STAGES OF LABOR
Four Stages of Labor
First Stage (Stage of dilatation) - which begins with the initiation of true labor contractions and ends when the cervix is fully dilated;
Second stage (Stage of Expulsion) - extending from the time of full dilatation until the infant is born;
Third Stage (Placental stage), lasting from the time the infant is born until after the delivery of the placenta
The first 1 to 4 hours after birth of the placenta is sometimes termed the “fourth stage” (Recovery Stage) to emphasize the importance of the close maternal observation needed at this time. These designations are helpful in planning nursing interventions to ensure the safety of both a woman and her fetus.
Friedman (1978), a physician who studied the process of labor extensively, used data to divide the first two stages of labor into phases: latent and active labor.
I. First Stage
Three separate divisions mark the first stage of labor: the latent, the active, and the transition phase
A. Latent Phase
The latent or preparatory phase begins at the onset of regularly perceived uterine contractions and ends when rapid cervical dilatation begins.
Intensity
Mild and Short
Duration of Contraction
20-40 Seconds
Cervical Dilatation
0-3 cm
Length of Phase
Nullipara - 6 Hrs
Multipara - 4.5 hrs
Cervical effacement occurs
A woman who enters labor with a “nonripe” cervix will have a longer than usual latent phase. Although women should not be denied analgesia at this point, analgesia given too early may prolong this phase.
Measuring the length of the latent phase is important because a reason for a prolonged latent phase is cephalopelvic disproportion (a disproportion between the fetal head and pelvis) that could require a cesarean birth
A woman can (and should) continue to walk about and make preparations for birth, such as doing last minute packing for her stay at the hospital or birthing center, preparing older children for her departure and the upcoming birth, or giving instructions to the person who will take care of them while she is away.
Nursing Responsibilities
Allow her to continue to be active (Greulich & Tarrant, 2007).
Encourage her to continue or begin alternative methods of pain relief such as aromatherapy or distraction
Breathing Exercises
Encourage to void every 2-4 hrs
Encourage non-pharmacotherapeutic measures
B. Active Phase
During the active phase of labor, cervical dilatation occurs more rapidly,
Intensity
Strong
Duration of Contraction
40-60 seconds every 3-5 minutes
Cervical Dilatation
4-7 cm
Length of Phase
Nullipara: 3hrs
Multipara: 2hrs
Show (increased vaginal secretions) and perhaps spontaneous rupture of the membranes may occur during this time.
This phase can be a difficult time for a woman because contractions grow strong, last longer, and begin to cause true discomfort. It is also an exciting time, because something dramatic is suddenly happening. It can be a frightening time as a woman realizes labor is truly progressing and her life is about to change forever
The active stage of labor in a Friedman graph can be subdivided into the following periods: acceleration (4 to 5 cm) and maximum slope (5 to 9 cm).
During the period of maximum slope, cervical dilatation proceeds at its most rapid pace, averaging 3.5 cm per hour in nulliparas and 5 to 9 cm per hour in multiparas.
Nursing responsibilities
Encourage women to remain active participants in labor by assuming what position is most comfortable for them during this time (Albers, 2007).
Encourage to drink at least a glass of fluid every hour
Support and provide comfort measures
Encourage Effective breathing patterns
C. Transition Phase
During the transition phase, contractions reach their peak of intensity,
Intensity
Peak of Intensity
Duration of Contraction
60-90 seconds every 2-3 minutes
Cervical Dilatation
8-10 cm
If the membranes have not previously ruptured or been ruptured by amniotomy, they will rupture as a rule at full dilatation (10 cm). If it has not previously occurred, show occurs as the last of the mucus plug from the cervix is released.
By the end of this phase, both full dilatation (10 cm) and complete cervical effacement (obliteration of the cervix) have occurred.
During this phase, a woman may experience intense discomfort, so strong that it is accompanied by nausea and vomiting. Because of the intensity and duration of the contractions, a woman may also experience a feeling of loss of control, anxiety, panic, or irritability
The peak of the transition phase can be identified by a slight slowing in the rate of cervical dilatation when 9 cm is reached (termed deceleration on a labor graph). As a woman reaches the end of this stage at 10 cm of dilatation, a new sensation (i.e., an irresistible urge to push) occurs.
Nursing Responsibilities
Prepare the LR, DR and Postpartum Room
Promoting Effective second stage pushing
Should push with contractions, rest in between them
Multipara - prevent from pushing but instead pant during contraction, assist the patient to maintain control
Holding breath during contraction
I. Second Stage
The second stage of labor is the period from full dilatation and cervical effacement to birth of the infant; with uncomplicated birth, this stage takes about 1 hour (Archie, 2007)
A woman feels contractions change from the characteristic crescendo–decrescendo pattern to an overwhelming, uncontrollable urge to push or bear down with each contraction as if to move her bowels.
She may experience momentary nausea or vomiting because pressure is no longer exerted on her stomach as the fetus descends into the pelvis.
She pushes with such force that she perspires and the blood vessels in her neck may become distended.
As the fetal head touches the internal side of the perineum, the perineum begins to bulge and appears tense.
The anus may become everted, and stool may be expelled.
As the fetal head pushes against the perineum, the vaginal introitus opens and the fetal scalp appears at the opening to the vagina.
At first, the opening is slitlike, then becomes oval, and then circular. The circle enlarges from the size of a dime, then a quarter, then a half-dollar. This is called crowning.
The need to push becomes so intense that she cannot stop herself. She barely hears the conversation in the room around her. All of her energy, her thoughts, her being are directed toward giving birth.
As she pushes, using her abdominal muscles to aid the involuntary uterine contractions, the fetus is pushed out of the birth canal.
Properly Timed Cord Clamping
After umbilical pulsations stopped, clamp the cord at 2cm from the umbilical base, clamp again at 5cm from the base
Cut the cord close to the plastic clamp
III. Third Stage
The third stage of labor, the placental stage, begins with the birth of the infant and ends with the delivery of the placenta. Two separate phases are involved: placental separation and placental expulsion.
After the birth of an infant, a uterus can be palpated as a firm, round mass just inferior to the level of the umbilicus.
After a few minutes of rest, uterine contractions begin again, and the organ assumes a discoid shape.
It retains this new shape until the placenta has separated, approximately 5 minutes after the birth of the infant.
A. Placental Separation
As the uterus contracts down on an almost empty interior, there is such a disproportion between the placenta and the contracting wall of the uterus that folding and separation of the placenta occur.
Active bleeding on the maternal surface of the placenta begins with separation; this bleeding helps to separate the placenta still farther by pushing it away from its attachment site. As separation is completed, the placenta sinks to the lower uterine segment or the upper vagina.
The following signs indicate that the placenta has loosened and is ready to deliver:
Lengthening of the umbilical cord
Sudden gush of vaginal blood
Change in the shape of the uterus
Firm contraction of the uterus
Appearance of the placenta at the vaginal opening
If the placenta separates first at its center and last at its edges, it tends to fold onto itself like an umbrella and presents at the vaginal opening with the fetal surface evident. Appearing shiny and glistening from the fetal membranes, this is called a Schultze presentation. Approximately 80% of placentas separate and present in this way. If, however, the placenta separates first at its edges, it slides along the uterine surface and presents at the vagina with the maternal surface evident.
It looks raw, red, and irregular, with the ridges or cotyledons that separate blood collection spaces showing; this is called a Duncan presentation. A simple trick of remembering the presentations is associating “shiny” with Schultze (the fetal membrane surface) and “dirty” with Duncan (the irregular maternal surface)
Bleeding occurs as part of the normal consequence of placental separation, before the uterus contracts sufficiently to seal maternal sinuses. The normal blood loss is 300 to 500 mL.
B. Placental Expulsion
After separation, the placenta is delivered either by the natural bearing-down effort of the mother or by gentle pressure on the contracted uterine fundus by a physician or nurse midwife (Credé’s maneuver)
Pressure must never be applied to a uterus in a noncontracted state, because doing so may cause the uterus to evert and hemorrhage. This is a grave complication of birth, because the maternal blood sinuses are open and gross hemorrhage could occur (Poggi, 2007).
If the placenta does not deliver spontaneously, it can be removed manually. With delivery of the placenta, the third stage of labor is complete
Fourth Stage
Observer the amount and charactheristics of Lochia
Lochia Rubra - Red in color 1-3 days postpartum
Lochia Serosa - Pink in color, 3-10 days postpartum
Lochia Alba - White in color 10-14 postpartum
Administer Oxytocin (pitocin 10 Units) IM or IV to help contraction and excessive bleeding with poor uterine contractions per doctors order
Pitocin causes hypertension by vasoconstriction
Obtain baseline BP before administration
Obtain vital signs q 15 mins for the first hour and record
Perineal Inspection - To be certain that the perineum did not tear from the pressure of the fetal head
Maternal and Fetal Responses to Labor
A. Physiologic Effects of Labor on a Woman
Cardiovascular System
Labor involves strenuous work and effort and requires a response from the cardiovascular system
Cardiac Output.
Each contraction greatly decreases blood flow to the uterus because the contracting uterine wall puts pressure on the uterine arteries
This increases the amount of blood that remains in a woman’s general circulation, leading to an increase in peripheral resistance, which in turn results in an increase in systolic and diastolic blood pressure. In addition, the work of pushing during labor may increase cardiac output by as much as 40% to 50% above the prelabor level.
Cardiac output then gradually decreases from this high level, within the first hour after birth, by about 50%.
An average woman’s heart adjusts well to these sudden changes. If she has a cardiac problem, however, these sudden hemodynamic changes can have implications for her health.
Blood Pressure
With the increased cardiac output caused by contractions during labor, systolic blood pressure rises an average of 15 mm Hg with each contraction
Higher increases could be a sign of pathology.
When a woman lies in a supine position and pushes during the second stage of labor, pressure of the uterus on the vena cava causes her blood pressure to drop precipitously, leading to hypotension.
An upright or side-lying position during the second stage of labor not only makes pushing more effective but also can help avoid such a problem
Hemopoietic System
The major change in the blood-forming system that occurs during labor is the development of leukocytosis, or a sharp increase in the number of circulating white blood cells, possibly as a result of stress and heavy exertion.
At the end of labor, the average woman has a white blood cell count of 25,000 to 30,000 cells/mm3, compared with a normal count of 5000 to 10,000 cells/mm3.
Respiratory System
Whenever there is an increase in cardiovascular parameters, the body responds by increasing the respiratory rate to supply additional oxygen.
Total oxygen consumption increases by about 100% during the second stage of labor.
Women adjust well to this change, which is comparable to that of a person performing a strenuous exercise such as running. It can result in hyperventilation.
Using appropriate breathing patterns during labor can help avoid severe hyperventilation.
Temperature Regulation
The increased muscular activity associated with labor can result in a slight elevation (1° F) in temperature.
Diaphoresis occurs with accompanying evaporation to cool and limit excessive warming.
Fluid Balance
Because of the increase in rate and depth of respirations (which causes moisture to be lost with each breath) and diaphoresis, insensible water loss increases during labor.
Fluid balance is further affected if a woman eats nothing but sips of fluid or ice cubes or hard candy.
Although not a concern in usual labor, the combination of increased fluid losses and decreased oral intake may make intravenous fluid replacement necessary if labor becomes prolonged.
Urinary System
With a decrease in fluid intake during labor and the increased insensible water loss, the kidneys begin to concentrate urine to preserve both fluid and electrolytes.
Specific gravity may rise to a high normal level of 1.020 to 1.030. It is not unusual for protein (trace to 1) to be evident in urine because of the breakdown of protein caused by the increased muscle activity.
Pressure of the fetal head as it descends in the birth canal against the anterior bladder reduces bladder tone or the ability of the bladder to sense filling.
Musculoskeletal System
All during pregnancy, relaxin, an ovarian-released hormone, has acted to soften the cartilage between bones.
In the week before labor, considerable additional softening causes the symphysis pubis and the sacral/coccyx joints to become even more relaxed and movable, allowing them to stretch apart to increase the size of the pelvic ring by as much as 2 cm
Gastrointestinal System
The gastrointestinal system becomes fairly inactive during labor, probably because of the shunting of blood to more life sustaining organs and also because of pressure on the stomach and intestines from the contracting uterus.
Digestive and emptying time of the stomach become prolonged.
Some women experience a loose bowel movement as contractions grow strong, similar to what they may experience with menstrual cramps.
Neurologic and Sensory Responses
The neurologic responses that occur during labor are responses related to pain (increased pulse and respiratory rate).
Early in labor, the contraction of the uterus and dilatation of the cervix cause the discomfort.
At the moment of birth, the pain is centered on the perineum as it stretches to allow the fetus to move past it.
B. Psychological Responses of a Woman to Labor
Fatigue
By the time a date of birth approaches, a woman is generally tired from the burden of carrying so much extra weight.
In addition, most women do not sleep well during the last month of pregnancy (Beebe & Lee, 2007).
It can make the process of labor loom as an overwhelming, unendurable experience unless they have competent support people with them.
Fear
Women appreciate a review of the labor process early in labor as a reminder that childbirth is not a strange, bewildering event but a predictable and well-documented one.
Being taken by surprise—labor moving faster or slower than the woman thought it would or contractions harder and longer than she remembers from last time—can lead a woman to feel out of control and increase the pain she experiences.
Explain that labor is predictable, but also variable, to limit this kind of fear. Be sure to explain that contractions last a certain length and reach a certain firmness but always have a pain-free rest period in between.
Cultural Influences
Cultural factors can strongly influence a woman’s experience of labor.
In the past, American women were accustomed to following hospital procedures and the medical model of care; therefore, they followed instructions during labor with few questions.
Today, women are educated to help plan their care. In addition, every woman responds to cultural cues in some way.
This makes her response to pain, her choice of nourishment, her preferred birthing position, the proximity and involvement of a support person, and customs related to the immediate postpartal period individualized (Price, Noseworthy, & Thornton, 2007).
C. Physiologic Effects of Labor to a Fetus
Neurologic System
Uterine contractions exert pressure on the fetal head, so the same response that is involved with any instance of increased intracranial pressure occurs.
The fetal heart rate (FHR) decreases by as much as 5 beats per minute (bpm) during a contraction, as soon as contraction strength reaches 40 mm Hg.
This decrease appears on a fetal heart monitor as a normal or early deceleration pattern
Cardiovascular System
The ability to respond to cardiovascular changes is usually mature enough that the fetus is unaffected by the continual variations of heart rate that occur with labor—a slight slowing and then a return to normal (baseline) levels.
During a contraction, the arteries of the uterus are sharply constricted and the filling of cotyledons almost completely halts.
The amount of nutrients, including oxygen, exchanged during this time is reduced, causing a slight but inconsequential fetal hypoxia.
Integumentary System
The pressure involved in the birth process is often reflected in minimal petechiae or ecchymotic areas on a fetus (particularly the presenting part).
There may also be edema of the presenting part (caput succedaneum).
Musculoskeletal System
The force of uterine contractions tends to push a fetus into a position of full flexion, the most advantageous position for birth.
Respiratory System
The process of labor appears to aid in the maturation of surfactant production by alveoli in the fetal lung.
The pressure applied to the chest from contractions and passage through the birth canal helps to clear it of lung fluid.
For this reason, an infant born vaginally is usually able to establish respirations more easily than a fetus born by cesarean birth.
Maternal Danger Signs
High or Low Blood Pressure
Normally, a woman’s blood pressure rises slightly in the second (pelvic) stage of labor because of her pushing effort.
A systolic pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg, or an increase in the systolic pressure of more than 30 mm Hg or in diastolic pressure of more than 15 mm Hg (the basic criteria for pregnancyinduced hypertension), should be reported.
Just as important to report is a falling blood pressure, because it may be the first sign of intrauterine hemorrhage.
Abnormal Pulse
Most pregnant women have a pulse rate of 70 to 80 bpm. This rate normally increases slightly during the second stage of labor because of the exertion involved. A maternal pulse rate greater than 100 bpm during the normal course of labor is unusual and should be reported. It may be another indication of hemorrhage.
Inadequate/Prolonged Contractions
Uterine contractions normally become more frequent, intense, and longer as labor progresses. If they become less frequent, less intense, or shorter in duration, this may indicate uterine exhaustion (inertia). If this problem cannot be corrected, a cesarean birth may be necessary. A period of relaxation must be present between contractions so that the intervillous spaces of the uterus can fill and maintain an adequate supply of oxygen and nutrients for the fetus. As a rule, uterine contractions lasting longer than 70 seconds should be reported,
Pathologic Retraction Ring
An indentation across a woman’s abdomen, where the upper and lower segments of the uterus join, may be a sign of extreme uterine stress and possible impending uterine rupture. For this reason, it is important to observe the contours of a woman’s abdomen periodically during labor. Fetal heartbeat auscultation automatically provides a regular opportunity to assess a woman’s abdomen.
Abnormal Lower Abdominal Contour
If a woman has a full bladder during labor, a round bulge on her lower anterior abdomen may appear. This is a danger signal for two reasons: first, the bladder may be injured by the pressure of a fetal head; second, the pressure of the full bladder may not allow the fetal head to descend. To avoid a full bladder, women need to try to void about every 2 hours during labor.
Increasing Apprehension
Warnings of psychological danger during labor are as important to consider in assessing maternal well-being as are physical signs. A woman who is becoming increasingly apprehensive despite clear explanations of unfolding events may only be approaching the second stage of labor. She may, however, not be “hearing” because she has a concern that has not been met. Increasing apprehension also needs to be investigated for physical reasons, because it can be a sign of oxygen deprivation or internal hemorrhage
Fetal Danger Signs
High or Low Fetal Heart Rate
As a rule, an FHR of more than 160 bpm (fetal tachycardia) or less than 110 bpm (fetal bradycardia) is a sign of possible fetal distress. An equally important sign is a late or variable deceleration pattern (described later) on a fetal monitor. The FHR may return to a normal range in between these irregular patterns, giving a false sense of security if FHR is assessed only between contractions.
Meconium Staining
Meconium staining, a green color in the amniotic fluid, is not always a sign of fetal distress but is highly correlated with its occurrence. It reveals that the fetus has had loss of rectal sphincter control, allowing meconium to pass into the amniotic fluid. It may indicate that a fetus has or is experiencing hypoxia, which stimulates the vagal reflex and leads to increased bowel motility. Although meconium staining may be normal in a breech presentation, because pressure on the buttocks causes meconium loss, it should always be reported immediately so that its cause can be investigated.
Hyperactivity
Ordinarily, a fetus is quiet and barely moves during labor. Fetal hyperactivity may be a sign that hypoxia is occurring, because frantic motion is a common reaction to the need for oxygen.
Oxygen Saturation
If a fetus is assessed for oxygen saturation level by a catheter inserted next to the cheek, a low oxygen saturation level (under 40%) or if fetal blood was obtained by scalp puncture, the finding of acidosis (blood pH 7.2) suggests that fetal well-being is becoming compromised. Oxygen saturation in a fetus is normally 40% to 70%.
Care of a Woman During the First Stage of Labor
Labor is a natural process and nurses can be instrumental in keeping labor as free of unnecessary interventions as possible (Sleutel, Schultz, & Wyble, 2007). Six major concepts to make labor and birth as natural as possible are:
Labor should begin on its own, not be artificially induced.
Women should be able to move about freely throughout labor, not be confined to bed.
Women should receive continuous support during labor.
No interventions such as intravenous fluid should be used routinely.
Women should be allowed to assume a nonsupine (e.g.,upright, side-lying) position for birth.
Mother and baby should be together after the birth, with unlimited opportunity for breastfeeding (Amis & Green, 2007).
A woman needs to feel that she has some control over her situation during labor to face this big event in her life.
Most women accomplish this by stating their preferences, breathing with contractions, and changing their position to the one that makes them most comfortable.
In contrast, some women handle the stress of labor by becoming extremely quiet and passive.
Others feel most comfortable when they can show their emotions by shouting or crying. Help a woman express her feelings in her own way, one that works the best for her.
Respect Contraction Time
Do not interrupt a woman who is in the middle of breathing exercises during labor because, once her concentration is disrupted, she will feel the extent of the contraction.
Promote Change of Positions
Because the bed is the main piece of furniture in a birthing room, many women assume that they are expected to lie quietly in bed during labor.
In early labor, however, a woman may be out of bed walking or sitting up in bed or in a chair, kneeling, squatting, or in whatever position she prefers
A woman whose membranes have ruptured should lie on her side until a fetal monitor shows good baseline variability and no variable decelerations or until she has been checked by a physician or nurse-midwife, because, unless the head of the fetus is well engaged (firmly fitting into the pelvic inlet), the umbilical cord may prolapse into the vagina if she walks.
If medication such as a narcotic is given, educate a woman to remain in bed for approximately 15 minutes afterward to avoid a fall if she should become dizzy from the medication. While a woman is in bed, encourage her to lie on her side, preferably the left side. This position causes the heavy uterus to tip forward, away from the vena cava, allowing free blood return from the lower extremities and adequate placental filling and circulation.
Some women have learned to do breathing exercises in a supine position and may need additional coaching to do them in a side-lying position. If a woman must turn to her back during a contraction to make her breathing exercises effective, help her to remember to return to her side between contractions
Offer Support
There is no substitute for personal touch and contact as a way to provide support during labor.
Patting a woman’s arm while telling her that she is progressing in labor, brushing a wisp of hair off her forehead, wiping her forehead with a cool cloth—these are indispensable methods of conveying concern
Respect and Promote the Support person
Admit a woman’s support person to the birthing area and allow him or her to remain with a woman throughout the birth.
Having someone with her during labor is important, because everything is new and unexpected.
Acquaint the woman and her support person with the physical facilities, and point out where supplies such as towels,washcloths, and ice chips are stored, so the support person can get them when necessary.
Support a Woman’s Pain Management Needs
Many women plan on using nonpharmacologic pain relief measures such as aromatherapy during labor; ask what the woman has planned and what your role should be (Burns et al., 2007).
Some women believe that using a prepared childbirth method will create a pain-free, effortless labor.
When this does not happen, they may panic and lose the ability to use prepared breathing.
Sometimes, simply the support of a person, such as a nurse, who is confident that breathing can be effective in reducing the discomfort of labor is all a woman needs to resume her breathing exercises with success.
Care of a Woman During Second Stage of Labor
The second stage of labor is the time from full cervical dilatation to birth of the newborn.
Even women who have taken childbirth education classes are surprised at the intensity of the contractions in this phase of labor.
Because the feeling to push is so strong, some women react to this change. in contractions by growing increasingly argumentative and angry or by crying and screaming.
Other women react by tensing their abdominal muscles and trying to resist, making the sensation even more painful and frightening.
Preparing the Place of Birth
For a multipara, convert a birthing room into a birth room by opening the sterile packs of supplies on waiting tables when the cervix has dilated to 9 to 10 cm.
For a primipara, this can be delayed until the head has crowned to the size of a quarter or half-dollar (full dilatation and descent).
A table set with equipment such as sponges, drapes, scissors, basins, clamps, bulb syringe, vaginal packing, and sterile gowns, gloves, and towels can be left, covered, for up to 8 hours.
Be certain that drapes and materials used for birth are sterile, so that no microorganisms can be accidentally introduced into the uterus.
Positioning for Birth
Women can choose a variety of positions for birth.
At one time, the lithotomy position was the major position for birth, but it is no longer the position of choice in birthing rooms or alternative birth centers—although the labor beds in these locales have attached stirrups to allow birth in a lithotomy position.
Alternative birth positions include the lateral or Sims’ position, the dorsal recumbent position (on the back with knees flexed), semi-sitting, and squatting.
Because pushing becomes less effective in a lithotomy position, the top portion of the table should be raised to a 30-to 60-degree angle, so that the woman can continue to push effectively.
Lying for longer than 1 hour in a lithotomy position leads to intense pelvic congestion, because blood flow to the lower extremities is impeded.
Pelvic congestion may lead to an increase in thrombophlebitis in the postpartal period. It may also contribute to excessive blood loss with birth and placental loosening.
For these reasons, place the woman’s legs in a lithotomy position only at the last moment.
Promoting Effective Second-Stage Pushing
For the most effective pushing during the second stage of labor, a woman should wait to feel the urge to push even though a pelvic examination has revealed that she is fully dilated.
She should push with contractions and rest between them. Pushing is usually best done from a semi-Fowler’s, squatting, or “all-fours” position rather than lying flat, to allow gravity to aid the effort.
A woman can use short pushes or long, sustained ones, whichever are more comfortable. Holding the breath during a contraction could cause a Valsalva maneuver or temporarily impede blood return to the heart because of increased intrathoracic pressure.
This could also interfere with blood supply to the uterus. To prevent her from holding her breath during pushing, urge her to breathe out during a pushing effort.
Perineal Cleaning
To remove vaginal or rectal secretions and prepare the cleanest environment for the birth of the baby, clean the perineum. with a warmed antiseptic such as Iodophor (cold solution causes cramping) and then rinse it with a designated solution before birth, according to the policy of the physician, nurse-midwife, or agency.
Always clean from the vagina outward (so that microorganisms are moved away from the vagina, not toward it), using a clean compress for each stroke. Be sure and include a wide area (vulva, upper inner thighs, pubis, and anus).
If a physician or nurse-midwife plans to use sterile drapes, help place them around the perineum.
Introducing the Infant
After the cord is cut, it is time for the new parents to spend some time with their newborn.
Take the infant from the physician or nurse-midwife and wrap the infant in a sterile blanket.
Be sure to hold newborns firmly, because they are covered with slippery amniotic fluid and vernix.
Both the mother and her partner usually want to see and touch their newborn immediately; this assures them the baby is well and is an important step in establishing a parent–child relationship.
Care of a Woman During the Third and Fourth Stage of Labor
Placenta Delivery
Oxytocin Administration
Perineal Repair
Immediate Postpartum Assessment and Nursing Care
Obtain vital signs (i.e., pulse, respirations, and blood pressure) every 15 minutes for the first hour and then according to agency policy.
Pulse and respirations may be fairly rapid immediately after birth (80 to 90 bpm and 20 to 24 respirations per minute) and blood pressure slightly elevated because of the excitement of the moment and recent oxytocin administration.
Palpate a woman’s fundus for size, consistency, and position and observe the amount and characteristics of lochia.
Perform perineal care, and apply a perineal pad.If the birth was in a birthing room, return the birthing bed to its original position.
Offer a clean gown and a warmed blanket, because a woman often experiences a chill and shaking sensation 10 to 15 minutes after birth.
Aftercare
This is the beginning of the postpartal period or the fourth stage of labor.
Because the uterus may be so exhausted from labor that it cannot maintain contraction, there is a high risk for hemorrhage during this time.
In addition, a woman often is so exhausted that she may be unable to assess her own condition or report any changes.