length is 19-21 inches

Vital Signs; unstable in newborn

-

Respirations vary; 50-80 right after birth 35-50 soon after; c-section baby has moist lung sounds
Temperature ranges from 97-100 with rapid body heat loss if not kept warm
Heart rate 120-150 at birth drop slightly throughout first year of life
Blood pressure assessed ONCE in delivery room; average pressure at birth 80/46 not routinely
assessed in newborn nursery

Elimination
-

Meconium first fecal material passed 8-24 hours after birth; dark green or black thick and sticky
after meconium passes stools called transition stools for first week (tend to have lots of mucous)
2-4 stools a day
-1) breast fed babies soft, bright yellow, pasty and more frequent
-2) bottle fed babies more solid and yellow-brown
Stool darker if infant receiving iron
Stool greener if under bilirubin lamp
Voiding should void in first 8 hours (sometimes void at birth)
-1) 6-8 wet diapers/day normal (2 messy diapers)(thats how breast-fed babies can keep tract of
getting enough)Not unusual to have small amount of vaginal bleeding in newborn because of
female hormones taken away
No wet diaper call the doctor

Sensory development
1) Vision can see at birth, can blink, prefer a human face, follow moving objects, likes bright colors
and look cross-eyed due to poorly developed eye coordination
2) Hearing responsive to verbal stimuli, avoid auditory overload
3) Sleep 15-20 hours/day at first; usually starts sleeping through night at 4-6 weeks

Activity
1) Lusty cry
2) Kicks and moves vigorously but cannot control (can respond to fast or slow talking)

3) Sucks often even when not eating

4) Lies on fetal position
Newborn Reflexes
1)
2)
3)
4)

Manifestations of an immature nervous system

Must be present or the infant is neurologically impaired
Appear and disappear at various stages of infancy
Moro startle; tonic fencing; palmar grasp; babinski toes curl out; rooting brush cheek goes
toward

Immediate Newborn Assessment

1) Airway (may use bulb syringe) 1st concern after delivery is clearing the airway
Spontaneous breathing usually occurs soon after birth (ideal) If breathing does not occur
a) immediate resuscitation b) tactile stimulation c) ventilation d) narcan to counteract narcotics
given too late in labor process
b) signs of respiratory distress 1) flaring of nostrils 2) grunting sounds 3)sternal or substernal
retractions
c) short periods of apnea are normal in newborn

2) APGAR scoring standardized system of immediate assessment of the newborn to evaluate

physical status
a) Performed 1-5 minutes of life
b) Heart rate, respiratory, muscle tone, reflex ability, color
c) Score at 0,1, or 2 - 7-10 good, 4-6 fair, 0-3 poor
3) Gestational age assessment (how many weeks of gestation is this baby)
a) Dubowitz evaluation within 24 hours of birth; evaluates physical characteristics and
neuromusclular tone in order to compare actual age; ie scarf sign if arm can wrap around
neck (immature if they can)
4) Meconium aspiration
a) Suggestive of fetal distress in utero
b) Common if fetus is other than cephalic presentation
- thick meconium - solid pieces of meconium that may be aspirated can result in death
- thin meconium not as serious, but amniotic fluid is stained green
- need immediate suctioning may exhibit respiratory distress usually mild and disappears in
48 hours if severe may result in aspiration pneumonia (require NICU)
Immediate Newborn Care
1) Prevent infection
- Sterile technique cutting cord
- Erythromycin opthalmia neonatorum ointment to eyes (prevents Gonorrhea/Chlamydia from the
female tract infecting infants eyes) State law
2) Provision of warmth
- Preheated tables, warming lamps, warm blankets
- Dry neonate well to loss of body heat (from evaporation)
- Placed on mothers chest
- Hat (loss of heat from top of head)
- Placed in warm isolette under radiant heat
3) Safety
- IM vitamin K to aid in clotting and prevent bleeding (given in vastus lateralis)
- Foot printed, ID to baby, mom, and dad
- Hep B vaccine before they leave hospital

Infant Screening Tests

1) Phenylketonuira inborn error in metabolism (baby cannot metabolize protein) need adequate
protein in system to test correctly usually 3-4 days before testing - if not treated baby can become
profoundly retarded
2) Hypothyroidism tested to make sure they do not have; if untreated brain damage can occur
3) Galactosemia inborn error of metabolism lactose/milk sugar cannot be broken down
4) Hypoglycemia important babies are fed every 2-3 hours for prevention (even if breast fed) for
gestational diabetic mom check blood sugar of baby before they eat for the first few weeks. Check
for sleepy baby can cause brain damage if not treated
Infant Care teaching
1) Bathing wash one part at a time, watch for evaporation, hands and feet are cooler
2) Diapering below cord (cord exposed NOT covered so it can dry out)
3) Safety baby should be on back, do not sleep with baby, carseat safety, donot leave baby alone,
yellow skin (jaundice should be reported)
4) Cord care clean dry do not cover
5) Sleep patterns -20 hours day at first
6) Feeding bottle fed positioned full of formula do not prop do not microwave burp every to
1 oz in the beginning. With formula throw out if not finished do not reuse especially at beginning
Pre-Term Delivery
1) Anamoly any deviation from usual in form, structure, or location; abnormality or malformation
2) Hyaline membrane disease disorder of alveoli and respiratory passages that cause inadequate
expansion of lungs (now called RDS respiratory distress syndrome) give surfactant
3) Premature neonate one who is born before the end of the 37th week of gestation
4) Characteristics of premature neonate
- Weigh less than 5 pounds
- Gestation less than 37 weeks
- Lack of physical development (Dubowitz scale)
5) Premature infant characteristics
- Skin reddish pink see thru
- Extremities thin with little muscle
- Head and abdomen large in proportion to body
- Soles of feet smooth
- Prominent superficial veins of abdomen and scalp
- Lanugo present (lots of hair)
- Immature muscular and skeletal systems
- Scrotum small / labia majora widely separated
6) Predisposing factors for premature birth
- Maternal; malnutrition, anemia, alcoholism or drug use, excessive smoking, age, pre-eclampsia,
multiple pregs or multiple births, lack of prenatal care, closely spaced pregnancy, physical or
emotional distress, diabetes or other endocrine disorders
- Fetal; anomalies in development (generally if anomalies they are born early), anemia, maternal
infection transmitted (rubella, syphilis, herpes II)
- Placental; anomalies in placenta itself, chronic placental deficiencies, placenta previa or abruption
placenta