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4th stage of labor m.sc 1st year
1. 4th STAGE OF LABOR
PRESENTED BY
MS. SANA USMANI
M.SC NURSING 1ST YEAR
2. INTRODUCTION
The recovery phase immediately after
delivery of the placenta often is
referred to as the fourth stage of
labor. This is misnomer because labor
and delivery are completed with the
expulsion of the placenta. The fourth
stage is critical time that begins
after delivery of the placenta and
ends when the mother’s system has
stabilized, usually 1 to 4 hours later.
3. LABOUR
DEFINITION-
A series of event that take place in
the genital organ in an effort to
expel the viable products of
conception out of the womb through
the vagina into the outer world is
called as labor.
4. STAGES OF LABOUR
• FIRST STAGE OF LABOUR
(CERVICAL STAGE):- It starts
with the onset of true labor pain
and ends with full dilation of
cervix.
• SECOND STAGE OF LABOUR:-It
starts with full dilatation of cervix
and ends with expulsion of the
fetus from the birth canal.
5. • THIRD STAGE OF LABOUR:-It
begins with expulsion of the fetus and
ends with expulsion of the placenta
6. FOURTH STAGE OF LABOUR
DEFINITIONS
• 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 observation for at
least one –two hour after expulsion of
the afterbirth.
7. MATERNAL ASSESSMENT
EVALUATION AND INSPECTION
• Pain
• Evaluation of the uterus
• Inspection of cervix and upper
vaginal vault.
• Inspection and evaluation of the
placenta, Membranes and
umbilical cord.
9. PAIN
• Assess the type, location and
intensity of pain.
• Look for signs of discomfort.
10. EVALUATION OF THE UTERUS
• After delivery of the placenta, the
uterus is normally found in the midline
of the abdomen approximately two
thirds to three fourths of the way up
between the symphysis pubis and
umbilicus.
• A uterus found the above the
umbilicus is indicative of blood clots
inside, which need to be expressed
and expelled.
11. • A uterus found above the umbilicus
and to one side usually the right side
indicates a full bladder.
• The uterus is assessed every 15
minutes for the first hour. The woman
is positioned with knees flexed and
head flat.
• The nurse uses one hand to stabilize
the uterus just above the symphysis
pubis and the outer edge of the other
hand to locate the fundus
12. • Position of the fundus is noted in
relation to the umbilicus and
recorded as centimeters above or
below the umbilicus.
• During the fourth stage, the
fundal height usually is at the level
of the umbilicus.
• Placement of the uterus also is
noted in relation to midline
13. • Consistency is noted. If the
uterus is not firm, it is referred
to as boggy, and the fundus is
massaged gently in a circular
motion until the uterus contracts
and becomes firm.
14. INSPECTION OF CERVIX AND UPPER VAGINAL
VAULT
• The uterus is well contracted but
there continues to be steady trickle or
flow of blood from the vagina.
• The mother was pushing prior to
complete dilatation of the cervix.
• The labor and delivery were rapid and
precipitous.
• Traumatic second stage of delivery
such as prolonged shoulder dystocia or
large baby.
15. INSPECTION AND EVALUATION OF THE
PLACENTA, MEMBRANES AND UMBILICAL CORD
• They are done before repairing any
laceration or episiotomy.
• This is because, if during the
examination of the placenta, the
midwife determines that the uterus
needs to exposed manually because of a
retained placental fragment, it needs to
be done as soon as possible since it has
the potential for causing hemorrhage
16. REPAIRS
• The repair of any laceration or an
episiotomy is done after the
examination of the placenta and
membranes. If a uterine exploration
for retained placental fragments is
necessary, it is done prior to the
repair. The uterus is checked again
for consistency and repair is begun.
17. PERINEAL CLEANSING AND POSITIONINGOF
LEGS
• The next nursing action is wash off the
mother’s entire perineal area including
the perineum, vulva, inner thighs,
buttocks and the rectal area.
• A perineal pad is then placed against
the perineum and mother assisted to
put her legs together.
• A perineal pad is then placed against
the perineum and mother assisted to
put her legs together
18. CONTINUINGCARE AND MONITORING
• Vital signs check
• Palpation of the fundus of the uterus
for contractility
• Massage of the fundus, and
expression of the clots and free
bloom from the uterus
• Measurement of the fundus in relation
to the umbilicus
19. • Inspection of the perineum for
discoloration and swelling
• Inspection of the bladder
• Inspection of the perineal pad and
change, if necessary
• Offering food and fluids if allowed
and comfort and safety measures.
25. • 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
26. 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 reddish in color, smooth and
puffy at birth
• Turgor good with quick recoil
27. • Vernix cadeosa- The white, cheesy
substance covering
• the newborn’s body.
• Lanugo – Fine downy body hair
29. 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
30. EYES
• Slate gray , black, brown or blue eye
colour
• 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
31. EARS
• Loud noise elicits Startle Reflex
• Flexible pinna with cartilage
present
• Pinna top on horizontal line with
outer canthus of eye
33. MOUTH AND THROAT
Expected findings:
• Uvula midline
• Minimal or absent salivation
• Tongue moves freely and does not
protrude
• Well developed fat pads bilateral
cheeks
35. CHEST
Expected findings:
• Evident xiphoid process
• Equal anteroposterior and lateral
diameter
• Bilateral synchronous chest
movement
• Symmetrical nipples
36. ABDOMEN
Expected findings:
• Dome-shaped abdomen
• Abdominal respirations
• Soft to palpation
• Well formed umbilical cord
• Three vessels in cord
• Cord dry at base
37. • 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
39. 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
40. 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
