Download The Third Stage….Plus

Third Stage Labor Management
….Plus
(The Immediate Post-Birth
Period)
Authors:
Marcia Gould Rohlik, MSN, RNC
Janet Smith, BSN, RNC
Evelyn M Hickson, RN, MSN, CNS
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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.
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Third stage of labor
Birth
Delivery of the placenta
Today’s scope – usually also includes the first
hour into the 4th Stage of labor (post partum)
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Decreases size of uterine cavity
Decreased size reduces implantation site
Uterine contractions of perpendicular muscle
layers encourage separation
Uterus contracts firmly after expulsion
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Spherical uterus
Uterus rises as placenta enters vagina
Increased cord length protruding
Gush of blood
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Fetal side: Shiny “Schultze”
Maternal side: Dirty “Duncan”
Cord – notice whether there are abnormalities
how many vessels are in the umbilical
cord
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Fundus/Bleeding
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Palpation
Massage
Oxytocin-Uterine Tonic
Baby to breast
Assessment of Injury:
◦ Cervical
◦ Vaginal
◦ Perineum
◦ Labial
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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
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Vaginal Delivery
◦ < 500 mL
Cesarean Section
◦ < 1000 mL
Primary Goals:
 Assessment of Recovery – follow Standards of
Care for assessment and documentation
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 Newest 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!
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Hemostasis
◦ Fundus
◦ Lochia
◦ VS
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Recovery from
epidural (regional)
vs local and IV
analgesia and
anesthesia
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Ice
Intake
Sensitivity,
modesty, Cultural
Competence
Topicals
Medications for
pain
Modified Aldrete for
analgesia recovery
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Vaginal delivery
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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 vital signs every 15 minutes x 8
(2 hours)
◦ Fundus, uterine tone and lochia every 15
minutes x 8 (2 hours)
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Infant
◦ Vital signs every 30 minutes x 2 hours, then every 4
hours x 2, then every 8 hours
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Maternal
◦ Pain assessment every 15 minutes with maternal
vital signs and after any intervention for pain
management
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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
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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/min
Dependent on:
Analgesia
Amount of blood loss during and after
delivery
Mode of delivery
Maternal position
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Heart Rate: remains stable or
decreases slightly after birth
depending on position
Decrease in heart rate may be
associated with rest/sleep or analgesia
Increase in heart rate may indicate:
Pain
Blood loss
Infection
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Blood Pressure – should remain stable or
decrease slightly
◦ Increase in BP may indicate pain or preeclampsia
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Significant decrease in BP is a late sign of
hypovolemia
◦ First sign will be maternal tachycardia
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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)
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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)
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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)
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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 catheter
 Volume (must be > 30 mL / hr)
 Color
 Presence or absence of blood clots
 Presence of bladder spasms / patient discomfort
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Postpartum hemorrhage
Lacerations
Hematomas
Amniotic fluid emboli
Other emboli – pulmonary, cerebral/stroke
MI
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Psycho-social issues
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Family
Psychiatric
CPS
Family members
Who is the baby daddy???
Impact of other medical problems
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Diabetes
Hypertension
Cardiac
Respiratory
Auto-immune
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Active bright red bleeding
Steady stream or trickle of unclotted blood
Firm uterus
Call provider
◦ **Remember – a patient can bleed enough to
become hypovolemic
Vaginal
Vulval
Retroperitoneal
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Definition: collection of blood in the subcutaneous 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
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Results from trauma to the maternal soft
tissues during delivery
Frequently associated with Instrument
(operative) forceps or vacuum delivery
but many occur spontaneously
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Less common than vulvar hematomas
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Blood accumulates – in the perineum,
vaginal walls, inguinal area
Symptoms:
 Severe rectal pressure
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Exam reveals a large mass protruding
into the vagina
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Scant or no vaginal lochia
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As with vulvar hematomas, it is
uncommon to find a single bleeding
vessel as the source of bleeding
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Interventions:
The incision need not be closed, as the
edges of the vagina will fall back together
after the clot has been removed
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Vaginal packing may be inserted to
tamponade the raw edges
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Packing removed in 12-18 hours –
◦ Make sure it is documented what and how many
left in and when it is removed.
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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
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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.
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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
Psycho-Social Issues
Pre-existing Medical Problems
Bonding
Teaching
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Support
Family dynamics
Adoptions
CPS alerts
Substance abuse
Depression/bipolar history
Psychotic illness
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Cardiac disease
Kidney disease
Trauma
Paralytic disorders
Contagious illness
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Physical contact and viewing
Assessing quality of bonding and support
First feedings
Cultural awareness
Reassurance, information
Time pressures
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Self care
Baby care and feeding
Newborn characteristics
Physical expectations next few days
Emotional expectations next few days
Keep info short, targeted
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Time of dramatic changes
Most physical care in background
Need for supportive, compassionate,
family-centered care
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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.
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AWHONN’s Compendium of Postpartum Care . Johnson and Johnson
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Chin, MD, FACOG. On Call Obstetrics and gynecology. W.B. Saunders
Co. Philadelphia; 1997.
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Jones, RNC, MSN, Marion W. Postpartum Complications. Health
Education Innovations, Inc.; 1996.
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Inc.; 2006.
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.