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Authors: Marcia Gould Rohlik, MSN,
RNCJanet Smith, BSN, RNC
Evelyn M Hickson, RN, MSN, CNS
Third Stage Labor Management ….Plus (The Immediate Post-Birth Period)
Discuss the nursing management of the third stage of labor.
List potential complications associated with the third stage of labor and nursing management of each complication.
Third stage of laborBirth Delivery of the placenta
Today’s scope – usually also includes the first hour into the 4th Stage of labor (post partum)
Decreases size of uterine cavity Decreased size reduces implantation site Uterine contractions of perpendicular
muscle layers encourage separation Uterus contracts firmly after expulsion
Spherical uterus Uterus rises as placenta enters vagina Increased cord length protruding Gush of blood
Fetal side: Shiny “Schultze” Maternal side: Dirty “Duncan” Cord – notice whether there are
abnormalities how many vessels are in the
umbilical cord
Fundus/Bleeding◦ Palpation◦ Massage◦ Oxytocin-Uterine Tonic◦ Baby to breast
Assessment of Injury:◦ Cervical◦ Vaginal◦ Perineum◦ Labial
Perineum◦ Laceration or
episiotomy◦ Regional – block still
functional if pt needs repair
◦ Is “Local” analgesia agent needed to provide comfort ?
◦ Sutures◦ Packing – radio-opaque
and documented
Primary Goals: Assessment of Recovery – follow Standards of
Care for assessment and documentationNewest national standards (as of Nov 2012) per Perinatal
Guidelines – ACOG and AAP: Q 15 min Vital signs and OB check for 2 hours post delivery
Comfort – get them off the wet stuff!! Bonding-baby and family Teaching – infant security, breast feeding,
postpartum routine Documentation!
Hemostasis◦ Fundus◦ Lochia◦ VS
Recovery from epidural (regional) vs local and IV analgesia and anesthesia
Ice Intake Sensitivity,
modesty, Cultural Competence
Topicals Medications for
pain Modified Aldrete
for analgesia recovery
Vaginal delivery◦Maternal vital signs every 15 minutes x 8
(2 hours)◦Fundus, uterine tone and lochia every 15
minutes x 8 (2 hours) Cesarean Section
◦Maternal vital signs every 15 minutes x 8 (2 hours)
◦Fundus, uterine tone and lochia every 15 minutes x 8 (2 hours)
Maternal◦ Pain assessment every 15 minutes with maternal
vital signs and after any intervention for pain management
Infant◦ Pain assessment once during the immediate
transition period
Auto-transfusion of 500-750 mL of utero-placental blood flow into the mother’s circulating blood stream after the placenta is delivered
Increases patient’s risk for pulmonary edema if patient has: Cardiac history – valve insufficiency
or poor cardiac function Preeclampsia Receiving medications –
Magnesium Sulfate Fluid overloaded
Cardiac Output (the amount of blood a heart pumps out – Stroke Volume X HR) peaks immediately after birth and then slowly declines reaching pre-labor values 1 hour after delivery
Labor Cardiac Output = 8-11 liters/minDependent on:
AnalgesiaAmount of blood loss during and after
deliveryMode of delivery Maternal position
Heart Rate: remains stable or decreases slightly after birth depending on positionDecrease in heart rate may be
associated with rest/sleep or analgesia Increase in heart rate may indicate:PainBlood lossInfection
Blood Pressure – should remain stable or decrease slightly◦ Increase in BP may indicate pain or
preeclampsia Significant decrease in BP is a late sign
of hypovolemia◦ First sign will be maternal tachycardia
Orthostatic hypotension may occur:◦ Woman sits up from a reclining position◦ Woman stands up to ambulate ◦ After emptying her bladder (due to a vaso-
vagal stimulation)
Oxygen saturations should remain at or above 95%
Increased respiratory rate may indicate pulmonary edema or pulmonary emboli
Monitor and assess breath sounds in patients with risk factors for respiratory compromise or who are symptomatic (asthma, preexisting pneumonia/URI, preeclampsia)
Postpartum patients with analgesia may not feel urge to urinate◦ Assess bladder for distension◦ Determine / Identify last void or if
catheterization occurred prior to delivery◦ Have 6 hours to demonstrate that they can
spontaneously void after delivery (as long as bladder is not distended and lochia flow has not increased)
Usually have indwelling catheter for up to 12 hours or until able to get up to void
Urine Output is monitored during and after surgery
Ensure that catheter is secured for patient comfort and integrity
Catheter /perineum care Assess:
Patency of catheterVolume (must be > 30 mL / hr)Color Presence or absence of blood clotsPresence of bladder spasms / patient discomfort
Postpartum hemorrhage Lacerations Hematomas Amniotic fluid emboli Other emboli – pulmonary, cerebral/stroke MI
Psycho-social issues◦ Family◦ Psychiatric◦ CPS◦ Family members ◦ Who is the baby daddy???
Impact of other medical problems◦ Diabetes◦ Hypertension◦ Cardiac◦ Respiratory◦ Auto-immune
◦ Active bright red bleeding ◦ Steady stream or trickle of unclotted blood◦ Firm uterus◦ Call provider
◦ **Remember – a patient can bleed enough to become hypovolemic
Definition: collection of blood in the sub-cutaneous layer of the pelvic tissue secondary to damage to a vessel wall without laceration of the tissue
Three types:vagina, vulva, or sub-peritoneal areas
Results from trauma to the maternal soft tissues during delivery
Frequently associated with Instrument (operative) forceps or vacuum delivery but many occur spontaneously
Less common than vulvar hematomas
Blood accumulates – in the perineum, vaginal walls, inguinal area
Symptoms: Severe rectal pressure
Exam reveals a large mass protruding into the vagina
Scant or no vaginal lochia
As with vulvar hematomas, it is uncommon to find a single bleeding vessel as the source of bleeding
Interventions:
The incision need not be closed, as the edges of the vagina will fall back together after the clot has been removed
Vaginal packing may be inserted to tamponade the raw edges
Packing removed in 12-18 hours – ◦ Make sure it is documented what and how
many left in and when it is removed.
Laceration of vessels in the superficial fascia of either the anterior or posterior pelvic triangle associated with:◦ Trauma due to forceps or vacuum ◦ Pressure of presenting fetal part◦ Excessive fundal pressure on the uterus
Symptoms: ◦ Subacute volume loss ◦ Vulvar pain/ pressure ◦ Visible hematoma, bluish and bulging◦ Difficulty voiding
Interventions: ◦ If small…observation, ice to
perineum, should resolve with time, need to monitor for infection
◦ If large and expanding… Surgical management:
incision of the mass through the skin and evacuation of blood and clots.
The area should be compressed by a sterile dressing for 12 hours.
An indwelling foley catheter should be placed for 24-36 hours.
Least common of the pelvic hematomas Most dangerous - Life-threatening Symptoms:
◦ May not be impressive until mother becomes tachycardia followed by sudden onset of hypotension or shock
Can result after C/S delivery with laceration of one of the vessels originating from the hypogastric artery or after rupture of a low transverse C/S delivery scar during VBAC.
Intervention: Surgical exploration and ligation of the hypogastric vessels
Support Family dynamics Adoptions CPS alerts Substance abuse Depression/bipolar history Psychotic illness
Physical contact and viewing Assessing quality of bonding and support First feedings Cultural awareness Reassurance, information Time pressures
Self care Baby care and feeding Newborn characteristics Physical expectations next few days Emotional expectations next few days Keep info short, targeted
Time of dramatic changes Most physical care in background Need for supportive, compassionate,
family-centered care
Gorrie, T., McKinney, E., Murray, S. (1999). Foundations of maternal newborn nursing (2nd ed.). Philadelphia, PA: Saunders
Davies, S., (2001). Amniotic fluid embolus: a review of the literature. Canadian Journal of Anesthesiology 48(1), 88-98.
AWHONN’s Compendium of Postpartum Care. Johnson and Johnson Inc.; 2006.
Chin, MD, FACOG. On Call Obstetrics and gynecology. W.B. Saunders Co. Philadelphia; 1997.
Jones, RNC, MSN, Marion W. Postpartum Complications. Health Education Innovations, Inc.; 1996.
Mattson, PhD, RNC, CTN, Susan and Smith, PhD, RNC, Judy E. Core Curriculum for Maternal-Newborn Nursing, AWHONN, 2nd Ed. ; W.B. Saunders Co. Philadelphia; 2000.
Rice-Simpson, RNC, MSN and Creehan, RNC, MS, MA, ACCE, Patricia A. Perinatal Nursing. AWHONN; Lippencott, Philadelphia; 2003.
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