You are on page 1of 4

1sr

Administer and maintain intravenous fluids--per physician's order and SOP. This is usually done
on all patients.

Perineal Preparation. Shaving of pubic hair to prevent infection of perineal


episiotomy/lacerations is rarely done anymore. There must be a physician's order to perform this
task

Monitoring and Recording Color and Amount of Show.

Fetal Monitoring.

Vital Signs. Monitor the patient's vital signs.

Positioning During Labor. Assist the patient in turning from side to side. Elevate the head of the
bed 30 degrees; this makes it easier for the patient to breathe. Try to keep the patient off her
back to prevent supine hypotensive syndrome. This syndrome results in pressure of the enlarged
uterus on the vena cava, reduces blood supply to the heart, decreases blood pressure, and
reduces blood circulation to the uterus and across the placenta to the fetus. The patient may
complain of being nauseated and feeling cool and clammy. The best position for the patient is on
her left side since this increases fetal circulation.

Prevention of Infection. Handwashing is essential before and after performing any procedure.
Fresh, clean scrub suits should be worn in the delivery area. Unauthorized persons should not be
allowed in the area. A patient with infections should be separated from other patients.

Vaginal Exams. Only the physician or a trained nurse performs this exam.

It is done to evaluate cervical effacement, cervical dilatation, status of membranes, and station of
presenting part. Care must be taken to perform good perineal cleansing before and after the
procedure (vaginal exam). Once membranes rupture, the exam should be limited even further to
prevent the risk of infection. See figure 2-6 for vaginal palpation of cervical dilatation, effacement,
amniotic membranes, and presenting part.

2nd

a. Never leave the patient alone once she has been transferred to the delivery room. In addition,
never turn your back on the perineum because the baby could push through the vaginal opening
while your back is turned.
b. Encourage the patient to rest between contractions and to push with contractions. Only one
person should coach. Verbal encouragement and physical contact help reassure and encourage
the patient.

c. Position the patient's legs in the stirrups for the lithotomy position. This is the most common
position for delivery. Facilities using birthing beds have the patient in an upright position.
Positioning also depends upon the type of anesthesia to be used and C-section delivery. Each
case may be different.

d. Prep the patient's perineum. A Betadine® scrub and water are used with 4x4's. Clean the
perineum by washing the pubic area, down each thigh, down each side of the labia, down the
perineum, and down the rectal area. Discard used sponges after each step. Rinse area with
the remaining solution.

e. Monitor the patient's blood pressure and the fetal heart tones every 5 minutes and after each
contraction.

3rd

Continue observation. Following delivery of the placenta, continue in your observation of the
fundus. Ensure that the fundus remains contracted. Retention of the tissues in the uterus can
lead to uterine atony and cause hemorrhage. Massaging the fundus gently will ensure that it
remains contracted.

b. Allow the mother to bond with the infant. Show the infant to the mother and allow her to hold
the infant. Record the following information.

a. Time the placenta is delivered.

b. How delivered (spontaneously or manually removed by the physician).

c. Type, amount, time and route of administration of oxytocin. Oxytocin is never administered
prior to delivery of the placenta because the strong uterine contractions could harm the fetus.

d. If the placenta is delivered complete and intact or in fragments.

FOURTH STAGE OF LABOR (RECOVERY STAGE)

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 legs.

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.

(2) Pitocin® is available in the event of hemorrhage.

(3) IV remains patent for possible use if complications develop.

e. Check the fundus.

(1) Ensure the fundus remains firm.

(2) Massage the fundus until it is firm if the uterus should relax

(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 distended
bladder.

(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 uterus.

f. Monitor lochia flow. Lochia is the maternal discharge of blood, mucus, and tissue from the
uterus. This may last for several weeks after birth.

(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.

h. Monitor the patient's vital signs and general condition.

Observe patient's urinary bladder for distention. Be able to recognize the difference between a full
bladder and a fundus.

Evaluate the perineal area for signs of developing edema and/or hematoma. Apply an ice pack to
the perineum as soon as possible to decrease the amount of developing edema

You might also like