Authors marcia gould rohlik msn rnc janet smith bsn rnc evelyn m hickson rn msn cns
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Authors: Marcia Gould Rohlik, MSN, RNC Janet Smith, BSN, RNC Evelyn M Hickson, RN, MSN, CNS PowerPoint PPT Presentation


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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. Objectives. Discuss the nursing management of the third stage of labor.

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Authors: Marcia Gould Rohlik, MSN, RNC Janet Smith, BSN, RNC Evelyn M Hickson, RN, MSN, CNS

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Authors marcia gould rohlik msn rnc janet smith bsn rnc evelyn m hickson rn msn cns

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


Objectives

Objectives

  • 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.


Definitions

Definitions

  • 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)


Delivery of placenta

Delivery of Placenta

  • Decreases size of uterine cavity

  • Decreased size reduces implantation site

  • Uterine contractions of perpendicular muscle layers encourage separation

  • Uterus contracts firmly after expulsion


Four signs of placental separation

Four Signs of Placental Separation

  • Spherical uterus

  • Uterus rises as placenta enters vagina

  • Increased cord length protruding

  • Gush of blood


Plaenta

Plaenta

  • Fetal side: Shiny “Schultze”

  • Maternal side: Dirty “Duncan”

  • Cord – notice whether there are abnormalities

  • how many vessels are in the umbilical cord


Immediate post placental delivery care

Immediate Post-Placental Delivery Care

  • 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

  • Fundus/Bleeding

    • Palpation

    • Massage

    • Oxytocin-Uterine Tonic

    • Baby to breast

      Assessment of Injury:

    • Cervical

    • Vaginal

    • Perineum

    • Labial


Normal blood loss at delivery

Normal Blood Loss at Delivery

  • Vaginal Delivery

    • < 500 mL

  • Cesarean Section

    • < 1000 mL


After delivery of placenta next hour

After Delivery of Placenta – Next hour

  • Primary Goals:

  • Assessment of Recovery – follow Standards of Care for assessment and documentation

    • 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!


  • Physical recovery comfort

    Physical Recovery & Comfort

    • Ice

    • Intake

    • Sensitivity, modesty, Cultural Competence

    • Topicals

    • Medications for pain

    • Modified Aldrete for analgesia recovery

    • Hemostasis

      • Fundus

      • Lochia

      • VS

    • Recovery from epidural (regional) vs local and IV analgesia and anesthesia


    Assessment parameters new this year

    Assessment Parameters – New This Year!

    • 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)


    Assessment parameters

    Assessment Parameters

    • Infant

      • Vital signs every 30 minutes x 2 hours, then every 4 hours x 2, then every 8 hours


    Pain assessment parameters

    Pain Assessment Parameters

    • 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


    Cardiovascular

    Cardiovascular

    • 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


    Hemodynamic changes

    Hemodynamic Changes

    • 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


    Hemodynamic changes1

    Hemodynamic Changes

    • 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


    Hemodynamic changes2

    Hemodynamic Changes

    • 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)


    Respiratory issues

    Respiratory Issues

    • 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)


    Urine output vaginal delivery

    Urine Output – Vaginal Delivery

    • 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)


    Urine output c section

    Urine Output – C-section

    • 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


    Potential complications

    Potential Complications


    Third stage complications will be discussed in ob emergencies

    Third Stage Complications(Will be discussed in OB Emergencies)

    • Postpartum hemorrhage

    • Lacerations

    • Hematomas

    • Amniotic fluid emboli

    • Other emboli – pulmonary, cerebral/stroke

    • MI


    Other issues

    Other Issues:

    • Psycho-social issues

      • Family

      • Psychiatric

      • CPS

      • Family members

      • Who is the baby daddy???

    • Impact of other medical problems

      • Diabetes

      • Hypertension

      • Cardiac

      • Respiratory

      • Auto-immune


    Things that bleed

    Things that Bleed


    Laceration of cervix or vaginal wall

    Laceration of cervix or vaginal wall

    • Active bright red bleeding

    • Steady stream or trickle of unclotted blood

    • Firm uterus

    • Call provider

    • **Remember – a patient can bleed enough to become hypovolemic


    Hematomas

    Hematomas

    Vaginal

    Vulval

    Retroperitoneal


    Pelvic hematomas

    Pelvic Hematomas

    • 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


    Vaginal hematomas

    Vaginal Hematomas

    • Results from trauma tothe 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


    Vaginal hematomas1

    Vaginal Hematomas

    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


    Vaginal hematomas2

    Vaginal Hematomas

    • 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.


    Vulvar hematomas

    Vulvar Hematomas

    • 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


    Vulvar hematomas1

    Vulvar Hematomas

    • 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.


    Retroperitoneal hematomas

    Retroperitoneal Hematomas

    • 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


    Other areas of focus

    Other areas of focus

    Psycho-Social Issues

    Pre-existing Medical Problems

    Bonding

    Teaching


    Psycho social issues

    Psycho-Social Issues

    • Support

    • Family dynamics

    • Adoptions

    • CPS alerts

    • Substance abuse

    • Depression/bipolar history

    • Psychotic illness


    Impact other medical problems

    Impact Other Medical Problems

    • Cardiac disease

    • Kidney disease

    • Trauma

    • Paralytic disorders

    • Contagious illness


    Bonding

    Bonding

    • Physical contact and viewing

    • Assessing quality of bonding and support

    • First feedings

    • Cultural awareness

    • Reassurance, information

    • Time pressures


    Teaching

    Teaching

    • Self care

    • Baby care and feeding

    • Newborn characteristics

    • Physical expectations next few days

    • Emotional expectations next few days

    • Keep info short, targeted


    Summary

    Summary

    • Time of dramatic changes

    • Most physical care in background

    • Need for supportive, compassionate, family-centered care


    References

    References

    • 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.

    • AWHONN’s Compendium of Postpartum Care. Johnson and Johnson Inc.; 2006.

    • Chin, MD, FACOG. On Call Obstetrics and gynecology. W.B. Saunders Co. Philadelphia; 1997.

    • Jones, RNC, MSN, Marion W. Postpartum Complications. Health Education Innovations, Inc.; 1996.

    • 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.


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