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Course: Maternity Nursing

Topic: Nursing Care During Fourth Stage of Labour

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Module Goals

The learner will be able to:

Identify immediate care needs of a patient in the 4th stage of labour
Describe assessment and treatment related to perineum care
Describe assessment and prevention related to postpartum hemorrhage
Recognize causes of uterine atony and/or abnormal uterine involution
Identify client teaching for self-care

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Stage 4 of Labour

First hour after delivery of the placenta
Most causes of maternal deaths are attributed to complications after childbirth. (WHO Maternal mortality- Fact Sheet, 2019)
Early identification and management of complications saves lives and prevents/reduces physical and psychological damages that may affect quality of life
Objectives of management during 1st hour of puerperium:

Ensure patient is stable
Prevention of postpartum hemorrhage (PPH)
Early detection and management of complications

Contact info: info@nursesinternational.org

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General Care Principles

When feasible, ensure that the woman has a support person of her choice with her
Provide information to the woman and support person concerning treatment, expected care, and estimated time of in-patient care
Obtain informed consent for all procedures - diagnostic or therapeutic - and care

WHO (2017). Managing Complications in Pregnancy and Childbirth

Contact info: info@nursesinternational.org

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Stage 4 of Labour: Immediate Care

Immediate care:

Assess and record patient vital signs
Assess uterus, massage if boggy
Assess for and prevention of postpartum haemorrhage

Continuing care:
Continue assessing for firm, well-contracted uterus and normal bleeding
Repeat vital signs every 15 minutes for 1st hour and every 30 minutes during the 2nd hour
Perform assessments more frequently if needed until the patient’s condition is stable

Contact info: info@nursesinternational.org

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Immediate Care: Check Mother’s Vital Signs

Assess and record

Blood pressure (BP)
Pulse rate
Respiratory rate
Temperature

The mother should be treated with appropriate antibiotics if febrile
Watch for signs of shock: Systolic pressure < 90 mmHg, weak, rapid, thready pulse rate, high respiratory rate, cool moist skin, altered consciousness

Summon immediate help!

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Immediate Care: Well Contracted Uterus

Assess for uterine tone by palpating abdomen and feeling the uterus
The uterus should be palpated at or slightly below the umbilicus following delivery
If uterus is soft:

Massage the fundus of the uterus through the mother’s abdomen until the uterus is firm and contracted. Be sure to support the lower segment during massage
Assess the uterus after massage is stopped
Teach the mother when and how to palpate and massage her uterus

Uterus

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Immediate Care: Prevent Postpartum Hemorrhage (PPH)

Estimate and record blood loss (normal is less than 500mL)
Normal bleeding after childbirth

As heavy as the monthly menstruation with some clots
Increased blood may be noted when the mother coughs, moves, or stands

Excessive bleeding can be caused by one or more of the following:

Uterine atony, retained placenta, infection, full bladder, genital tears/episiotomy, ruptured uterus

*The primary cause of postpartum hemorrhage is uterine atony (soft uterus that will not contract effectively)

Close monitoring of postpartum uterine tone, vaginal bleeding, pulse, and blood pressure is recommended for prompt identification of and rapid response to uterine atony, excessive bleeding, and hemodynamic changes

Contact info: info@nursesinternational.org

Uterine Atony: A condition where the uterus can contract

According to WHO (2017) - Integrated Management of Pregnancy and childbirth’:

· PPH is commonly defined as blood loss of over 500 ml within 24 hours after vaginal birth

· Severe PPH defined as blood loss of 1000 mL or more in 24 hours

· However, there are problems with these definitions:

o Estimates of blood loss are often half the actual loss.

o The importance of a given volume of blood loss varies with the woman’s haemoglobin level before she gives birth. A woman with a normal haemoglobin level will tolerate blood loss that may be fatal for an anaemic woman

o Active management of the third stage of labour should be offered to all women in labour to reduce the incidence of PPH due to uterine atony

According to Hesperian Health Guides - ‘A Book of Midwives’:

· A uterus that will not contract after childbirth feels soft.

· A soft uterus is the most common reason a mother bleeds heavily after birth

· A uterus may stay soft because:

o bladder is full

o retained placenta or membrane in the uterus

o the uterus needs more oxytocin to make it contract

o womb needs more stimulation to make it contract

o presence of infection

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Vaginal Bleeding: Soft (Boggy)Uterus

Initial interventions:

Massage the uterus (top of the uterus is called the fundus)
Help the mother breastfeed
Help mother urinate
Examine the placenta for intactness

Pharmacological management of heavy bleeding:

Oxytocin
Ergometrine
Misoprostol
Antibiotics for treating infection of uterus

Contact info: info@nursesinternational.org

Please refer to the slide deck ‘Nursing care of stage 3 of labour’ for information on identification and management of retained placenta/partial placental fragments.

According to the Hesperian Health Guides ‘A Book for Midwives’, chapter 13:

· Massage the uterus

o put your hand on the top of the uterus and squeeze while you move the same hand in a circle

· check for retained placenta again

· Help the mother breastfeed

o Breastfeeding stimulates oxytocin production by the mother’s body

o Oxytocin causes contraction of the uterus

· Assist the mother to urinate- a full bladder may keep the uterus from contracting

If the mother does not urinate in 4-6 hours, she may need to be catheterized to empty the bladder

· 2 hand pressure massage:

o Massage the uterus until it gets hard

o cup one hand over the top of the uterus while the other hand is placed above the pubic bone

o Now push the uterus towards the cupped hand and squeeze the uterus between your hands

o slowly stop the 2 hand pressure as soon as the bleeding slows down and the uterus feels firm.

· If all of the above does not work, then give medication

o Oxytocin:

o Ergometrine

o Misoprostol

According to WHO (2017), managing complications in pregnancy and childbirth: a guide for midwives and doctors – 2nd ed:

Pharmacological management of heavy bleeding

· Oxytocin

o Initial IV dose: infuse 20 units in 1 liter at fastest flow rate possible

o Continuing IV dose: Infuse 20 units in 1 liter IV fluids at 40 drops/minute

o Maximum dose: not more than 3 liters of fluids containing oxytocin

o Precaution/contraindication: Do not give as an IV bolus

· Ergometrine/Methylergometrine:

o IM/IV 0.2 mg slowly

o Continuing dose IM: 0.2 mg slowly after 15 minutes

o If required, give 0.2 mg IM or IV slowly, every 4 hours

o Maximum dose: Five doses (total 1.0 mg)

o Contraindications: high blood pressure, pre-eclampsia, heart disease, retained placenta

· Misoprostol PGE1

o Sublingual: 800 mcg

o Repeat dose: 200 to 800 mcg

o Maximum dose: not more than 1600 mcg

· 15-Methyl Prostaglandin F2 alpha

o Initial dose IM: 0.25 mg

o Repeat 0.25 mg every 15 minutes

o Maximum dose: eight doses (total 2 mg)

o Contraindications: Asthma, do not give IV route

· Tranexamic acid

o Initial dose IV: 1 g slowly

o Repeat after 30 minutes if bleeding continues

o Maximum dose: not more than 10 mg per kg body weight, three to four times daily

o Precautions/contraindication: History of coagulopathy or active intravascular clotting, convulsion

· The drip rate is calculated using a set with 20 drops/ml.

· Prostaglandins should not be given intravenously. They can be fatal.

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Vaginal Bleeding: Cervical Tear

Cervical or vaginal tear should be considered when:

Heavy bleeding does not resolve despite well contracted uterus
Uterine rupture has been ruled out

Cervix is examined for tear under good visualization, which may require transfer to theatre (operating room) for anaesthesia
Management:

Minor lacerations with no bleeding do not require suturing
Hemostasis of tear can sometimes be achieved by grasping the torn edges of the bleeding area with the sponge-holders while the patient is transferred to the theatre for surgical repair

Contact info: info@nursesinternational.org

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Vaginal Bleeding: Vaginal/Perineal Tear

Tear in the tissues of the the vagina and perineum
Tear is graded:

1^st- degree- first layer of skin in the vagina. No suture is needed
2^nd- degree-includes muscular tissue of vagina and perineum
3^rd - degree-involves skin, muscular tissues as well as damage to the anal sphincter muscle
4^th - degree tear- involves anal sphincter as well as rectum

Episiotomy can also cause bleeding
There is risk of vaginal infection with fecal contamination if tears are not sutured within 12 hours

Contact info: info@nursesinternational.org

According to WHO (2017) Managing complications in pregnancy and childbirth: a guide for midwives and doctors – 2nd ed:

Examination of the tear:

· Explain to the woman what needs to be done and obtain her verbal consent. Repair of tears is performed by a skilled provider. Depending on country standards for scope of nursing practice, this may be done by a nurse-midwife or trained nurse

· Ensure good lighting.

· Ensure that the woman is in a suitable position to enable e visualization of the genital tract.

· Visually assess the extent of perineal trauma to include the structures involved, the apex of the injury, and any bleeding.

· Use instruments or gauze pads to assist with visualization to ensure that you see the apex of any tear or laceration.

· If the tear is long and deep through the perineum, inspect it to be sure that there is no third or fourth-degree tear: -

o Place a gloved finger in the anus.

o Gently lift the finger and identify the sphincter or lack of it.

o Feel for the tone or tightness of the sphincter.

o Feel the surface of the rectum and look carefully for protrusion of the finger into the vagina, which shows a tear.

o Change gloves after the rectal exam, carefully wash and dry hands, and put on a new pair of sterile gloves to repair any identified tears.

According to Hesperian Health Guides ‘A Book for Midwives’- Chapter 19:

· Small tears that stop bleeding quickly do not need to be sutured.

· They also usually heal on their own.

· Deeper tears or tears that will not stop bleeding, need suturing

· Discuss with the mother if the tear needs to be sutured.

· Tears must be sutured within 12 hours.

· Must be sutured by a skilled care provider.

· 3rd and 4rth degrees need to be repaired in an operating theatre.

· 1st and 2nd-degree tear that has not been sutured within 12 hours needs to be cleaned, and the mother needs to be counseled to rest for two weeks.

· 3rd and 4rth degrees must be cleaned and sutured or the mother can have permanent damage to her body. The mother may not be able to control her need to pass stool. If possible, take the mother to the medical center.

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Vaginal/Perineal Tear

vaginal opening

Length of tear

Anus

First degree tear

Second degree tear

Fourth degree tear

Third degree tear

Perineal muscle

Rectum

Anal sphincter

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Case study:

Thirty minutes after the delivery of an intact placenta, the nurse helped the woman clean herself and provided her with a sanitary pad to wear.

Her vital signs are stable and her uterus (fundus) is palpated above and to the left of the umbilicus. She has a few small clots and heavier than menstrual bleeding.

What immediate care should the nurse provide this mother?

Is it normal for a mother to be bleeding after childbirth?

How can nurses prevent postpartum haemorrhage in this mother?

Contact info: info@nursesinternational.org

What immediate care should the nurse provide to this mother?

The nurse should provide the following care:

· Assess and record patients vital signs

· Assess and promote the well-contracted uterus

· Assess and prevent postpartum haemorrhage

· Have the patient empty her bladder as the uterus is misplaced do to a full bladder

The nurse should reassess this mother every 15 minutes for the first hour and every 30 minutes for the next.

Is it normal for a mother to be bleeding after childbirth?

Yes, it is normal for mother to bleed per vaginal after childbirth. However, it important to assess how much she bleeds.

How can the nurse prevent postpartum haemorrhage in this mother?

The nurse can prevent postpartum haemorrhage by

Ensuring delivery of the complete placenta

Ensure contracted uterus post placental delivery, massaging uterine /fundus until the uterus is well contracted

Assess for cervical or vaginal tears, repairing if bleeding present

Assessing for vaginal hematomas, and if present then managing treatment if it continues to grow larger

Assessing vital signs, manage the treatment of fever with antibiotics

Encouraging and assisting in breastfeeding for stimulation of uterine contraction

Continuous monitoring of blood loss through assessment of wet sanitary pads mother uses and taking prompt action if the risk for postpartum haemorrhage

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Immediate Management of Shock

Apply basic principles of care explained previously
Obtain help. Urgently mobilize all available personnel
Monitor vital signs (pulse, BP, respiration, temperature)
If the mother is unconscious, turn her onto her side to minimize the risk of aspiration if she vomits, and to ensure that an airway is patent
Ensure an intravenous access for immediate administration of fluids
Keep the mother warm, but do not overheat her, as this will increase peripheral circulation and reduce blood supply to vital centers
Elevate the legs to increase the return of blood to the heart. If possible, raise the foot end of the bed (Trendelenburg position)

Contact info: info@nursesinternational.org

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Stage 4 of Labour: Routine Care for Normal Vaginal Delivery

Monitor vital signs
Monitor uterus/fundus
Clean the mother’ genitalia, abdomen, and legs
Prevent heavy bleeding
Check genitals for tears and
Assist the mother to urinate
Offer food, fluids and promote rest
Promote maternal-infant attachment

Contact info: info@nursesinternational.org

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Hygiene Care

Provide hygiene care to the mother soon after the immediate care is provided
Wash hands and put on gloves before touching mother’s genitals

Cleanse blood from perineal area and legs
Clean genitals very gently using clean water and sterile cloth
Wash downward, away from the vagina
Change linen

Provide clean pads to mother for vaginal bleeding
Teach mother self-perineal cleansing care and remind her to wash her hands before and after urinating or defecating

Contact info: info@nursesinternational.org

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Check Genitals for Tears and Problems

Explain procedure to the mother
Use a gloved hand to gently examine the mother’s genitals in good lighting
Check for:

Tears
Blood clots
Hematoma (bleeding under the skin)
Whether the cervix has prolapsed (dropped down to the vaginal opening)

Inform mother of abnormal finding, if present, and treat them accordingly

Contact info: info@nursesinternational.org

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Hematoma or Pain in Vagina

Hematoma may present as a large amount of bleeding into vaginal skin

Often looks swollen, dark in color, painful, and soft
The mother may feel dizzy and weak if she is bleeding too much even though the uterus is firm
Pain in the vagina can be a sign that she is bleeding into a hematoma

Hematoma is usually not serious unless it gets very large
If hematoma keeps growing:

Press on the area with sterile gauze for 30 minutes or until it stops growing
Blister can be incised and the trapped blood evacuated by medical-surgical intervention

Contact info: info@nursesinternational.org

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Cervix Prolapse

Cervix at the vaginal opening after childbirth indicates uterine prolapse
Uterus may be pushed farther in with a gloved hand

Teach the mother to squeeze her vaginal muscles as if she were trying to stop urgency to micturate (kegel exercise)
Help mother raise her hips so that they are higher than her head, then ask her to squeeze muscles in her vagina as instructed through kegel exercise- repeat it a couple of times

Emphasise to mother the importance of doing kegel exercises a minimum of four times a day to recover from prolapse

Resting and completely avoiding heavy work

Monitor mother for signs of infection during the next two weeks

Contact info: info@nursesinternational.org

According to the Royal College of Obstetricians and Gynaecologists website on ‘Your pelvic floor’:

‘Tighten your pelvic floor. You can do this by imagining you are desperate to pass urine and you are trying to stop yourself. Hold this for as many seconds as you can, up to a maximum of 10 seconds.

Release and rest for 5 seconds.

Repeat this 'tighten, hold, and release' movement as many times as you can. Aim to do 10 in a row. These exercises will increase your stamina.

You should work at your speed, and you will need to determine your own 'starting level'. For example, if you can hold the contraction for 2 seconds and repeat 4 times, this is your starting level.

To increase the reaction of your pelvic floor muscles you should also do some 'fast squeezes'. To do this, tighten your muscles as before, but stronger and faster. Then release straight away. Aim to do 10 of these in a row.

You can do them anywhere at any time! However, do not do them whilst you are passing urine.

Initially, it may be easier to do them lying down.

You can then try them sitting, or standing.

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Prevent Heavy Bleeding

Palpate the uterus to see if it is firm

If uterus feels hard; it is contracting as it should
Check fundus immediately after the placental delivery
Then, check it every 5 or 10 minutes for 1 hour
For the next 1 or 2 hours, check it every 15 - 30 minutes

Check mother’s pads often for excess bleeding - 500 ml (about 2 cups)
Check the mother’s pulse and blood pressure as indicated in previous slides

Contact info: info@nursesinternational.org

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Case Study:

A patient had a spontaneous normal delivery of a health infant. The placenta is intact. The woman’s fundus is firm and there is no excessive vaginal bleeding. Twenty minutes later, the nurse, who is the only staff member in the clinic, is called away and will have to leave the patient alone for a while.

What is the nurse’s major concern about the patient?

What instructions should the nurse give the patient?

What should the patient do if she notices that her uterus relaxes and/or there is excessive vaginal bleeding?

What should the nurse check on before leaving the patient?

Contact info: info@nursesinternational.org

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Urination

Nutrition and Rest

Encourage the mother to urinate
A full bladder can cause bleeding
If the mother does not urinate within 4-6 hours, urine drainage with a catheter needs to be performed

Encourage mothers to eat within the first few hours and to increase fluids
If she is not hungry, offer liquids that provide energy (juices)
Avoid high sugar drinks like sweet soda that are lacking in nutrition
Counsel her to eat a mix of foods: carbohydrates, vegetables, fruits, and proteins

Contact info: info@nursesinternational.org

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Lack of Mothers Appetite

If the mother will not eat or drink after 2 or 3 hours

She may be tired
Assist her with post delivery hygiene
She may be ill
Check for bleeding, infection, and other signs of illness
She may be depressed (sad, angry, or without feelings)
Encourage her to talk about her feelings
The mother may have cultural beliefs that certain foods are bad to eat after birth
Counsel her on the need for eating nutritious food after birth. Work with her to develop an eating plan that is culturally appropriate for her.

Contact info: info@nursesinternational.org

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Maternal Attachment

If the mother and baby both are healthy, then the baby should be given to the mother soon after birth
Inform mothers about the condition of the baby and answer her queries about the baby’s health
Providing privacy promotes bonding between mother, baby, and father
Assist the mother in taking care of herself and the baby so she can focus on the infant
If the mother is not interested in her baby, talking to her about her feelings might help
If mother is depressed begin a plan for support/care

In this event, someone should care for the baby while the mother recovers

Contact info: info@nursesinternational.org

According to Hesperian Health Guides ‘A Book for Midwives’, Chapter 14:

· Some mothers do not feel good about their new babies and there can be many reasons for it

o the mother may be very tired

o she may be ill or bleeding

o She may not have wanted the baby, or

o She might be worried that she cannot take care of the baby

o She may be very depressed

What to do

· Check mother for signs of blood loss or infection

· you might talk to the mother about her feelings, or you may feel it is better to leave her alone and to watch and wait

· if the mother is depressed after a past birth, talk to the family about giving her extra attention and support in the next weeks.

· Usually, depression passes in time, but sometimes it takes a few weeks or even months.

· Ensure someone in the family takes care of the new baby

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Nursing Management During the 4th Stage of Labor

Ensure mother and baby are continuously monitored for any signs of emergency
Ensure mother and baby are kept together all the time unless one of them requires medical attention
Provide compassionate communication with mother regarding assessments and their results
Assist mother with post delivery hygiene care and breastfeeding
Support attachment between the mother and the baby

Contact info: info@nursesinternational.org

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Red Flags

Bonding issues; not wanting to see or care for the infant

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Cultural Considerations

A cultural practice that does not harm the mother and the baby should be allowed
Cultural practice of putting oil or other things to make the cord fall quicker may need to be reassessed with the family members and counsel them on appropriate cord care

Contact info: info@nursesinternational.org

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References:

Bettercare (n.d.). Maternal Care/12. The puerperium. Retrieved from: https://bettercare.co.za/learn/maternal-care/text/12.html#12-the-puerperium

Royal College of Obstetricians and Gynaecologists, 2020, Your pelvic floor. Retrieved from: https://www.rcog.org.uk/en/patients/tears/pelvic-floor/

WHO Maternal mortality- factsheet, 2019. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality

World Health Organization (2015). Pregnancy, childbirth, postpartum and newborn care: A guide for essential practice (3^rd ed.) Switzerland, Geneva: WHO Press. https://apps.who.int/iris/handle/10665/249580

World Health Organization (2017). Managing complications in pregnancy and childbirth: a guide for midwives and doctors (2nd ed.). Licence: CC BY-NC-SA 3.0 IGO. Retrieved from: https://apps.who.int/iris/handle/10665/255760

Contact info: info@nursesinternational.org

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