Welcome to Midwifery & Obstetrical Nursing Blog!!

Welcome to Midwifery and Obstetrical Nursing Blog!

This blog is a platform for me to share all my lecture notes on Midwifery Nursing. Hope this will be useful to all the nursing students out there! Happy Reading!

Monday 23 July 2012

Fourth Stage of Labour


Fourth stage of Labour
The delivery of the placenta does not mark the end of risk for bleeding; on the contrary, the uterus may have a tendency to relax slightly following placental delivery, and this is the point at which problems most commonly begin. The prophylactic use of a uterotonic helps ensure that the uterus continues to contract and retract, but the obstetrician must remain vigilant. Nearly every clinician can recount an episode of being briefly distracted at this point only to have his or her attention abruptly reclaimed by a cascade of blood.
Following delivery of the placenta, palpate the abdomen to assess and monitor uterine tone and size. At this point, uterine massage is reasonable, especially if concern exists regarding uterine tone. Uterine massage can be uncomfortable; therefore, explain the rationale to the patient. If intravenous access is in place, a continuous infusion of oxytocin for a period following delivery is reasonable. If ongoing concerns exist regarding uterine tone, then start an oxytocin infusion or administer a longer-acting agent. Encourage early breastfeeding to promote endogenous oxytocin release.
Once good, sustained uterine tone has been established, the presence of any bleeding from the lower genital tract can be assessed. If bleeding is minimal, assess the placenta for completeness. (First, manage any significant lower genital tract bleeding.) Assessment of the placenta before repair of an episiotomy or any lacerations is advised in order to avoid disrupting these repairs if uterine exploration or instrumentation is necessary.
Examine the fetal side for any evidence of vessels coursing to the edge of the placenta and into the membranes. Such vessels suggest the presence of a succenturiate placental lobe. If the vessels are torn and the lobe is not present, it is quite likely retained and may subsequently lead to bleeding or infection. If this is the case, turn the placenta over and lay it on a flat surface to examine the maternal side, with special attention to any defect suggestive of a missing, retained cotyledon. Note other abnormalities of the placenta, and consider whether pathological examination is warranted. Cultures of the placenta seem to be of little value in the diagnosis or management of fetal or uterine infection.
The lower genital tract is examined using adequate lighting and appropriate positioning and analgesia. Any episiotomy or lacerations are repaired. During this time, note any ongoing blood loss from the upper vagina, and, if present, reassess uterine tone and size. Closely observe the patient for blood loss over the next hour, with skilled assessment of uterine tone and size at least every 15 minutes. The duration of close observation and the presence and/or length of any uterotonic administration depends on the risk factors present and the clinical course.
Complications 
Postpartum hemorrhage 
The most common complication of the third stage of labor is PPH. Active management of the third stage has clearly been shown to reduce the frequency of this complication and therefore most likely has a positive impact on maternal mortality and longer-term morbidities such as anemia. 
Retained placenta 
Retained placenta is defined in various ways. The most common definition is retention of the placenta in utero for more than 30 minutes. This is an arbitrary definition, and management is greatly influenced by the clinical assessment of whether significant bleeding is occurring. This bleeding may be visible or may manifest only by the increasing size of the uterus. In the absence of any evidence of placental detachment, consider the diagnosis of complete placenta accreta or a variant. This condition may be present with bleeding if only a portion of the placenta is abnormally implanted.
Ensuring that the bladder is empty may speed the delivery of the placenta and at least aid in the assessment and control of the uterus. Ideally, women should have an empty bladder at the time of delivery. This usually occurs naturally because of pressure from the presenting part and maternal expulsive effort. Encouraging the woman to attempt to void late in the second stage or following delivery is not unreasonable, although this may be difficult. Emptying the bladder is mandatory before any attempt at assisted vaginal delivery.

Manual removal of the placenta is warranted if  significant bleeding occurs. The retained or partially detached placenta interferes with uterine contraction and retraction and leads to bleeding. Perform manual removal with a level of analgesia that matches the clinical urgency of the situation. The cessation of an oxytocin infusion or the administration of uterine relaxants to promote uterine exploration and manual removal is of questionable value and may lead to increased bleeding. Ultrasound may be useful in select cases.
When possible, an elbow-length glove is worn and attention is paid to asepsis. The perineum and vagina must be prepared. The vaginal hand may be immersed in povidone-iodine solution (Proviodine) to facilitate easier entry. The hand is passed into the vagina through the cervix and into the lower segment following the umbilical cord. Care is taken to minimize the profile of the hand as it enters, keeping the thumb and fingers together in the shape of a cone to avoid damage.
Control of the uterine fundus with the nonvaginal hand is essential. If the placenta is encountered in the lower segment, it is removed. If the placenta is not encountered, the placental edge is sought. Once found, the fingers gently develop the space between the placenta and uterus and shear off the placenta. The placenta is pushed to the palmar aspect of the hand and wrist; when it is entirely separated, the hand is withdrawn. Ensure that an oxytocin infusion is running rapidly as the hand is withdrawn in order to encourage strong uterine contraction, and then perform uterine massage. Care must be taken to tease out the membranes. Once uterine contraction is established, examine the placenta and membranes to determine whether further exploration or curettage is necessary. The administration of antibiotics following manual removal is sometimes advocated.
How to gain experience with potentially lifesaving procedures such as manual removal poses a dilemma. The days of regional anesthesia being an indication for manual removal are hopefully past, and this opportunity no longer exists. Manual removal at cesarean delivery allows the clinician to gain the most critical skills needed for this procedure. 

Uterine inversion 
This condition is very rare. The risk of uterine inversion is increased in abnormalities of placentation, such as accreta, and is more likely with fundal cord insertions and any condition that predisposes patients to uterine atony and prolapse. Cord traction should never occur without countertraction or in the absence of uterine contraction. Leave the placenta attached, and focus management on maternal resuscitation and rapid return of the uterus to the abdominal cavity.
The fingers are formed into a single cone-shaped unit and placed at the most dependent portion of the protruding mass, which represents the inverted uterine fundus. Gentle upward pressure is exerted in the axis of the birth canal with the fingers and thumb together to minimize the risk of uterine perforation. The action has been likened to that of placing the fingers at the toe of an inside-out sock and pushing to make the sock right-side out. Following uterine replacement, vigorous massage and uterotonic administration should undertaken.
Manual removal of the placenta may be performed when the mother's vital signs are stable unless concern exists regarding abnormal placentation. Uterine relaxants, such as nitroglycerin, may be helpful. 
Placenta accreta 
Placenta accreta and its variants are not complications of third-stage management but are most commonly recognized during the third stage. These life-threatening abnormalities of placentation may occur spontaneously; however, they are much more common in situations in which the placenta has implanted over a previously scarred uterus. The routine use and improving capabilities of ultrasound may suggest this diagnosis in the antepartum period, and the diagnosis should be considered in high-risk situations. The possibility of placenta accreta mandates that preparations for the management of severe PPH are in place and, if suggested based on ultrasound findings, that expertise is available to deal with the complications of placenta percreta.

38 comments:

  1. May I simply just say what a comfort to find an individual who really knows what they're talking about over the internet. You definitely understand how to bring an issue to light and make it important. A lot more people should read this and understand this side of your story. I can't believe you are not
    more popular because you surely possess the gift.

    Here is my website http://Www.PearlyPenilePapulesRemovalReview.com

    ReplyDelete
  2. I've attempted for your preceding 35 a long time to get rid of and Protect OFF my belly unwanted fat. I have tried each and every little matter from eating prepare capsules, personal trainers, every consuming system ever proposed, I on the second spend on two gym memberships, at any provided time, and also have not had the time to advantage from the advantages of both amid them in in excess of a year. I have to state that only challenge that assisted me weight loss advice for women hoping the surroundings, ease and also the availability in the providers at present getting opened from 5:00a.m until eventually last but not least 10:00pm would inspire me to stay on track, attend a great deal from the cardio classes, aquatics lessons, phase lessons etc…

    Check out my web-site ... go.violetdeville.com

    ReplyDelete
  3. I simply couldn't go away your web site prior to suggesting that I really loved the standard info a person provide on your guests? Is going to be again often to check up on new posts

    My homepage :: Home Staging Minneapolis

    ReplyDelete
  4. Hi to every body, it's my first pay a quick visit of this web site; this blog consists of awesome and genuinely excellent stuff in favor of readers.

    Here is my blog: any dicount for adiphene

    ReplyDelete
  5. Ɗigɑmоs quue no еstoy completamente de acuerѕo con la forma en que se dicе, рero creo qque
    eѕt� bien llo que se quiere hacer enteոder.Un saludo!


    Articulos relaciοnaԀos : Pepe

    ReplyDelete
  6. Hey there! I just wanted to ask if you ever have any problems with hackers?
    My last blog (wordpress) was hacked and I ended up losing a few months of hard work due to
    no data backup. Do you have any solutions to protect against hackers?


    my blog post; natural cleanse detox

    ReplyDelete
  7. Hi! Someone in my Myspace group shared this website with us so I came to take a look.
    I'm definitely loving the information. I'm book-marking and will be tweeting this to
    my followers! Superb blog and brilliant design and style.



    Also visit my homepage ... seo rankings

    ReplyDelete
  8. I savor, lead to I found exactly what I used to be having a look for.

    You have ended my 4 day lengthy hunt! God Bless you man. Have a
    nice day. Bye

    Here is my web site: seo rankings

    ReplyDelete
  9. Now I am going to do my ƅreakfast, afеrwаrd having mʏ breakfast coming yet again to read more
    news.

    Mƴ site - pro bono child custody lawyers

    ReplyDelete
  10. Hі thеrе, I want to subscribe for this blog to get ոewest updates, thus where can i doo
    it please assiѕt.

    Tɑke a look at my blog - bicycle racks

    ReplyDelete
  11. It is one of promise, of hope, of power, of emotions
    and of practicality, as it is a journey of spirituality.
    You might not be able to achieve all you hope and strategy for.
    Emotions are getting in the way of typical sense.


    Also visit my site California Psychics Review

    ReplyDelete
  12. Hello, I check your new stuff like every week.

    Your writing style is awesome, keep it up!

    my website: seo [http://seofornown4eva.com]

    ReplyDelete
  13. I loved as much as you'll receive carried out right here.

    The sketch is attractive, your authored material stylish.

    nonetheless, you command get bought an impatience over that
    you wish be delivering the following. unwell
    unquestionably come further formerly again as exactly the same nearly a
    lot often inside case you shield this increase.


    my homepage: search engine optimization - ,

    ReplyDelete
  14. Hello there! I could have sworn I've visited this site before but after
    going through a few of the posts I realized it's new to me.
    Regardless, I'm definitely happy I came across it and I'll be book-marking it and checking back regularly!


    my web-site ... domain

    ReplyDelete
  15. Hello there! This article could not be written much
    better! Reading through this article reminds me of my previous roommate!

    He continually kept preaching about this. I will send this article to him.
    Pretty sure he will have a good read. Many thanks for sharing!


    My web site: domain

    ReplyDelete
  16. Splendide pοst : comme d'habitude

    my web ѕіte: defonce hard

    ReplyDelete
  17. Puis-je vοus reρrendre 2-3 phrases sur un ѕite web personnel ?


    Herе is my wbsitе nymphomane sexy

    ReplyDelete
  18. Heya i'm for the first time here. I came across
    this board and I find It really useful & it helped me out much.
    I hope to give something back and help others like you aided me.


    Feel free to surf to my weblog; persistence
    success (http://en.wikipedia.org/)

    ReplyDelete
  19. I almost never leave a response, but i did
    some searching and wound up here "Fourth Stage of Labour". And I
    actually do have 2 questions for you if you tend not to mind.

    Is it only me or does it give the impression like some of these responses
    look as if they are written by brain dead individuals?
    :-P And, if you are posting at additional sites, I would like to
    keep up with everything fresh you have to post.
    Could you make a list of every one of all your community sites like your linkedin profile, Facebook page or twitter feed?


    Also visit my website :: Pictures Of Prom dresses

    ReplyDelete
  20. I'm really loving the theme/design of your weblog.
    Do you ever run into any browser compatibility problems?
    A handful of my blog readers have complained
    about my website not operating correctly in Explorer but looks great in Safari.
    Do you have any recommendations to help fix this issue?



    Review my blog: quest bars

    ReplyDelete
  21. Your method of describing everything in this paragraph is truly pleasant,
    all can without difficulty understand it, Thanks a lot.



    Here is my site: minecraft games

    ReplyDelete
  22. What i don't realize is in reality how you are no longer actually much more smartly-appreciated than you may be now.
    You're so intelligent. You understand therefore considerably on the subject of this topic,
    produced me in my view consider it from a lot of varied angles.
    Its like women and men aren't fascinated until it's something to accomplish with Woman gaga!
    Your own stuffs nice. At all times maintain it up!


    My web page: minecraft games download

    ReplyDelete
  23. Hello there! I could have sworn I've been to this blog before but after reading through some of the post I
    realized it's new to me. Nonetheless, I'm definitely happy I found it
    and I'll be book-marking and checking back frequently!

    my blog - music downloads free mp3

    ReplyDelete
  24. I was wondering if you ever thought of changing the page
    layout of your site? Its very well written; I love what youve got to say.
    But maybe you could a little more in the way of content so
    people could connect with it better. Youve got an awful lot of text diet
    plans for women to lose weight - http://dietplansforwomentoloseweightfast.com - only
    having 1 or 2 images. Maybe you could space it out better?

    ReplyDelete
  25. When I initially commented I clicked the "Notify me when new comments are added"
    checkbox and now each time a comment is added I get four emails with the same comment.
    Is there any way you can remove people from that service?
    Thanks!

    Here is my web blog :: free music player

    ReplyDelete
  26. It's in fact very difficult in this full of activity life to listen news on Television,
    so I just use world wide web for that purpose, and get the newest information.

    Here is my homepage ... paid surveys online

    ReplyDelete
  27. I used to be able to find good info from your articles.


    Here is my web page :: free music downloads (freemusicdownloadsb.com)

    ReplyDelete
  28. Excellent pieces. Keep writing such kind of information on your site.
    Im really impressed by it.
    Hi there, You've performed a great job. I'll definitely digg it and individually suggest to my friends.

    I'm confident they will be benefited from this web site.


    Feel free to visit my homepage: minecraft.net

    ReplyDelete
  29. Do you have a spam issue on this blog; I also am a blogger, and I was wanting to know
    your situation; many of us have developed
    some nice practices and we are looking to swap
    methods with other folks, please shoot me an email if
    interested.

    Look at my page: HiramHChandier

    ReplyDelete
  30. I could not resist commenting. Very well written!

    Here is my web blog MichellOSedano

    ReplyDelete
  31. Untuk Nama ADRO sendiri adalah gabungan nama dari para pendiri.


    Feel free to visit my website: konveksi jakarta

    ReplyDelete
  32. Paragraph writing is also a fun, if you know then you can write if not it is
    complex to write.

    Here is my web-site - CT limo service

    ReplyDelete
  33. Hi, its good paragraph concerning media print, we all be
    familiar with media is a great source of facts.

    Here is my web-site; quest bars

    ReplyDelete
  34. Excellent website. Lots of helpful info here. I am sending it to several buddies
    ans additionally sharing in delicious. And of course, thank you for your sweat!



    Also visit my page; quest bars

    ReplyDelete
  35. Everything is very open with a clear clarification of the challenges.
    It was really informative. Your site is very useful. Thanks
    for sharing!

    Also visit my web site: google

    ReplyDelete
  36. The nevеr ending ρrocedսrе tߋ accօmρ&#8572іѕ&#1211 t&#1211e ԛu&#6513ѕtіоnnaіr&#6513.
    W&#1211ߋeνег Һаs &#1088геνiοսѕ&#8572ʏ tɑқen ɑ г&#6513νіеԝ maу геlatе sߋ&#8572&#6513lу tօ tɦіѕ
    ɑffігmɑtiօn.

    Rеνі&#6513ա mʏ &#7457eƄb ρaǥе ::
    How Green Is Your Online Surveys?

    ReplyDelete
  37. Accοrding numerous websites aand adѵeгtisementѕ maкіng
    mondү &#1086nlіne rгѕ іncг&#6513dіЬlү &#6513aѕү
    tߋօ trү. It lоօҝѕ &#8572іқе ѡҺ&#6513ге&#7456ег οne
    turns no&#7457ɑ&#8574аʏs sօmеοne іѕ іnt&#6513ndіng
    tο сonvіnc&#6513 tɦе
    maѕѕеѕ ɦοw &#6513ɑѕү іt wօulԁ bе еaгn аn e&#11437tгa incomе.


    Ϝе&#6513l fе&#6513 to ѕսгf tߋ
    mʏ աеƅ ƅlοց
    http://smartmoneyfix.com/easy-money/exploring-the-benefits-of-completing-surveys-for-money/

    ReplyDelete
  38. In general, Gold wave generally, is an approach where drugs, vitamins, compounds
    and herbs are combined together in a given formulation and injected to the central region of the skin (named mesoderm) to destroy fat and cellulite.


    Look at my site: Visit This Link

    ReplyDelete