Fourth stage of labor: The hour or two after delivery when the tone of the uterus is reestablished as the uterus contracts again, expelling any remaining contents. These contractions are hastened by breastfeeding, which stimulates production of the hormone oxytocin.

1. FOURTH STAGE OF
LABOR (1/3)
Mukesh Sah, MD
Post graduate Medical Intern

2. FOURTH STAGE OF LABOR (1/3)
• Fourth stage of labor begins with the delivery of the placenta and
end 1-2 hours later.
• The fourth stage of labor is a crucial time for mother and
newborn. Both are not only recovering from the physical process
of birth but also becoming acquainted with each other and
additional family members.

3. FOURTH STAGE OF LABOR (2/3)
• The fourth stage of labor is a excellent time to begin breast
feeding because the infant is in an alert stage and ready to
nurse.
• Breast feeding at this time also aids in the contraction of the
uterus and prevention of PPH.

4. FOURTH STAGE OF LABOR (3/3)

5. Assessment of newborn
• Health assessment is
thorough inspection or a
detailed study of entire body
or some part of the body to
determine the general
physical or mental conditions
of the body.

6. Purposes:
• To understand the physical and mental well being of the child.
• To detect disease in early stage.
• To determine the cause and effect of the disease.
• To determine the nature or treatment or care needed for the
child.

7. • On the basis of time of performing assessment, it is of three
types:
1. Immediate newborn assessment
2. Transitional assessment during period of reactivity
3. Periodical assessment

8. Immediate assessment of newborn
• For assessment of the baby immediately after birth Apgar score
is done.
• Apgar score is a quantitative method of assessing the infant’s
respiratory, circulatory and neurological status.
• It is done at 1 minute and 5 minutes after birth.

9. • immediate newborn assessment includes:
 Apgar scoring.
 Recording of birth weight.
 Umbilical cord is examined for presence of 2 umbilical arteries
and 1 vein.

10.  Orifice counting and checking their patency.
 Mouth is checked for cleft palate and lip.
 Ears and nose
 Anus is checked for hypospadiasis or epispadiasis.
 Any visible lesions on back or front.

11. Transitional assessment during the period of
reactivity
• After birth the neonate tries to adjust with the extra uterine
environment. This period of first 24 hours of life is the ‘period of
reactivity’ in which changes occur in vital functions like heart rate,
respiration, motor activity, skin color, bladder and bowel activity.

12. A. First period of reactivity (1/2)
• First 6-8 hours of birth is the first period of reactivity, during the
first 30 minutes of birth the neonate is very active and alert. He
cries and has strong sucking.
• This time is best for breast feeding and eye-to-eye contact .

13. First period of reactivity (2/2)
• During this time following assessment is done-
A. General examination.
B. Anthropometric assessment.
C. Head-to-Toe examination.
D. Neurologic examination.
E. Reflexes.
F. Estimation of Gestational age.

14. B. Second period of reactivity:
• The second period of reactivity starts when the newborn awakes
from first sleep, that is about 6-8 hours after birth.
• This period is lasts for about 2-5 hours.
• In this period, the neonate is again alert, active and responsive.
Heart rate and respiratory rate are slightly increased. Gastric and
respiratory secretions are increased. This stage is followed by
period of stabilization of physiological system.

15. A. General Examination (1/3)
• Posture: In full terms babies,
generalized flexion is seen.
The neck and extremities are
flexed. Pre term babies may
lie in frog like posture.

16. A. General Examination (2/3)
• Activity: Normal neonates are alert and active. The baby may
be irritable or drowsy if having any neurological problem.
• Cry: normal neonate cries when hungry or wet. Weak cry is seen
in preterm or low birth weight babies. High pitch cry is seen in
babies with raised intracranial pressure.

17. General Examination (3/3)
• Color: the entire body and extremities are pink. If the baby is
having respiratory distress., extremities may be blue.
• Vital signs: TPR are checked. The temperature of newborn
ranges between 35.5 degree centigrade to 37.7 degree
centigrade (axially temperature) . The heart rate should be
auscultated with stethoscope when the baby is calm. Apical beat
normally ranges from 120-140 beats/minute. The respiratory rate
ranges from 40-60 beats/minute.

18. . Anthropometric assessment

19. Length (Head to heel)
• The average length of a neonate is 45-50 cm.

20. Weight
• the body weight of the
neonate on an average is 2.5-
3kg. The neonate loses about
10% weight in the first day of
the life. Thereafter babies
gains about 25-30 gm/day.

21. Chest circumference
• it is about 31-33cm. It is 2-
3cm less than head
circumference.

22. Head circumference
• Immediately after birth,
moulding of skull may give
inaccurate measurement of
head circumference. So it
should be measured of head
circumference is 33-35cm
 It may be larger in case of
hydrocephalus and smaller in
microcephaly or craniostenosis
(premature closure of sutures).

23. Chest circumference:
• it is about 31-33cm. It is 2-
3cm less than head
circumference

24. C. Head to Toe Examination (1/2)
• Complete physical examination within 24 hours of birth.
• It is best to examine when the infant is quiet.
• Ensure infant is naked.
• Do not forget to wash your hands prior to examination.
• Following examination is done:
 Skin
 Head

25. Head to Toe Examination (2/2)
• Face, eyes, ears, nose, mouth, neck, chest, abdomen, feet and
heads, genitalia, back and spine.

27. D. Neurological Assessment (1/3)
• The neurological assessment is based on four fundamental
observations:-
i. Muscle Tone.
ii. Joint mobility.
iii. Automatic Reflexes.
iv. Body Movements.

28. Muscle tone
This is assessed by three
parameters- posture, passive
tone, active tone.

29. Joint Mobility:
In preterm babies the joints relatively stiff so the degree of flexion
at ankle and wrist is limited. In term babies are more flexible and
relaxed.

30. Certain automatic reflexes
The presence of certain reflexes
such as Moro's reflex, pupillary
reflex, blinking, grasp, rooting
and sucking reflex help in
establishing neurological health
of the neonate. These reflexes
disappear after maturity of
nervous system.

31. iv. Body Movements:
The neonate if not sleeping, is
active and alert. The baby
moves extremities actively.

32. ASSESSMENT OF REFLEXES
• Assessment of following reflexes and behavioral response of it:
 Blinking, Pupillary reaction, Doll’s eye, sneezing , glabellar,
rooting, sucking, gag, extrusion, cough, grasp, Babinski, Moro's,
tonic neck, Galant reflex, dance or stepping, Crawl,

33. Assessment of Gestational Age
• Assessment of gestational age of baby can be done using ‘New
Ballards scale’. The scale can be used with neonates born
between 20-44 weeks of gestation; with accuracy to +/- 2 weeks.
1. Physical assessment:
• Skin texture, lanugo, planter creases, breast nodule, ear
firmness, genitalia.
2. Neurological assessment:
• Posture, arm recoil, popliteal angle, head lag, glabellar tap.

34. •Physical score: 0-16
•Neurological score: 0-13
•Combined total score: 0-29

36. REFERENCES
• https://www.slideshare.net/hafizaafrin/newborn-assessment-
51065080
• https://www.slideshare.net/mohanasundariskrose/newborn-
assessment-65534602
• Rimple Sharma, Essential of pediatric Nursing Page no: 149-
168.
• Durga Subedi (Prasai), Saraswoti Gautam (Bhattarai), Midwifery
part-II page no: 105-106.