NURSING MANAGEMENT OF THIRD AND FOURTH STAGE OF LABOUR.docx.pptx

In this ppt you will learn about Nursing management of third stage of labor(expected and active management) and Nursing management fourth stage of labor.

1. NURSING MANAGEMENT OF THIRD AND FOURTH STAGE OF LABOR PRESENTED BY AYUSHI CHAVHAN MSc(Nursing)prev year CCON

2. CONTENT MANAGEMENT OF THIRD STAGE OF LABOR INTRODUCTION DEFINITION PHYSIOLOGICAL PROCESS OF PLACENTAL SEPARATION AND EXPULSION MECHANISM OF BLEEDING CONTROL NURSING MANAGEMENT OF THIRD STAGE OF LABOUR EXAMINATION OF PLACENTA,MEMBRANE AND CORD EXAMINATION OF GENITALIA

3. MANAGEMENT OF FOURTH STAGE OF LABOR INTRODUCTION NURSING CARE DURING FOURTH STAGE OF LABOR NURSING DIAGNOSIS CONCLUSION BIBLIOGRAPHY

4. NURSING MANAGEMENT OF THIRD STAGE OF LABOUR Introduction Third stage is the most crucial stage of labour. The principles underlying the management of third stage are to ensure strict vigilance and to follow the management guidelines strictly in practice so as to prevent the complications, the important one being PPH.

5. Definition: 3rd stage of labor: Commences with the delivery of the fetus and ends with delivery of the placenta and its attached membranes. The third stage of labour comprises the phase of placental separation: its descent to the lower segment and finally its expulsion with its membrane.

6. Duration : Normally 5 to 10 minutes. 15-20 minutes have been suggested if there is no evidence of significant bleeding.

7. Physiological processes of placental separation and expulsion Placental separation Descent of the placenta Expulsion of the placenta

8. Placental separation Cause of placental separation After delivery of the fetus the uterus retracts and the placental bed diminished. As placenta is inelastic and does not diminish in size it separates. Primary and secondary mechanism for placental separation Primary mechanism: Is the reduction in surface area of placental site as the uterus Shrinks. Secondary mechanism : Is the formation of haematoma due to venous occlusion and vascular rupture in the placental bed caused by uterine contractions

9. Before separation Per abdomen. Uterus become discoid in shape, firm in feel and non-ballotable. Fundal height reaches slightly below the umbilicus. Per vaginum: There may be slight trickling of blood. length of the umbilical cord as visible from outside remains static.

10. After separation Per abdomen : Uterus become globular ,firm and ballotable Fundal height is slightly raised Supra pubic bulging Per vaginum : Slight gush of vaginal bleeding Permanent lengthening of the cord

11. Methods of Placental separation Schultze Method Placenta separates in the centre and folds in on itself as it descends into the lower part of uterus (80%). Fetal surface appears at vulva with membranes trailing behind Minimal visible blood loss as retroplacental clot contained within membranes (inverted sac).

12. Duncan Method Separation starts at the lower edge of placenta lateral border separates (20%) Maternal surface appears first at vulva usually accompanied by more bleeding From placental site due to slower separation and no retro placental clot.

13. Descent of the placenta Sudden trickle or gush of blood. Lengthening of umbilical cord. Change in the shape of the uterus, globular. Change in the position of the uterus

14. Expulsion of placenta and membrane After complete separation of the placenta, it is forced down in to the flabby lower uterine segment or upper part of the vagina by effective contraction and retraction of the uterus. Therefore, it is expelled out by either voluntary contraction of abdominal muscles (bearing down efforts) or by manipulative procedure.

15. Mechanism of control bleeding After placental separation, innumerable torn sinuses which have free circulation of blood from uterine and ovarian vessels have to be obliterd. The occlusion is effected by complete retraction where by the arterioles, as they pass tortouously through the interlacing intermediate layer of the myometrium, are literally clamped. Apposition of the walls of the uterus following expulsion of the placenta also contribute minimize the blood loss.

16. NURSING MANAGEMENT OF THIRD STAGE OF LABOUR Steps of management: there are two methods of management are- Active management(preferred) Expectant management

17. Difference between expected and active management   EXPECTED MANAGMENT ACTIVE MANAGEMENT Placental delivery   By gravity and maternal effort By controlled cord traction with counter traction on fundus Uterotonic   No uterotonic medication given   Given after the delivery of baby Uterus   Assessment of size and tone   Assessment of size and tone Cord clamping Umbilical cord not cut or clamped until after cessation of pulsating  Delayed cord clamping done after minimum 1 to 3 min Time taken  15-20 minute  5-10 minute

18. AMTSL - The underlying principle in active management is to excite powerful uterine contractions within 1 minute of the delivery of the baby (WHO) by giving parenteral oxytocin. this facilitates not only early separation of the placenta but also produces effective uterine contraction following its separation. Increased incidence of retained placenta (1-2%) and consequent incidence of manual removal. Active management is certainly of value for cases likely to develop postpartum haemorrhage. these cases likely to develop postpartum hemorrhage these cases are anemia, hydramnios, twins, grand multiparae and previous history of PPH. tablet misoprostol 600mcg can be given orally or rectally.

19. Methergine should not be used in cardiac cases or severe pre-eclampsia for the risk of precipitating cardiac overload in the former and aggravation of blood pressure Advantages of AMTSL- To minimize blood loss in third stage approximately to one-fifth To shorten the duration of third stage to half Reduces maternal anemia Disadvantage of AMTSL - Increased incidence of retained placenta (1-2%) and consequent incidence of manual removal.

20. EXAMINATION OF PLACENTA MEMBRANE AND CORD

21. EXAMINATION OF PLACENTA The maternal surface of the placenta is the underside opposite to the side where the umbilical cord emerges. A portion of the maternal surface (bottom of the placenta, is missing, or there are torn membranes with blood vessels, suspect that retained placenta fragments remain in the uterus and refer the mother quickly Checking the underside (maternal surface) of the placenta to see if it is intact. The irregular rounded shapes on the underside of the placenta are called lobes (some textbooks call them cotyledons). By contrast the top of the placenta (the side that was facing the baby) is smooth and shiny. The cord attaches on this side, and then spreads out into many deep-blue blood vessels that look like tree roots

22. Checking the placenta for completeness Hold the placenta in the palms of your hands, with the maternal side facing upward. Make sure that all the lobules are present and fit together. Then hold the cord with one hand, allowing the placenta and membranes to hang down. Place the other hand inside the membranes, spreading the fingers out, to make sure that the membranes are complete. Hold the membranes open like this to check they are complete.

23. . Ensure that the position of cord attachment to the placenta is normal, and inspect the cut end of the cord for the presence or two arteries and one vein . If the membrane tear, gently examine the upper vagina and cervix of the women. you must wear sterile/disinfected gloves and use a sponge forceps to remove any pieces of membrane that are present

24. EXAMINATION OF GENITALIA Gently separate the labia and inspect the lower vagina and perineum for lacerations that may need to be repaired to prevent further blood loss. Gently cleanse the vulva and perineum with boiled (then cooled) warm water or a weak antiseptic solution Apply a clean pad or cloth with firm pressure to the area that is bleeding for about 10 min. if bleeding continues after this time, refer the women immediately, keeping the pressure applied to the wound.

25. Nursing diagnosis on third stage of labor Pain related to strong contraction secondary to the effect of oxytocin as evidence by the complains of the mother. Injury to the birth canal related to laceration/perineal tear related as evidence by vaginal examination. Constant trickle of blood flow related to injury to the birth canal/perineal tear/improper suturing of episiotomy as evidence by observation/vaginal examination/soaked pad. Bleeding related to retained bids of cotyledon and membranes as evidence by vaginal examination and inspection of placenta. Hypotension related to bleeding as evidence by BP monitoring.

26. NURSING MANAGEMENT OF FOURTH STAGE OF LABOUR

27. NURSING MANAGEMENT OF FOURTH STAGE OF LABOUR INTRODUCTION The fourth stage of labour, is the period from the delivery of the placenta until the uterus remains firm on its own and duration of fourth stage is minimum of 1 hour. In the stabilization phase, the uterus makes its initial readjustment to the non-pregnant state. the primary goal is to prevent hemorrhage from the uterine atony and the cervical or vaginal lacerations. NOTE: Atony is the lack of normal muscle tone. Uterine atony is failure of the uterus to contract.

28. Nursing Care During the Fourth Stage of Labor Provide care of the perineum . A clean perineal pad between the legs. An ice pack may be applied to the perineum to reduce swelling from episiotomy Transfer the patient from the delivery table . Remove the drapes and soiled linen. Remove both legs from the stirrups at the same time and then lower both legs down at the same time to prevent cramping. Assist the patient to move from the table to the bed.

29. Transfer the patient to the recovery room. a) This will be done after you place a clean gown on the patient, obtained a complete set of vital signs, evaluated the fundal height and firmness, and evaluated the lochia. Ensure emergency equipment is available in the recovery room for possible complications. Suction and oxygen in case patient becomes eclamptic. Pitocin (Oxytocin) is available in the event of hemorrhage. IV remains patent for possible use if complications develop.

30. Check the fundus . Ensure the fundus remains firm. Massage the fundus until it is firm if the uterus should relax. Massage the fundus every 15 minutes during the first hour, every 30 minutes during the next hour, and then, every hour until the patient is ready for transfer. Inform the doctor if the fundus remains boggy after being massaged.

31. Monitor lochia flow Lochia is the maternal discharge of blood, mucus, tissue from the uterus. Keep a pad count Record the number of pads soaked with lochia during recovery Identify presence of bright red bleeding or blood clots. Observe for constant trickle of bright red lochia Document lochia flow when the fundus is massaged

32. Observe the mother for chills Monitor the patient vital sign and general condition Observe patient urinary bladder for distention Be able to recognize the difference between a full bladder and a fundus. 1) Characteristics of a full bladder. a) Bulging of the lower abdomen b) Spongy feeling mass between the fundus and the pubis. c) Displaced uterus from the midline, usually to the right. d) Increased lochia flow

33. 2) Full bladders may actually cause postpartum hemorrhage because it prevents the uterus from contracting appropriately. 3) Nerve blocks may alter the sensation of a full bladder to the patient and prevent her from urinating. 4) If at all possible, ambulate the patient to the bathroom. 5) Urine output less than 300ml on initial void after delivery may suggest urinary retention.

34. Evaluate the perineal area for signs of developing edema and /or hematoma Predisposing conditions includes prolonged second stage, delivery of a large infant, rapid delivery, forceps delivery, and fourth degree lacerations. Nursing considerations for perineal edema. Apply an ice pack to the perineum as soon as possible to decrease the amount of developing edema. Stress the importance of peri-care and use of sitz baths on the postpartum ward

35. SITZ BATH APPLY ICE PACK OVER PERINEAL AREA

36. Assessment for perineal hematoma Look for discoloration of the perineum Observe the sign of hemorrhage Uterine atony Vaginal or cervical lacerations Retained placental fragments Bladder distention Severe hematoma in vagina or surrounding perineum

37. ASSESS FOR AMBULATORY STABILITY

38. Assess for ambulatory stability 1) The patient is at risk of fainting on initial ambulation after delivery due to hypovolemia from blood loss at delivery and hypoglycaemia from prolonged nothing by mouth (NPO) status. 2) The patient should be accompanied on the first ambulation and observed for stability. 3 ) The patient should be closely monitored while in the bathroom to prevent injury if fainting does occur 4 ) The patient who received regional anaesthesia at deliver(that is, pudendal block) should be assessed for possible loss of sensation in the lower extremities. 5 ) Discontinue IV on a normal patient once she is stable and the physician has ordered removal. 6 ) Complete notes and transfer the stable patient to the ward (on normal vaginal delivery-others require physician clearance).

39. NURSING DIAGNOSIS Pain related to episiotomy site as evidence by verbalization Risk of retention of placenta cotyledons related to ineffective third stage management as evidence by observation Risk of PPH related to atony of the uterus as evidence by inspection of lower abdomen. Chills and shivering related to heavy bleeding as evidence by BP monitoring/soaked pad/observation. Difficulty in breast f eeding related to lack of knowledge/initiation as evidence by verbalization.  

40. CONCLUSION Knowledge of management of the third and fourth stage of labour enables the midwife to anticipate the to prevent further complications. This is considered a dangerous time because of the possibility of hemorraging. The women deliver placenta by AMTSL may prevent pph. The fourth stage of labour, is the period from the delivery of the placenta until the uterus remains firm on its own.in this phase the uterus makes its initial readjustment to the non-pregnant state. The primary goal is to prevent hemorrhage from the uterine atony and the cervical or vaginal lacerations.

41. ASSIGNMENT Write short note on third and fourth stage of nursing management?

42. BIBLIOGRAPHY Text book of obstetrics, D.C. Dutta sixth edition 2004 P.No.161-162. Myles text book for midwife’s 11 th edition published by Longman group ltd. P.No.209-219. C.S. Dawn textbook of obstetrics and Neonatology 15 th edition publish by Dawn book, Calcutta. 97-106. Midwifery and obstetrical nursing Nima Bhaskar third edition 2019, published by EMMESS Medical publishers. Page no 185-190 www.google.com (net information)