Third and Fourth Stages of Labor Flashcards
definition of 3rd stage? average time?
3rd stage= from expulsion of baby to expulsion of placenta
normal is 5-15 but can be up to 1 hr
mechanism of placental delivery?
- uterine size decreases= placental attachment size decreases
- placenta is squeezed and then blood is forced into the spongy layer of decidua, buckles
- oblique fibers tighten around maternal vessels
- w/contraction vessels burst= thin layer of blood seeps btw decidua and placenta
- placenta begins to separate
- separation usu begins centrally so retroplacental clot forms, increased wt helps strip adherent lateral borders; can also shear asym at lateral border
- placenta falls into lower uterine segment
- expulsion
simple 3 step way the placenta is delivered?
- blood forced into spongy layer
- central separation
- retroplacental clot forms
2 types of separation and presentation?
schultz: baby’s side, smooth; usu occurs w/placenta that is attached higher in fundus; assoc w/more complete shearing and less blood loss
(matthews) duncan: mom’s side; side-separation, more common for lower lying placentas; assoc w/more bleeding
6 sxs of separation?
- separation gush
- lengthening of cord
- change in uterine shape (more globular)
- follow cord up and feel placenta
- see placenta
- modified brand-andrews maneuver: take slack out of cord, press in caudally on uterus, if cord remains the same length then have seapration
when can you wait for placenta w/o intervening?
uterus is firm
no bleeding (frank or occult- fundus will be rising)
vitals are stable
mom not dizzy, she is lucid
8 ways to assist with expulsion of the placenta?
- push w/contraction
- squatting, birth stool
- nursing, nipple stim, breast pump
- appropriate botanical or homeopathics
- cord traction (guard the uterus so as to not pull it out)
- pitocin (1 cc IM)
- manual extraction
how much blood circulates through the placenta per minute?
~400 cc
what is considered normal blood loss?
less than 500 cc (1 c= 240 cc)
4 ways to manage/treat bleeding?
- rub uterus
- monitor vitals (pulse will drop first then BP rises)
- nursing, nipple stim, breast pump
- consider pitocin
what to look for when examining placenta?
completeness meconium staining? infarctions? calcifications? cord size smell color wt
what can palor of the placenta be assoc w/?
TORCH infxns
ratio of vessels a cord should have?
2 umbilical arteries + 1 umbilical vein
different cord insertions?
battledore (on the perimeter of the placenta)
velamentous (cord not wrapped all together in warfarin’s jelly)
5 placental abnormalities?
- bipartite placenta vs. placenta duplex (can indicate there was a multiple gestation PG)
- placenta succenturiata (accessory lobes)
- placenta membranaceae (very LG placental, more assoc w/death, not safe for home birth)
- circumvallate placenta (more assoc w/fluid leak, chorio or TORCH infxns)
- placenta accreta (implanted in uterine muscle)
what is fourth stage? what should happen? effects of sleep?
from birth of placenta up to 1 hr PP (mb up to 6 hrs)
all vitals should return to normal
pulse and resps may be slightly elevated
sleeping helps prevent PPD, high BP, PIH, breastfeeding problems
what should a PP uterus feel like? causes of uterus to the side?
uterus should be firm, central, at or below umbilicus
if to the side: mb bladder (to the L) or uterus full, uterine prolapse, uterine rupture, undetected twin, broad ligament hematoma
how much blood is normal blood loss in the 1st hr PP? what is definitely an abn amount? what does it depend on?
up to 100 cc = a soaked chux pad
greater than 100 cc in 15 mins is abn!
depends on: blood loss w/placenta, if she tore (and where), general health status
how to increase bonding?
get chest to chest, nose to breast in first 30 mins (ASAP)
quicker= quicker suckling response= better bonding
ssxs of hematoma?
pain, pressure, swelling, displaced uterus, boggy uterus
complications of a hematoma?
blood loss
infection
urinary retention
how to manage a hematoma?
ice
pressure
arnica
may need to incise and drain (last resort)
how should involution progress?
0.5-1 fingerbreadth/day after delivery
day 1: 1.5-2 below umbilicus or at umbilicus
by day 14 should be at pubic bone (normal)
7 reasons for subinvolution?
- retained membranes
- retained placental parts
- infection
- LGA
- twins
- multip
- age-dependent
what to assess in regards to the infant after birth?
dry off provide tactile stimulation suction if necessary evaluate HR check for respirations check color ultimately assign APGAR
how to score an APGAR?
5 categories: heart rate, respiration, color, muscle tone, reflex to stimulus
scored 0-5
total of 10 pts possible
what does a 0 look like for HR, respirations, color, muscle tone, reflex to stimulus?
0 for the following- HR: absent respirations: absent color: blue, pale muscle tone: limp reflex to stimulus: absent
what does a 1 look like for HR, respirations, color, muscle tone, reflex to stimulus?
1 for the following- HR: less than 100 respirations: slow, irregular color: body pink, extremities pale muscle tone: mild flexion reflex to stimulus: minimal, grimace
what does a 2 look like for HR, respirations, color, muscle tone, reflex to stimulus?
2 for the following- HR: greater than 100 respirations: strong, crying color: pink muscle tone: active, full flexion reflex to stimulus: cough, sneeze, cry
normal temp for a newborn?
97.8-99.4
what can cause an irregular temp in an infant? (3)
dehydration
infection
meconium
how should the fontanelles feel?
not too big or small, not hard, not bulging
sunken= dehydration
1-3 cm is normal
what 4 things can you assess from cord blood?
- Rh factor2. direct Coombs
- paternity
- cord blood banking
danger signs you might see in a newborn infant? (7)
grunting, nasal flaring, high resps gray, white blue in color lethargy no urine or poop high or low temp dehydration cord smells foul, bleeding
