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

Vaginal Delivery◦< 500 mL

Cesarean Section◦< 1000 mL

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)

Infant◦ Vital signs every 30 minutes x 2 hours, then every

4 hours x 2, then every 8 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

VaginalVulval

Retroperitoneal

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

Psycho-Social IssuesPre-existing Medical Problems

BondingTeaching

Support Family dynamics Adoptions CPS alerts Substance abuse Depression/bipolar history Psychotic illness

Cardiac disease Kidney disease Trauma Paralytic disorders Contagious 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

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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.

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