The document discusses various postnatal complications including the fourth stage of labor. It defines the fourth stage as beginning with delivery of the placenta and ending one hour later. It describes assessing the woman's vital signs, fundus, lochia, perineum and more frequently during this stage. Potential postnatal complications discussed include hemorrhage, infection, mastitis, pulmonary embolism, subinvolution, thrombophlebitis and perinatal loss. Nursing interventions focus on monitoring, providing comfort measures, administering medications as needed, and supporting the woman through grief as needed.

1. •FOURTH STAGE OF LABOR ,
ASSESSMENT & MANAGEMENT
OF POASTNATAL
COMPLICATION
•

2. OBJECTIVES
Introduction
Definition of fourth stage of labor.
Assessment of fourth stage of labor.
Nursing action required in the fourth stage
of labor.
Assessment & management of postnatal
complication

3. INTRODUCTION OF FOURTH
STAGE OF LABOR
The fourth stage of labor begins with the birth
of the placenta and ends one hour later .This
stage marks the completion tasks associated with
the first three stage of labor. The mother have
expression of relief and accomplishment
,intermingled with excitement.

4. •Definition
• This is the period from the delivery of the afterbirth to the
time when the women is examined and then transferred to
her room.
• It is stage of observation for at least one – two hour after
child birth.

5. ASSESSMENT :
Initial assessment –
Vital sign
Pain
Location and Firmness of the Fundus
Amount and color of lochia
Perineum
Intravenous Infusion
Urinary output
•

6. VITAL SIGN –
Temperature : is taken atleast once during the 4th stage.
Temperature more than 38 degree celsius is normal during
1st 24 hour.
Pulse ,blood pressure and respiration are evaluated every
15 min .
Hypotension may indicate Dehydration & Hypovolemia
PAIN –
Assess the type , location and intensity of pain
Look for sign for discomfort.

7. FUNDUS -
The fundus remain firm and at or near the umbilical level
A boggy uterus may indicate uterine atony or retained
placenta fragments.
Boggy refers to being inadequately contracted
and having a spongy rather than firm feeling.
• LOCHIA –
• Excessive lochia in presence of contracted uterus
indicates laceration of birth canal’
• A constant trickles ,dribble or oozing of lochia indicates
excessive bleeding.
•

8. PERINIUM –
The acronym REEDA is used as reminder to asses the
episiotomy or perineal site.
R-redness
E-edema
E-ecchymosis
D-discharge
A –approximation of wound edges
URINARY OUTPUT –
Look for bladder distention as the mother usually don’t feel
the urge to void .

9. INTRAVENOUS INFUSION –
Type of IV fluid
Rate of fluid administration
Type and amount of medication
Patency of IV Lines
•
NEONATAL OBSERVATION –
•
Apgar score taken at 1 and 5 minutes after birth.
Heart rate and respiratory rate, and color used as the basis for
resuscitation need totals ;
0-2 =severe distress
3-6= moderate distress
7-10=minimal distress
Vital sign & General measurement (general appearance & other
finding)

10. •Nursing care-
Assist the patient move from the table to the bed.
Provide care of perineum . An ice pack may be applied to the
perineum to reduce swelling from episiotomy .
Apply clean perineal pad between the legs. .
Monitor the patient vital signs and general condition.
Take BP ,P and R every 15 min for an hour , then every 30 min
for an hour , and then every hour as long as patient is stable.
Document thick,foul-smelling lochia.
Document lochia flow when the fundus is ,massaged
Observe for uterine atony or hemorrhage.
Observe for any untoward effects from anesthesia.
Orient the patient to the surrounding (bathroom ,call bell,lights
etc)

11. Cont...
Allow the patient time to rest.
Encourage the patient to drink fluids .
Observe patients urinary bladder for distention.
Bulging of the lower abdomen.
Full bladders may actually cause postpartum hemorrhage
because it prevents the uterus from contracting.
Ambulate the patient to the bathroom.
Evaluate the perineal area for signs of develop edema.
Apply ice pack to the perineum to decrease the amount of
developing the edema .
Look for discoloration of perineum area

12. POSTNATAL COMPLICATION
Introduction
Postnatal period begins immediately after
the birth of child till the first 6 weeks and
the complication arising during this period is
called Postnatal complication..

13. A. Description
• 1. A hematoma is a localized collection of blood in the
tissues and can occur internally, involving
• the vaginal sulcus or other organs; vulvar hematomas are
the most common.
B. Assessment
• Abnormal, severe pain
Pressure in the perineal area
• Sensitive, bulging mass in the perineal area with
discoloured skin
• Inability to void
• Decreased haemoglobin and haematocrit levels

14. C. Interventions
Monitor vital signs.
Monitor client for abnormal pain or perineal pressure,
especially when forceps delivery has occurred.
Place ice at the hematoma site.
Administer analgesics as prescribed.
Monitor intake and output.
 Encourage fluids and voiding.
Prepare for urinary catheterization if the client is unable
to void.
Administer blood products as prescribed.

15. • Hemorrhage :
• A. Description
• Bleeding of 500 mL or more after delivery
• B. Assessment
• Causes
Laceration of the cervix or vagina
Uterine atony
 Hematoma development in the cervix, perineum, or
labia
 Retained placental fragments

16. 1. Early: Hemorrhage occurs during the first 24 hours after
delivery.
2. Late: Hemorrhage occurs after the first 24 hours
following delivery.
C. Interventions
Massage fundus for uterine atony .
 Monitor vital signs and fundus every 5 to 15 minutes;
monitor for early signs of hemorrhaging
and shock, including restlessness and increased pulse
rate. (A decrease in blood pressure is a later sign of
hemorrhage.)
Remain with the client if hemorrhage or signs of shock
occur.

17. Assess and estimate blood loss by pad count (1 gram
= 1 mL of blood).
Assess level of consciousness.
Administer fluids and monitor intake and output
 Monitor haemoglobin and haematocrit levels.
Maintain asepsis because haemorrhage predisposes to
infection.
Prepare for the administration of oxytocin (Pitocin) if
prescribed.
Prepare for the administration of intravenous fluids
and blood transfusions if prescribed.
Prepare for surgical intervention (e.g., dilation and
curettage or hysterectomy).

18. • INFECTION
• A. Description: Any infection of the reproductive organs that
occurs within 28 days of delivery or abortion
• B. Assessment
oFever
o Chills
oAnorexia
o Pelvic discomfort or pain
oVaginal discharge that is fleshy odor or an odor similar to a
menstrual period.
oElevated white blood cell count

19. • C. Interventions
Monitor vital signs and temperature every 2 to 4 hours.
 Make the client as comfortable as possible; position the client
to promote vaginal drainage
 Keep the client warm if chilled.
Isolate the new born from the client only if the client can
infect the new born.
Provide a nutritious, high-calorie, high-protein diet.
Monitor culture results if cultures were prescribed.
 Administer antibiotics according to identified organism, as
prescribed.

20. • MASTITIS
• A. Description
• 1. Mastitis is inflammation of the breast as a result of infection.
• 2. Mastitis occurs primarily in breast-feeding mothers 2 to 3
weeks after delivery, but may occur at any time during
lactation.
• B. Assessment
• Localized heat and swelling
• Pain; tender axillary lymph nodes
• Elevated temperature
• Complaints of flulike symptoms

21. • C. Interventions
Instruct the client in good hand washing and breast hygiene
techniques.
 Promote comfort.
Apply heat or cold to the site as prescribed.
Maintain lactation in breast-feeding mothers.
Encourage manual expression of breast milk or use of a breast
pump every 4 hours.
 Encourage the client to support the breasts by wearing a
supportive bra;
. Administer analgesics as prescribed.
 Administer antibiotics as prescribed.

22. • PALMONARY EMBOLISM
• A. Description: Passage of a thrombus, often originating in a
uterine or other pelvic vein, into the
• lungs, where it disrupts the circulation of the blood
• B. Assessment
Sudden dyspnoea and chest pain
 Tachypnoea and tachycardia
Cough and lung crackles
Haemoptysis

23. • C. Interventions
Administer oxygen.
 Position client with the head of the bed elevated.
 Monitor vital signs frequently, especially respiratory and heart
rate and breath sounds.
 Monitor for signs of respiratory distress and for signs of
increasing hypoxemia.
Administer intravenous fluids as prescribed.
Administer anticoagulants as prescribed.

24. • SUBINVOLUTION
• A. Description: Incomplete involution or failure of the uterus
to return to its normal size and
• condition
• B. Assessment
• Uterine pain on palpation
• Uterus larger than expected
• More than normal vaginal bleeding

25. • C. Interventions
Assess vital signs.
Assess uterus and fundus.
 Monitor for uterine pain and vaginal bleeding.
Elevate legs to promote venous return.
Encourage frequent voiding.
 Monitor haemoglobin and haematocrit.
Prepare to administer methylergonovine maleate (Methergine),
which provides sustained contraction of the uterus, as
prescribed.

26. THROMBOPHLEBITIS
• A. Description
• A clot forms in a vessel wall as a result of inflammation of the
vessel wall.
• A partial obstruction of the vessel can occur
B . Assessment
• Superficial
• ■ Palpable thrombus that feels bumpy and hard
• ■ Tenderness and pain in affected lower extremity
• ■ Warm and pinkish red color over the thrombus area
• Femoral
• ■ Malaise
• ■ Chills and fever

27. • Pelvic
• ■ Severe chills
• ■ Dramatic body temperature changes
• ■ Pulmonary embolism may be the first sign
• D. Interventions
Specific therapies may depend on the location of
thrombophlebitis.
 Assess the lower extremities for edema, tenderness, varices,
and increased skin temperature.
 Maintain bed rest.
 Elevate affected leg.

28. Apply hot packs or moist heat to the affected site as prescribed
to alleviate discomfort.
Administer analgesics and antibiotics as prescribed.
 Heparin sodium intravenously may be prescribed for femoral
or pelvic thrombophlebitis to prevent further thrombus
formation
• PERINATAL LOSS
• A. Description
• 1. Perinatal loss is associated with miscarriage, neonatal death,
stillbirth, and therapeutic abortion.
•

29. • B. Interventions
Communicate therapeutically and actively listen, providing
parents time to grieve.
Notify the hospital chaplain or other religious person.
Discuss with the parents options such as seeing, holding,
bathing, or dressing the deceased infant; visitation by other
family members or friends; religious or cultural rituals; and
funeral arrangements.
Prepare a special memories box with keepsakes such as
footprints, handprints, locks of hair, and pictures, if appropriate.
Admit the mother to a private room; if possible, mark the door
to the room with a special card

30. • CYSTITIS
• A. Description: Cystitis, an infection of the bladder, can occur
in the postpartum period and the
• postpartum woman should be encouraged to consume adequate
fluids and void frequently to avoid
• bladder distention.
• B. Assessment
 Frequency and urgency
 Burning on urination
 Voiding in small amounts
 Inability to void
 Incomplete emptying of the bladder
 Lower abdominal discomfort or back discomfort
 Cloudy, dark, foul-smelling urine
 Haematuria

31. Encourage the client to increase fluids up to 3000
mL/day, especially if the client is taking a
sulfonamide; sulfonamides can form crystals in
concentrated urine.
Administer prescribed medications, which may
include analgesics, antiseptics, antispasmodics
antibiotics, and antimicrobials.
Maintain an acid urine pH (5.5); instruct the client
about foods to consume to maintain acidic urine.
 Provide heat to the abdomen or sitz baths for
complaints of discomfort..
Use sterile technique when inserting a urinary
catheter.

32. • POSTPARTUM DEPRESSION
• Description
• It is transient state of mental illness observed 4-5 days after
delivery & it lasts for a few days.
• Assessment
 By clinical manifestation –
 Depression
 Anxiety
 Tearfulness
 Insomnia
 Helplessness
 Feeling of inadequacy to care for the newborn
• Intervention
• Antidepressant
• Reassurance & psychological support by the family member.

33. • POSTPARTUM PSYCHOSIS
• Description
• The onset is more common in women with past family history
& occurring within 1st few days of delivery.
• Assessment
 By clinical manifestation –
 Restlessness
 Confusion
 Insomnia
 Delusion & hallusination
• Intervention
 Antipsychotic drug
 Hospitalization is needed.
 ECT Therapy if considered.

34. Thank you