STAGES OF LABOR – Stage IV

LAST STAGE

  • Last stage of labor begins with delivery of placenta and ends with postpartum stabilization
  • Duration: usually 1-2 hours after delivery (primipara or multipara)
  • Blood pressure returns to the pre-labor level
  • Pulse is slightly lower than during labor
  • Fundus remains contracted, in the midline, 1-2 fingerbeadths below the umbilicus

Nursing Interventions:
  • Maternal assessment every 15 minutes for 1 hours, every 30 minutes for 1 hours, and hourly for 2 hours
  • Administer oxytocin product if ordered
  • Assess fundus every 15 minutes, if soft, massage with side of hand
  • Assess lochia, checking peripad and under lower back
  • Assess bladder for distention because full bladder will prevent contractions and increase bleeding
  • Assess episiotomy for intactness and possible bleeding

No comments: