third and fourth stages of labor

Question 1

third stage

Answer 1

from expulsion of baby to expulsion of placenta

Question 2

average time for third stage

Answer 2

5-15 mins

Question 3

mechanism of placental delivery

Answer 3

1. Uterine size decreases as baby is born placental attachment site decreases.
2. Placenta squeezed and blood forced into spongy layer of decidua and placenta begins to buckle in.
3. Oblique fibers tighten around maternal blood vessels, which prevents draining of blood into maternal system.
4. With contraction, vessels become turgid and burst, causing a thin layer of blood to seep between decidua and placenta
5. Placenta begins to separate.
6. Separation usually begins centrally so that a retroplacental clot forms, which may further aid separation. Increased weight helps strip adherent lateral borders. OR
   Placenta detaches asymmetrically at lateral border
7. Placenta falls into lower uterine segment, fundus changes shape (more Globular)
8. EXPULSION - Placenta expelled into vagina via uterine contraction. After: uterus should be at or below umbilicus, firm and central.

Question 4

schultze separation

Answer 4

center separation

Usually occurs with a placenta attached high in the fundus
Associated with more complete shearing of placenta and less blood loss

Question 5

matthews-duncan separation

Answer 5

side separation

More common for lower lying placentas.
Associated with more ragged, incomplete expulsion of placenta and more blood loss

Question 6

types of presesntation

Answer 6

fetal surface/schultze presentation
maternal surface/matthews presentation
schultze=baby side first
duncan=maternal side first

Question 7

most placentas separate _____ and are born _____ OR separate _____ and are born _____

Answer 7

schultze/schultze

duncan/schultze

Question 8

signs of separation

Answer 8

Separation gush
Cord lengthening
Change in shape - more globular
Follow cord up and feel placenta
See placenta

Question 9

what is the modified brandt-andrews maneuver

Answer 9

1. Take slack out of cord
2. With suprapubic hand, press in caudally
3. Cord remains same length means placenta has separated.
4. If it moves with you, it is probably still in the upper uterine segment

Question 10

When can you wait for the placenta without intervening?

Answer 10

When uterus is firm, not boggy
When there is no bleeding
Frank
Occult - can tell because fundus is rising
When mother’s vitals are stable - esp pulse, BP(pulse shouldn’t get faster postpartum)
When mother is not dizzy, she is lucid

Question 11

what can assist with expulsion?

Answer 11

Push with a contraction
Squatting, birth stool
Nursing, nipple stimulation, or breast pump
Appropriate botanical or homeopathic
Cord traction - guard uterus, follow curve of birth canal, do with a contraction. Need to traction cord posteriorly toward sacrum in order to deliver the placenta around the suprapubic bone; guard uterus while doing this
Pitocin - 1cc (10 units) IM usually in vastus lateralis muscle
Manual extraction

Question 12

how much blood circulates through the placenta per minute?

Answer 12

~400cc

Question 13

what is normal blood loss?

Question 14

tx of bleeding

Answer 14

Rub uterus - only until firm, do not overstimulate
Monitor vitals - pulse will rise first, then blood pressure drops
Nursing, nipple stimulation, or breast pump
Consider Pitocin
Bleeding could mean partial or total separation

Question 15

examination of placenta

Answer 15

Completeness of lobes and membranes 
Meconium staining 
Infarctions 
Calcifications 
Cord (should attach firmly into placenta)
Size (relative to baby; 1/5 or 1/6 of baby's weight; thick placenta could be missed diabetes)
Smell 
Color (rich dark red)
Weight

Question 16

placenta abnormalities

Answer 16

Bipartite placenta vs. placenta duplex:
Placenta succenturiata:
Placenta membranacea: associated with more fetal demise, still birth, and hemorrhage
Circumvallate placenta:
Placenta acreta: abnormally attached into the uterine muscle and myometrium
Meconium Stained Placenta
Accessory lobe

Question 17

fourth stage

Answer 17

from birth of placenta to 1 hour postpartum (mb up to 6 hours)

Question 18

postpartum uterus should be

Answer 18

firm, central, at or below umbilicus

Question 19

if uterus to the side consider

Answer 19

mb bladder or uterus is full
Uterine prolapse
Uterine rupture
Undetected twin
Broad ligament hematoma (higher on one side with pain greater on side of the hematoma)

Question 20

mom should urinate within _ hours of the birth

Answer 20

2

Question 21

pp bleeding 1st hour

Answer 21

up to 100cc

> 100cc in 15 mins is abnormal

Question 22

evaluating/managing blood loss

Answer 22

Consider where uterus is and how much total blood loss
Pulse reacts first to blood loss
Document amount of blood loss with change of kotex and chux
Give fluids, replace fluids for energy, keep pt voiding and eating

Question 23

bonding

Answer 23

Important in first 30 minutes
Increases sucking response in baby
Chest to chest, nose to breast

Question 24

checking for tears

Answer 24

Remember to look at perineum before birth so you know what is normal for her
Visualize inside and out
Use flashlight, gloves, gauze, warm water, povidone or calendula succus
Assess whether you need to suture
Clean her up – wipe away from perineum

Question 25

hematoma (labial/vulvar) ssx

Answer 25

pain, pressure, swelling

Question 26

complications of hematomas

Answer 26

results in blood loss site for infxn urinary retention (hematoma can block urethra)

Question 27

management of hematomas

Answer 27

ice, pressure, arnica | may need to incise and drain as a last resort

Question 28

involution

Answer 28

1/2-1 Fingerbreadth/day after delivery Day 1 - 1 1/2-2 FB below umbilicus or at umbilicus By Day 14 should be normal (at pubic bone)

Question 29

reasons for subinvolution

Answer 29

``` Retained membranes Placental parts Infection LGA Twins Multip Age-dependent ```

Question 30

management of infant during 3rd/4th stage

Answer 30

``` Dry/Provide tactile stimulation Suction if necessary Evaluate HR Check for respirations Check color Assign Apgar ```

Question 31

fontanelles

Answer 31

Not too small, not hard, not bulging Sunken reflects dehydration Can measure fontanelles 1-3 cm is normal for ant fontanelle

Question 32

what can you measure from cord blood?

Answer 32

Rh factor Direct Coombs Paternity Cord Blood Banking

Question 33

danger signs

Answer 33

Respiration - Grunting, nasal flaring, high resps Poor color - gray, white, blue Lethargy (most common cause is hypoglycemia) No urine, poop High or low temp Dehydration Cord - Foul smell, bleeding indicates infection or trauma to cord

Question 34

arsenicum

Answer 34

Uterus is inflamed/infected More a remedy for retention of a piece of the placenta after 4th stage Woman is anxious, restless, wants company and reassurance.

Question 35

belladonna

Answer 35

``` Copious, bright red hemorrhage Blood feels hot and clots quickly Her face is also red, flushed She is sensitive to the least jarring, touching the cord etc. Hour glass contractions. ```

Question 36

cantharis

Answer 36

Spanish fly Indicated when there are no uc's to expel placenta Burning with urination or burning of pelvic area Entire abdomen is sensitive Swollen os Vomiting

Question 37

carbo veg*

Answer 37

Scanty bleeding despite retention of placenta Lack of muscle tone and weak contractions in labor Women has prenatal hx of: Fatigue Anemia Sluggishness Weakness

Question 38

caulophyllum*

Answer 38

Retention of placenta due to weakness Primip postpartum atony Retention may cause flooding due to partial separation

Question 39

cimicifuga*

Answer 39

Absence of contractions but tearing pains She reports soreness all over, even eyeballs Seems like she is in more physical pain than practitioner can explain

Question 40

crocus

Answer 40

``` Wildy alternating emotions Exuberance and gratitude to rage This is usually a remedy used when a piece of placenta is retained (so maybe a week postpartum) Hemorrhage is: dark and slimy mb with stringy blood large clots ```

Question 41

gelsemium*

Answer 41

``` Exhaustion after delivery That jasmine state Sleepy Dopey, Unresponsive Severe lower abdominal pains radiating up and back ```

Question 42

gossypium

Answer 42

Firmly adhered placenta Or if os closes down after delivery Remedy helps dislodge stuck placenta

Question 43

hydrastis

Answer 43

Used preventatively in women with history of adherent placenta Use either low potency or mother tincture

Question 44

ipecacuanha

Answer 44

Constant nausea Bright red blood flow Sharp, pinching pains around umbilicus which shoots into uterus Worse lying down

Question 45

pulsatilla*

Answer 45

``` Most common state to get in during pregnancy, labor, and postpartum No expulsive contractions Just spasms of uterus Intermittent blood flow Pulsatilla mental/emotional picture Emotional Irritable Worried about baby Needy Restless Weepy Requests fresh air, cool air ```

Question 46

secale

Answer 46

Constant bearing down pains No palpable uterine contractions Or hourglass, ineffective contractions

Question 47

sepia

Answer 47

Strong bearing down sensation With sharp, shooting or burning pains in the cervix Irritable, snappish, controlling Flaccid muscle tone

Question 48

viscum

Answer 48

Other major remedy for adherent placenta Bright red blood, partially clotted Signs of shock Sacral pains that travel down into pelvis.

Question 49

calc carb (subinvolution)

Answer 49

Uterus remains enlarged and low down Sense of weight and bearing down Poor pelvic tone Woman may report inability to stand dt bearing down sensation Constipation with dry, knotty stools, which take much straining to pass Woman may be unaware of constipation for long periods of time She may need to insert vaginal finger to express stool or use perineal counterpressure.

Question 50

carbo veg (subinvolution)

Answer 50

``` Uterus remains weak and enlarged due to poor tone Etiology can be: excessive blood loss prenatal weakness anemia ```

Question 51

lilium tig (subinvolution)

Answer 51

Enlarged, bloated feeling of lower abdomen, not specifically uterus All of pelvis feels swollen Intense bearing down sensation She feels the most relief by applying counterpressure to vulva Urgent desire to move bowels Aching in low back and knees All is better when resting

Question 52

natrum muriaticum (subinvolution)

Answer 52

``` Etiology of prolonged congestion and afterpains Poor recovery after childbirth Very sensitive to: Music Noise Loud talking Unexpected noises ```

Question 53

pulsatilla (subinvolution)

Answer 53

``` Enlarged uterus presses against bladder Pain at end of urination Pain worse if she delays urinating Urinary incontinence Stress incontinence with coughing Prolapse with no bearing down sensation ```

Question 54

secale (subinvolution)

Answer 54

``` Bearing down sensation in entire abdomen Foul smelling discharge Thin, dark lochia General weakness following delivery Thin, weak, emaciated women, who look older than they are Prolonged weakness postpartum ```

Question 55

sepia (subinvolution)

Answer 55

Constant bearing down Venous congestion of uterus and rest of pelvis Grandmultiparity Weak, worn out feeling with low back pain

Question 56

ustilago (subinvolution)

Answer 56

``` Uterus remains enlarged Flabby with constant aching Bearing down Worse with nursing Os remains dilated and flabby Pains shooting into thighs ```