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

1. 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

2. 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.

3. 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)

4. 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

5. Four Signs of Placental Separation • Spherical uterus • Uterus rises as placenta enters vagina • Increased cord length protruding • Gush of blood

6. Plaenta • Fetal side: Shiny “Schultze” • Maternal side: Dirty “Duncan” • Cord – notice whether there are abnormalities • how many vessels are in the umbilical cord

7. 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

8. Normal Blood Loss at Delivery • Vaginal Delivery • < 500 mL • Cesarean Section • < 1000 mL

9. 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!

10. 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

11. 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)

12. Assessment Parameters • Infant • Vital signs every 30 minutes x 2 hours, then every 4 hours x 2, then every 8 hours

13. 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

14. 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

15. 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

16. 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

17. 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)

18. 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)

19. 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)

20. 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

21. Potential Complications

22. Third Stage Complications(Will be discussed in OB Emergencies) • Postpartum hemorrhage • Lacerations • Hematomas • Amniotic fluid emboli • Other emboli – pulmonary, cerebral/stroke • MI

23. 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

24. Things that Bleed

25. 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

26. Hematomas Vaginal Vulval Retroperitoneal

27. 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

28. 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

29. 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

30. 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.

32. 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

33. 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.

34. 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

35. Other areas of focus Psycho-Social Issues Pre-existing Medical Problems Bonding Teaching

36. Psycho-Social Issues • Support • Family dynamics • Adoptions • CPS alerts • Substance abuse • Depression/bipolar history • Psychotic illness

37. Impact Other Medical Problems • Cardiac disease • Kidney disease • Trauma • Paralytic disorders • Contagious illness

38. Bonding • Physical contact and viewing • Assessing quality of bonding and support • First feedings • Cultural awareness • Reassurance, information • Time pressures

39. Teaching • Self care • Baby care and feeding • Newborn characteristics • Physical expectations next few days • Emotional expectations next few days • Keep info short, targeted

40. Summary • Time of dramatic changes • Most physical care in background • Need for supportive, compassionate, family-centered care

41. 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.