Section V. FOURTH STAGE OF LABOR (RECOVERY STAGE)
2-14. FOURTH STAGE OF LABOR
shows the making of a midline episiotomy to facilitate a normal vaginal
delivery of a baby. Following delivery, the episiotomy is closed using
sutures and a standard technique.
The fourth stage of labor, as previously mentioned, is the period from the delivery of the placenta until the uterus remains firm on its own. In this stabilization phase, the uterus makes its initial readjustment to the nonpregnant state. The primary goal is to prevent hemorrhage from the uterine atony and the cervical or vaginal lacerations.
Atony is the lack of normal muscle tone. Uterine atony is
failure of the uterus to contract.
NURSING CARE DURING THE FOURTH STAGE OF LABOR
a. Transfer the patient from the delivery table. Remove the
drapes and soiled linen. Remove both legs from the stirrups at the same time and
then lower both legs down at the same time to prevent cramping. Assist the
patient to move from the table to the bed.
b. Provide care of the perineum. An ice pack may be applied to
the perineum to reduce swelling from episiotomy especially if a fourth degree
tear has occurred and to reduce swelling from manual manipulation of the
perineum during labor from all the exams. Apply a clean perineal pad between the
c. Transfer the patient to the recovery room. This will be done
after you place a clean gown on the patient, obtained a complete set of vital
signs, evaluated the fundal height and firmness, and evaluated the lochia.
d. Ensure emergency equipment is available in the recovery room
for possible complications.
(1) Suction and oxygen in case patient becomes eclamptic.
is available in the event of hemorrhage.
(3) IV remains patent for possible use if complications
e. Check the fundus.
(1) Ensure the fundus remains firm.
(2) Massage the fundus until it is firm if the uterus should
relax (see figure 2-10).
Figure 2-10. Massaging the fundus.
(3) Massage the fundus every 15 minutes during the first hour,
every 30 minutes during the next hour, and then, every hour until the patient is
ready for transfer.
(4) Chart fundal height. Evaluate from the umbilicus using
fingerbreadths. This is recorded as two fingers below the umbilicus (U/2), one
finger above the umbilicus (1/U), and so forth. The fundus should remain in the
midline. If it deviates from the middle, identify this and evaluate for
(5) Inform the Charge Nurse or physician if the fundus remains
boggy after being massaged.
NOTE: A boggy uterus many indicate uterine atony or retained
placental fragments. Boggy refers to being inadequately contracted and having a
spongy rather than firm feeling. This is descriptive of the postdelivery of the
f. Monitor lochia flow. Lochia is the maternal discharge of
blood, mucus, and tissue from the uterus. This may last for several weeks after
(1) Keep a pad count. Record the number of pads soaked with
lochia during recovery.
(2) Identify presence of bright red bleeding or blood clots.
(3) Document thick, foul-smelling lochia.
(4) Observe for constant trickle of bright red lochia. This
may indicate lacerations.
(5) Identify lochia amounts as small, moderate, or heavy
(large) (see figure 2-11).
(6) Document lochia flow when the fundus is massaged.
(a) Every fifteen (15) minutes times one hour.
(b) Every thirty (30) minutes times one hour.
(c) Every hour until ready for transfer.
g. Observe the mother for chills. The cause of the mother being
chilled following birth is unknown. However, it refers primarily to the result
of circulatory changes after delivery. The best means of relief is to cover the
mother with a warm blanket.
Figure 2-11. Assessing lochia flow.
h. Monitor the patient's vital signs and general condition.
(1) Take BP, P, and R every 15 minutes for an hour, then every
30 minutes for an hour, and then every hour as long as the patient is stable.
Take the patient's temperature every hour.
(2) Observe for uterine atony or hemorrhage.
(3) Observe for any untoward effects from anesthesia.
(4) Orient the patient to the surroundings (bathroom, call
bell, lights, etc.).
(5) Allow the patient time to rest.
(6) Encourage the patient to drink fluids.
i. Observe patient's urinary bladder for distention. Be able to
recognize the difference between a full bladder and a fundus.
(1) Characteristics of a full bladder.
(a) Bulging of the lower abdomen (see figure 2-12).
Figure 2-12. Bulging of the lower abdomen.
(b) Spongy feeling mass between the fundus and the pubis.
(c) Displaced uterus from the midline, usually to the right.
(d) Increased lochia flow.
(2) Full bladders may actually cause postpartum hemorrhage
because it prevents the uterus from contracting appropriately.
(3) Nerve blocks may alter the sensation of a full bladder to
the patient and prevent her from urinating.
(4) If at all possible, ambulate the patient to the bathroom.
(5) Urine output less than 300cc on initial void after
delivery may suggest urinary retention.
(a) Document the fundal height and bladder status before the
(b) Reevaluate and document the fundal height and bladder
status after the patient urinates to accurately document an empty bladder.
j. Evaluate the perineal area for signs of developing edema
(1) Predisposing conditions includes prolonged second stage,
delivery of a large infant, rapid delivery, forceps delivery, and fourth degree
(2) Nursing considerations for perineal edema.
(a) Apply an ice pack to the perineum as soon as possible to
decrease the amount of developing edema.
(b) Stress the importance of peri-care and use of "sitz-baths"
on the postpartum ward.
(c) Assess for urinary distention which is due to edema of
(3) Assessment for perineal hematoma.
(a) Look for discoloration of the perineum.
(b) Listen for the patient's complaints or expression of
severe perineal pain.
(c) Observe for edema of the area.
(d) Observe/listen for patient's feeling the need to defecate
if forming hematoma is creating rectal pressure.
(e) Observe for patient's sensitivity of the area by touch
(by sterile glove).
k. Observe for signs of hemorrhage.
(1) Uterine atony.
(2) Vaginal or cervical lacerations.
(3) Retained placental fragments.
(4) Bladder distention.
(5) Severe hematoma in vagina or surrounding perineum.
l. Assess for ambulatory stability.
(1) The patient is at risk of fainting on initial ambulation
after delivery due to hypovolemia from blood loss at delivery and hypoglycemia
from prolonged nothing by mouth (NPO) status.
(2) The patient should be accompanied on the first ambulation
and observed for stability.
(3) Ammonia ampuls should be readily available.
(4) The patient should be closely monitored while in the
bathroom to prevent injury if fainting does occur.
(5) The patient who received regional anesthesia at deliver
(that is, pudendal block) should be assessed for possible loss of sensation in
the lower extremities.
m. Observe C-section patients. Most C-section patients are
still initially recovered in the recovery room. If not, monitor the patient as
you would any patient in a recovery room immediately during post delivery.
Include monitoring of the fundus and lochia flow. Times are consistent with the
normal vaginal delivery patient.
n. Instruct the patient in the proper perineal care. The
patient should use the peribottle after each void and bowel movement, wipe from
front to back to avoid contamination, and apply the perineal pad from front to
o. Discontinue IV on a normal patient once she is stable and
the physician has ordered removal.
p. Complete notes and transfer the stable patient to the ward
(on normal vaginal delivery--others require physician clearance).
2-16. FACTORS THAT MAY EXTEND OR INFLUENCE THE DURATION OF
There are five essential factors that affect the process of
labor and delivery. They are easily remembered as the five Ps (passenger,
passage, powers, placenta, and psychology).
a. Passenger (Fetus).
(1) Presentation of the fetus (breech, transverse).
(2) Position of the fetus (ROP, LOP).
(3) Size of the fetus.
b. Passage (Birth Canal).
(1) Parity of the woman, if she has ever delivered before.
(2) Resistance of the soft tissues as the fetus passes through
the birth canal.
(3) Fetopelvic diameters.
c. Powers (Contractions).
(1) Force of the uterine contractions.
(2) Frequency of the uterine contractions.
(1) Site of implantation.
(2) Whether it covers part of the cervical os.
e. Psychology (Psychological State of the Woman).
(a) Patient extremely anxious.
(b) Emotional factors related to the patient.
(c) Amount of sedation required for the patient.
Continue with Exercises