What is the most important nursing intervention during the fourth stage of Labour?

Fourth stage of labor OUTLINE: Nursing Interventions &
Assessments (8)

Fourth stage of labor OUTLINE
Placental exam Inspection
2) Assess Uterus status
3) Clamping of the cord "AVA"
4) Assessment of episiotomy "REEDA"
5) Lochia
6) Maternal infant bonding
7) Maternal VS
8) Encourage Voiding

Fourth stage of labor: Inspection and clamping of the cord 1) Delayed
2) Before applying the cord clamp examine

1) Delayed cord clamping is associated with positive outcome and is the preferred approach
(London 416)

Fourth stage of labor: Inspection and clamping of the cord 1) Before applying the cord clamp examine for ?
2) Document ?
3) Cord is clamped where? (distance
)4) Avoid clamping?
5) Hollister clamp removed when?

1) Cut end of cord for two arteries and one vein (largest vessel) AVA
2) Record number of vessels on the birth and newborn records
3) Cord is clamped appx .5 to 1 inch from abd
4) abd skin must not be clamped
5) Hollister clamp is removed in the nursery about 24 hrs after the cord has dried
(London 416)

Fourth stage of labor/Assessment/Lochia Rubra
1) What is it?
2) Color
3) A soak perineal pad contains appx how much blood?

1) Bloody vaginal discharge presents shortly after birth/placenta delivery
2) Bright Red with or without clots
3) 100 mL of blood

Fourth stage of labor/Assessment/Lochia Rubra
1) If perineal pad becomes soaked in a ___?___min period or blood pooling under buttock ___?___

1) 15 mins
2) Monitor closely

If fundus rises and displaces to the right consider two factors:

1) As the uterus rises, the uterine contractions become less effective and increased bleeding may occur
2) The most common cause of uterine displacement is bladder distention
(London 420)

Fourth stage of labor/Assessment/Bladder
1) Palpate to determine?
2) Reasons bladder may be full and cannot void

1) Distended?
2) IV, uteroplacental circulation, loss of sensation due to trauma to bladder and urethra, regional anesthesia
(London 420)

Fourth stage of labor/Assessment/Episiotomy & Perineum
1) Inspect for (2)
2) Relief measure

1) Edema and hematoma formation2) Ice pack

Fourth stage of labor/Assessment/Episiotomy & Perineum REEDA

Redness
Edema
Ecchymosis
Drainage
Approximation

Fourth stage of labor/Assessment/Fundus
1) After childbirth why is it critical that the uterine fundus stay well contracted?
2) Palpate fundus frequently for the next,,,,?
3) Fundus located?
4) Palpate fundus but do not massage it unless
5) What does boggy uterus indicate?

1) To clamp off uterine blood vessels at the placental site and prevent hemorrhaging
2) 4 hours to ensure that it remains firmly contracted
3) Midline at or below umbilicus
4) it is soft (boggy)
5) Pooling of blood within uterus causing clots

Fourth stage of labor/Assessment/During the recovery period monitor VS
1) BP every 5-15 mins
2) HR
3) A rise in BP may be in response/caused (2)
4) A lowered blood pressure and rising pulse may indicate?

1) should return to prelabor level
2) slightly lower than it was during labor
3) Oxytocic or preeclampsia
4) Blood loss

Fourth stage of labor/Assessment/During the recovery period monitor VS (cont)
1) Temperature
2) Fundus and lochia every ___ min?

1) Often tremors offer heated blanket
2) 15 min for first hour

then according to facility protocol

Bleeding under the skin
1) Petchiae
2) Purpura
3) Ecchymosis

(Medline Plus)

Bleeding under the skin can occur from broken blood vessels that form tiny pinpoint red dots (called petechiae). Blood also can collect under the tissue in larger flat areas (called purpura), or in a very large bruised area (called an ecchymosis).

Lochia rubia
1) Color?
2) Postpartal Day
3) Composition

1) Red
2) 1-3
3) Blood, fragments of decidua and mucus

Lochia serosa
1) Color?
2) Postpartal Day
3) Composition

1) Pink
2) 3-10
3) Blood, mucus, and invading leukocytes

Lochia alba
1) Color?
2) Postpartal Day
3) Composition

1) White
2) 10-14 (may last 6 weeks)
3) Largely mucus, leukocyte count high