Third and Fourth Stages of

Labor and Common

Interventions
Teri Stone Godena
N 344
Spring, 2016
1

Spontaneous Rupture Of
Membranes
Most common time for membranes to
rupture spontaneously?
At end of first stage
What are nursing responsibilities with
ROM?
Assess fetal heart
Note color, amount, odor of fluid
Observe for umbilical cord
2

Review second stage

Signs it is coming (no epidural)
Urge to bear down
Increased restlessness
Perspiration on the upper lip
Shaking
Vomiting
Identify phases
Latent
Descent (Expulsive). Ferguson reflex
Transition (Compulsive) Overwhelming
3

Review 2nd stage

How long is it?
Primips without epidural up to 2 hours
With epidural up to 3 hours
Multip without epidural up to 1 hr.
With epidural up to 2 hrs.
Identify Positions for pushing
Sidelying
Squatting
Standing
4

Review 2nd stage

Describe Open versus closed glottis
pushing
Open= Bearing down while exhaling
Benefits to open glottis
Less fetal hypoxia, Less trauma to
pelvic musculature
How often is fetal assessment done?
Continuously with documentation Q 5
min.
5

Goals of 3rd and 4th stage

Safe delivery of the placenta
(prevention or control of hemorrhage)
Safe transition of baby from
intrauterine to extrauterine
environment.
Establishing a new family unit.

Third stage
Timing up to 30 minutes
Phases 3rd stage:
Placenta separates. Uterus contracts
and detaches placenta from the center
or less commonly, the periphery
Signs:
Lengthening of cord, gush of blood,
assumption of globular shape by the
uterus.
Placenta expels
7

Placenta
Weight
approximately 500 gms or 1.2 lbs (about 1/7th
1/8th of baby weight)

Appearance: Maternal-velcro or velvet,

matte finish called dirty Duncan
and fetal is shiny (Schultz)
8

Placenta
Cord inserts in to fetal surface,
generally near the center
Maternal surface may show
degenerative changes, fibrin
deposition

Nursing Care 3rd stage

Anticipate postpartum hemorrhage:
Identify risks
Observe for signs and symptoms
Administer ordered medications.
Pitocin first line. 10-30 u IM or IV May be
with anterior shoulder or with expulsion of
placenta
Massage uterus
Dry infant. Assign Apgars. Initial newborn
heart and lung sounds
10

Postpartum hemorrhage
Definition
>500 ml EBL after vaginal birth;
>1000 ml after C/S.
Alternative definitions include >10%
of admission Hct
Any blood loss resulting in vasomotor
instability
11

4th stage maternal care

Maternal vital signs, Uterine tone/
involution and Lochia
Q 15 min X 4, Q 30 min X 2 then
hourly X 2
Bladder status/Urinary output
Recovery from anesthesia
Offer nutrition
Facilitate avoid separation
12

Newborn during 4th stage

Ongoing assessment of color and
respirations
Delay eye ointment and vitamin K
until after first hour
Weight, security banding if not done
before, footprints for memento.
Vital signs per institutional protocol,
eg. at 30 minutes and 1 hour.
13

Skin to skin the evidence

30 studies (n=1925) found benefits of
immediate mother and infant skin-to skincontact (Kangaroo care):
Keeps the newborn warmer
Reduces infant crying in the first hour of life
Improves breastfeeding initiation and
duration
Improves infant sleeping
and maternal attachment
behavior
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Skin to skin in the OR

15

Procedures can be done skin to skin

Maternal and Newborn vital signs
Assessment of maternal bleeding,
pain level, bladder status
Assessment of newborn color,
breathing
Assessment of bonding
Initiation of breastfeeding
16

Review Care maps

17

Induction
Augmentation
Assisted Vaginal Delivery

COMMON INTERVENTIONS
18

Induction (IOL)
Indications:
Any condition that makes birth safer than
continuing the pregnancy (for mother or fetus).
Eg. preeclampsia, diabetes, chorioamnionitis,
PROM, IUGR, IUFD
Contraindications:
Severe fetal distress, malpresentation, severe
hemorrhage, placenta previa, previous uterine
incision
Risks:
Increase Cesarean rate. Iatrogenic prematurity .
19

IOL
Elective inductions scheduled for maternal or
clinician convenience. Have no medical indication.
Up to 40% of inductions are elective, with no
medical reason. Rate doubled: <10% of all
deliveries in 1990, to >22% in 2006 (CDC).
Primips with IOL twice as likely to have epidurals,
Caesarean births and neonatal resuscitation as
those with spontaneous labor.
Reducing the use of elective labor induction could
lower the national C-section rate by as much as
20%.
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Cervical ripening

Bishop Score
21

Cervical Ripening
Preparing for labor,
the cervix moves forward, softens, effaces, and
may begin to dilate. The fetal head descends.
Bishop score
measures maternal readiness for labor by
assessing if cervix is favorable.
>8 for nullips and >4 for multips associated with
more successful inductions.

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Ripening agents

Misoprostol
Prostaglandin E1

Cervical Balloon

,Prostaglandin E2

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Nursing responsibilities
Explain procedure & obtain consent.
Assess maternal status: H&P, VS, cervical
status, UCs
Assess fetal status: presentation, station, FHR
(usually 20-40 min. on EFM or reactive NST 1 st).
Encourage voiding since Mother remains in bed
for 1-2 hours after insertion.
Have Terbutaline 0.25 mg sq available for
tachysystole per provider order.
Caution/Contraindication: maternal asthma,
renal, hepatic or cardiovascular disorders,
glaucoma, uterine scar, fetal malpresentation
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Misoprostol
Action:
Ripens cervix, stimulates contractions
Dose/route administered:
25-50 mcg to posterior vaginal fornix q4 hours,
may be given 50-100 mcg orally but increased
GI SE and may be less effective at ripening.
Tablet split in or (comes in 100 & 200 mcg
doses), inserted into posterior fornix.
SE:
N/V, diarrhea, fever, tachysystole (+ fetal
distress).
Commonly causes frequent, irritable
contractions, may dilate quickly once begins.

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Prostaglandin E2: Dinoprostone, Cervidil

Action:
Ripens cervix, stimulates contractions
Dose:
Cervidil 10 mg over 12 hours, in posterior
fornix Prepidil 0.5 mg in 2.5 ml gel q 6 hrs
prn (max 1.5 mg in 24 hr), in cervical canal
or posterior fornix
SE:
HA, N/V, diarrhea, fever, hypotension,
tachysystole + fetal distress
If tachysystole, remove Cervidil by pulling
string. Cannot remove gel. May administer
Terbutaline 0.25 mg sq. per provider order 26

Balloon catheter
Balloon or foley catheter inserted into cervical canal by
clinician. Inflate balloon with NS (30-40 mL for foley,
up to 80 ml for double balloon catheter).
Tug gently to apply to internal cervical os. For foley,
weight external tubing or tape to thigh to provide
tension.
Expelled (into vagina or out) once cervix dilated 3-4
cm.
Lower risk tachysystole, some
ROM.
Sometime Pitocin 1-2 mU
simultaneously.

risk bleeding,
infused
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Next steps
Once cervix is ripe, induction begins.
Pitocin (oxytocin) + amniotomy.

28

Pitocin
Incidence of Use
Up to 80% of all labors in U.S., for induction or
augmentation! (US Birth Certificate data)
MOA:
Increases contraction frequency and intensity.
SE= Early Epidural (inability to cope). Epidural=
no mobility slow progress more Pitocin
uterine hyperstimulation (tachysystole) fetal
distress uterine rupture or C/S Postpartum
hemorrhage
Continuous EFM
29

Administering Pitocin
Administered via IV pump .
Often mixed 15 Units pitocin in 250 ml LR.
Pump setting 1 ml = 1 milliunit of pitocin).
Start at 1-2 milliunits/minute and increase by 12 milliunits/minute every 30-60 minutes until
adequate contractions.
Maximum 20 milliunits/minute without provider
reassessment of situation
Nursing role: monitor dosing, contractions, FHR.
Explain to client how pitocin is dosed gradually.

30

Tachysystole
Definition : >5 contractions in 10 min.
Contractions >90-120 seconds duration
Uterine resting tone >20 mmHg

Nursing responsibilities. Turn off pitocin.

Reposition client, IV bolus LR, oxygen,
consider terbutaline, notify provider.
After recovery, may restart at half ending
dose.

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AVD

http://www.youtube.com/watch?v=YGYfia8oI34
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Assisted Vaginal delivery(AVD)

Indications:
Fetal distress in 2nd stage, need rapid delivery.
Maternal exhaustion.
Maternal cardiopulmonary or cerebralvascular
disease (so continued pushing not advised).
Conditions:
Fetal head must be +2 or lower.
Procedure:
Mother pushes while OB pulls.
Nursing role:
inform mother, ready equipment .
33

Cesarean
In 1970, the U.S. cesarean rate was about 5%.
In 2011, it was 33% and climbing (higher at many
hospitals.)
Most women having cesareans today will have
repeat C/S in future, raising C/S rate even higher.

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Cesarean

http://www.youtube.com/watch?v=bkZjcVl0cqw

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Risks

36

Nursing responsibilities
Before procedure:
Assess FHR, maternal VS.
Position client supine w/ wedge under 1 hip.
Insert foley catheter & IV.
Administer pre-op meds, usually includes
Cephazolin (Ancef) antibiotic prophylaxis
within 1 hour before surgery.
Assure NPO.
Send ordered blood work.
Explain procedure, get informed consent,
provide emotional support
37

During the Procedure

Help position client on operating table.
Monitor FHR, maternal VS, IV fluids, urinary
output.
May be scrub nurse or circulating nurse.
If acting as baby nurse, prepare supplies &
warmer.

38

After birth
Monitor VS, LOC, returning sensation after
anesthesia.
Assess uterine fundus and lochia .
Maintain skin to skin and assist with breastfeeding.
Monitor I&O (x 24-48 hrs).
Provide pain relief & antiemetics as prescribed.
Encourage cough & deep breathing, splinting
incision with pillows, early ambulation.
Assess for postpartum complications: pneumonia,
wound infection or dehiscence, endometritis,
thrombophlebitis, UTI, urinary retention, anemia.
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Emotions
Some women feel they failed if they have a
cesarean.
With emergency cesarean, may have
experienced extreme fear for infants safety,
especially if newborn resuscitation or immediate
transfer to NICU.
Encourage them to talk about their experience,
fears, and feelingsstarts the healing process!
Higher risk PPD, breastfeeding problems d/t
exhaustion, anemia, postpartum pain and
narcotic analgesia.
Mother the mother. Help family set up support
system for discharge.

40

Birth the next time

VBAC, AVBAC, TOLAC
Success rates 13-89% depending on
reason for prior C/S.
0.5-1% risk uterine rupture:
Risk higher with Pitocin use. Cytotec
contraindicated
Risk higher if h/o 2 or more prior C/S
Low transverse incision only
41

Where to have a VBAC

ACOG recommends VBAC only if
emergency personnel and equipment
immediately available throughout
active phase: Surgeon,
Anesthesiologist, OR staff. Many
hospitals no longer offer the option.

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