5B Fourth Stage of Labour Vocabulary

Fourth Stage of Labour

• Postnatal care promotes:

  • Physical and psychological health/well-being.

  • Education on breast/infant feeding.

  • Maternal/newborn relationship.

  • Confidence in caring for self and baby.

  • Compassionate and respectful care.

  • Respect for views and beliefs.

  • Flexible and tailored care.

• Involution: Uterus returns to pre-pregnancy state.

  • Uterus contracts to birth the placenta.

  • Fundal height is halfway between umbilicus and pubic bone immediately post-birth; size of a small cantaloupe or grapefruit.

  • Fundus should be firm and central (F+C).

  • Contractions control bleeding from the placental wound.

  • Uterus involutes ~1cm/24 hours (1 finger per day).

  • Displacement may indicate a full bladder.

  • Promote contractions via skin-to-skin, breastfeeding, or fundal rub.

  • Uterotonic drugs may be needed for excessive bleeding (PPH).

Care of the woman immediately following birth

• Maternal Assessments:

  • Vital Signs:

    • Temperature: 36.0-37.5^{\circ}C

    • Pulse: 60-100 bpm

    • Respiratory Rate: 12-20 breaths/min

    • Blood Pressure: 100/60 - <140/90 mmHg

  • Perineum: Inspect for trauma; provide comfort measures like ice packs (10-20 minutes, every 2 hours for up to 72 hours); offer analgesia.

  • Palpate Uterus: Firm and central between umbilicus and pubic bone.

  • Observe Lochia: Volume, color, and clots.

  • Bladder Care:

    • Encourage voiding within 2 hours of birth.

    • Document first void.

    • Encourage fluid intake.

    • Enquire about sensation, emptying, incontinence, or retention.

    • Assess if bladder is palpable; escalate if issues arise (catheter may be needed).

  • Rh-Negative Women: Kleihauer blood test and cord blood to determine Anti-D requirement.

  • IV Fluids and Medication: Administer if prescribed.

  • Pain Relief: Assess needs; monitor block levels if epidural/spinal was used.

• Further Care:

  • Congratulate the woman.

  • Keep woman and baby skin-to-skin.

  • Involve other parent/family.

  • Keep the woman warm (e.g., pre-warmed blanket).

  • Encourage breastfeeding and bonding.

  • Offer food and fluids.

  • Assist with first shower and void.

  • Transfer to postnatal ward when stable.

Fetal Transition to Neonatal Circulation

• Requires rapid, complex processes for survival.

• Health professionals need a clear understanding to recognize and manage deviations from normal.

• Transitions include:

  • Increased systemic vascular resistance.

  • Closure of right-to-left shunts.

    • Foramen ovale: Closes due to pressure changes with first breath.

    • Ductus arteriosus: Closes over days due to reduced pulmonary vascular resistance and increased sensitivity to PaO_2; decreased prostaglandin levels influence closure.

  • Lowering of pulmonary vascular resistance with ventilation.

  • Clearance of fluid from airways.

  • Increased metabolic rate and glucose needs.

  • Increased catecholamine levels.

• Umbilical cord clamping increases SVR and blood pressure.

• Elimination of placental blood flow causes functional closure of ductus venosus.

• Umbilical vessels constrict and close.

• Successful Transition:

  • Deoxygenated blood returns to heart via vena cava.

  • Blood flows through right atrium, right ventricle, and pulmonary artery.

  • Oxygenated blood returns via pulmonary veins to left atrium, left ventricle, and aorta.

• Cord clamping decreases oxygen/increases carbon dioxide, stimulating respiration.

• Chest compression during birth forces fluid out of lungs; re-expansion draws air in.

• Crying establishes positive intrathoracic pressure, keeping alveoli open.

• Fluid is forced into lymphatic circulation.

• Essential components for normal transition:

  • Clearance of fetal lung fluid.

  • Surfactant secretion and breathing.

  • Transition of fetal to neonatal circulation.

  • Decreased pulmonary vascular resistance.

  • Endocrine support.

Apgar Score

• Quantitative assessment tool for newborn well-being (Virginia Apgar, 1952).

• Completed while newborn is skin-to-skin with the mother.

• Assessed at 1 minute and 5 minutes of age.

• Resuscitation commences regardless of Apgar score.

• Apgar Score Interpretation:

  • 7 or more at 5 minutes: Adapting well.

  • 4-6 at 5 minutes: Moderate respiratory depression.

  • 0-3 at 5 minutes: Severe respiratory depression.

• Clinical indicator, maternity units collect, monitor, and review.

• Data limited to liveborn babies.

• Lower scores more common in:

  • Low birthweight babies.

  • Pre-term babies.

  • Breech presentation.

• Low Apgar scores increase the likelihood of resuscitation and NICU admission.

Care of the Baby Immediately Following Birth

• Assessment begins at birth and continues until transition is successful.

• Initial assessment determines if intervention is needed, based on:

  • Response to Stimulation: Drying usually stimulates breathing; if not, transfer to resuscitaire.

  • Breathing: Regular respirations maintain HR > 100 bpm. Apnea with hypotonia indicates severe compromise.

  • Muscle Tone: Healthy newborns move limbs and flex. Hypotonia suggests severe compromise.

  • Color: Not used to guide intervention; 'dusky' appearance is normal for first few minutes if breathing effectively, HR > 100 bpm, and good muscle tone.

• Cord Clamping: Delayed/deferred in vigorous newborns not requiring resuscitation.

• Immediate Care of Well Newborn:

  • Dry with a warm towel.

  • Place skin-to-skin on mother’s chest.

  • Cover with a warm blanket.

  • Observe in a warm environment if born in theatre.

  • Suctioning not routinely required.

  • Regularly assess breathing, heart rate, color, and tone.

  • Record Apgar scores at 1 and 5 minutes.

  • Continue assessment for 24 hours.

• Vital Signs:

  • Assess within the first hour, then hourly until four hours old, then once each shift if stable.

  • Meconium-stained liquor or GBS+ may require more frequent monitoring.

• Risk Factors for Hypoglycemia: Blood glucose monitoring per organizational guidelines.

• Instrumental/Vacuum Births: Increased risk of subgaleal hemorrhage.

  • Assess scalp and nape of the neck for ballotable mass or free fluid; escalate immediately.

  • Monitor head circumference; escalate if asymmetrical, cephalhaematoma/caput succedaneum present, or new/increased bruising.

Thermoregulation

• Maintaining body temperature to minimize oxygen consumption.

• Hypothermia/hyperthermia can have severe adverse outcomes.

• Correct temperature maximizes metabolic efficiency and decreases oxygen use.

• Temperature control and neonatal mortality are linked.

• Newborn transitions from 37.7^{\circ}C intrauterine temperature to cooler birthing room (21-23°C).

• Newborns have limited subcutaneous fat and are born wet, increasing heat loss.

• Heat Loss:

  • Conduction: Heat loss to cooler surfaces in direct contact.

  • Convection: Heat loss to cooler air.

  • Evaporation: Heat loss as amniotic fluid evaporates.

  • Radiation: Heat loss to cooler surfaces not in direct contact.

• Best way to keep baby warm: Skin-to-skin contact.

Initiation of Breastfeeding

• Exclusive breastfeeding recommended until 6 months, continuing with solids until 12 months and beyond.

• Golden Hour (or two):

  • Time immediately following birth (until first breastfeed).

  • Includes delayed cord clamping, skin-to-skin contact, and early initiation of breastfeeding.

  • Attending to Apgar score while newborn is on woman’s abdomen.

  • Delay non-urgent tasks.

  • Promotes physiological adaptation of mother/newborn.

• Benefits of skin-to-skin contact:

  • Attachment.

  • Reduced stress.

  • Support for transition to extrauterine life.

  • Stabilized heart rate, breathing, temperature, and blood glucose levels.

  • Reduced postpartum bleeding.

  • Increased milk supply and breastfeeding success.

  • Reduced risk of postnatal depression/anxiety.

  • Improved weight gain.

• Interruptions should be kept to a minimum.

• Benefits of Golden Hour continue beyond initial period.

• Skin to Skin Contact and Breastfeeding Initiation:

  • Should be initiated at birth until the newborn has completed the first breastfeed.

  • Oxytocin release through skin-to-skin contact, warmth, touch, stroking, massage.

  • Initiated at birth or at any time

  • Can stimulate sleepy newborns

• Early initiation of breastfeeding within the first hour protects the newborn from:

  • Acquiring infection

  • Reduces newborn mortality rates

  • Facilitates emotional bonding of the woman and her newborn

    • Has a positive impact on the duration of exclusive breastfeeding

• Timely initiation of breastfeeding enables the newborn to receive colostrum, the first breast milk containing antibodies to protect the newborn against disease

Nine Infant Behavioural Stages After Birth

• Pre-programmed behaviours support physiological processes.

• Practised in utero in a specific order.

Exclusive Breastfeeding and its Effects

• Only breast milk (including expressed breast milk), prescribed medicines, oral rehydration solution, vitamins and minerals.

• Benefits:

  • Reduced risk of sudden infant death.

  • Reduced risk of necrotising enterocolitis.

  • Protection against infectious diseases.

  • Protection against overweight and obesity.

  • Reduced risk of type 1 and type 2 diabetes.

  • Reduction in malocclusion.

  • Improved cognitive development.

• Benefits for the woman:

  • Immediate: Reduced bleeding and infection, longer amenorrhoea, maintaining healthy weight.

  • Long term: Reduced risk of type 2 diabetes, hyperlipidaemia, hypertension, cardiovascular disease, ovarian/endometrial cancer, invasive breast cancer, and depression.

Injections and Vaccinations for Newborn

• Vitamin K (Konakion): Prevents haemorrhagic disease of the newborn (HDN).

  • Administered IM or orally (less effective).

  • Dose: 1mg IM or 2mg oral.

  • High risk include: traumatic births, premature babies, babies who required resuscitation.

• Hepatitis B Vaccination:

  • Recommended.

  • 0.5ml (Engerix-B or H-B-Vax II).

  • Preterm babies < 32 weeks gestation or < 2000 grams birth weight require a booster dose at 12 months.

  • Newborns of mothers with chronic hepatitis B receive hepatitis B vaccine and hepatitis B immunoglobulin (HBIG) within 12 hours of birth.

Normal Variations of the Newborn

• Moulding: Change in head shape due to cranial bones overriding.

• Caput Succedaneum: Oedematous swelling between skin and periosteum.

• Milia: Distended sebaceous glands on the nose.

• Erythema Toxicum: White papules on erythematous base.

• Acrocyanosis: Peripheral cyanosis of hands and feet (first 24 hours).

  • Central cyanosis is not normal.

• Mongolian Spots: Blue-black patches over sacral regions.

Examination of the Newborn

• Careful assessment is important to recognize and manage issues.

• Initial assessment without direct contact during skin-to-skin.

  • Aids in temperature regulation, heart rate/breathing, blood sugar, breastfeeding, bonding.

• Initial Assessment:

  • Identification labels.

  • Vital Signs:

    • Temperature: 36.5-37.5^{\circ}C

    • HR: 110-160 bpm

    • Respirations: 40-60 rpm

  • Measurements:

    • Weight: ~3.5kgs

    • Length: ~50 cms

    • Head circumference: ~35cms

  • General Overview: Anomalies, dysmorphic features, sex.

  • Head to Toe:

    • Head: Fontanelles, sutures, abnormalities.

    • Face: Symmetry, skin, eyes, ears, nose, mouth, palate.

    • Neck: Skin color, folds, abnormalities.

    • Chest: Nipples, symmetry, respirations, heart sounds.

    • Abdomen: Umbilicus.

    • Legs: Symmetry, digits, webbing, talipes.

    • Arms: Symmetry, digits, webbing.

    • Back: Spine, dimples, tufts of hair.

    • Genitalia: Female/male, testes.

    • Anus: Patent.

    • Skin: Abnormalities, bruising, marks, dry skin, lanugo, vernix.

  • Hips:

    • Symmetry, movement, dislocations.

  • Newborn Reflexes:

    • Rooting, Moro, Sucking, Babinski, Grasp, Stepping, Asymmetrical tonic neck reflex.