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. 1)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.

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

19. 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

20. 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.

21. • 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.

22. EXAMINATION OF PLACENTA MEMBRANE AND CORD

23. 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

24. 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.

25. .
 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

26. 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.

27. 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.

28. NURSING MANAGEMENT OF FOURTH STAGE OF
LABOUR

29. 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.

30. Nursing Care During the Fourth Stage of Labor
Provide care of the perineum.
a)A clean perineal pad between the legs.
b)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.

31. 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.
a)Suction and oxygen in case patient becomes eclamptic.
b) Pitocin (Oxytocin) is available in the event of hemorrhage.
c)IV remains patent for possible use if complications develop.

32. Check the fundus.
a)Ensure the fundus remains firm.
b) Massage the fundus until it is firm if the uterus should relax.
c) 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.
d)Inform the doctor if the fundus remains boggy after being
massaged.

33. 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

34. 1)Observe the mother for chills
2)Monitor the patient vital sign and general condition
3)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

35. 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.

36. Evaluate the perineal area for signs of developing edema and /or
hematoma
a)Predisposing conditions includes prolonged second stage, delivery of a
large infant, rapid delivery, forceps delivery, and fourth degree
lacerations.
b)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

37. SITZ BATH
APPLY ICE PACK OVER
PERINEAL AREA

38. a)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

39. ASSESS FOR AMBULATORY STABILITY

40. 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).

41. 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 feeding related to lack of knowledge/initiation as evidence by
verbalization.

42. 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.

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

44. BIBLIOGRAPHY
 Text book of obstetrics, D.C. Dutta sixth edition 2004 P.No.161-
162.
 Myles text book for midwife’s 11th edition published by Longman
group ltd. P.No.209-219.
 C.S. Dawn textbook of obstetrics and Neonatology 15th 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)