Learning Objectives
By the end of this section, you will be able to:
- Obtain assessment data on the person who has completed the first three stages of labor and birth
- Explain the nursing actions when caring for a person during the fourth stage of labor
- Monitor parent-newborn attachment
- Provide education to the person who has given birth and the family related to the fourth stage of labor
Assessment during the Fourth Stage of Labor
The delivery of the placenta initiates the fourth stage of labor. This stage ends after 1 to 4 hours or until the birthing person is clinically stable. During this stage, the nurse will closely monitor the birthing person’s vital signs, uterine tone, lochia, and recovery from any anesthesia for complications and encourage parent-newborn bonding and breast-feeding. The nurse will also assist the health-care provider during the repair of any lacerations.
Vital Signs
During the first hour following delivery, the nurse will monitor the birthing person’s vital signs every 15 minutes, followed by every 30 minutes during the second hour (Table 18.12) summarizes the assessment data to be collected. The nurse should compare the vital signs to predelivery vital signs and look for subtle changes to report to the physician (Hutchison et al., 2023).
| Assessment Data | Fourth Stage of Labor | Expected Findings |
|---|---|---|
| Vital signs | Every 15 minutes for the first hour, every 30 minutes for the second hour, every hour for the third and fourth hours Temperature Within the first hour of delivery, as needed after the first hour |
Vital signs will return to baseline following the 1-hour recovery. |
| Uterus | Monitor location, size, and consistency every 15 minutes for the first hour, every 30 minutes for the second hour, every hour for the third and fourth hours | The uterus will remain firm, midline, and approximately at the level of the umbilicus. |
| Lochia | Monitor amount, color, and consistency every 15 minutes for the first hour, every 30 minutes for the second hour, every hour for the third and fourth hours | The lochia will remain rubra in color, will not contain large clots, and will remain consistent or decreased in quantity. |
| Perineum | Monitor for edema, ecchymoses, and discomfort every 15 minutes for the first hour, every 30 minutes for the second hour, every hour for the third and fourth hours | The perineum will remain free from infection. |
| Pain | Hourly, or more frequently as needed | Pain will be managed with pain medications when required. |
| Recovery from anesthesia | Monitor every 15 minutes for a return of sensation and movement in the lower extremities | Birthing person will return to normal sensation and movement. |
| Emotional response | Continuous | Birthing person will discuss feelings and concerns with health-care providers and family. |
Involution
During the fourth stage of labor, it is critical for the nurse to assess uterine tone, size, and location, as well as any vaginal bleeding. The nurse should assess and monitor for uterine involution, the process by which the uterus begins to return to its prepregnant size, using regular fundal massage (Milton, 2024). Involution follows a predictable rate. During the first hours after childbirth, the fundus should be at the level of the umbilicus, and that level should not rise over the first couple of hours following delivery. A rise in uterine height warrants further assessment and notification of the provider.
The vaginal discharge composed of blood, mucus, and tissue during the postpartum period is called lochia. Assessing lochia is a critical aspect of postpartum care for people who have recently given birth. Monitoring its characteristics helps health-care providers to ensure that the birthing person’s recovery is progressing normally and to identify any potential complications.
Assessing lochia provides valuable information about the birthing person’s postpartum recovery. By closely monitoring and promptly reporting any abnormal findings, nurses can ensure the birthing person’s well-being and address any potential issues as they arise. This assessment is an essential component of postpartum care and helps in promoting a safe and healthy recovery for the new parent.
Clinical Safety and Procedures (QSEN)
How to Assess Lochia
- Frequency: Lochia is assessed at regular intervals (sample protocol: every 15 minutes in the first hour of the fourth stage of labor, hourly for the next 1 to 4 hours, then every 4 hours for 24 to 48 hours.
- Explanation and privacy: Explain the assessment procedure to the birthing person, ensuring they understand what to expect. Maintain the birthing person’s privacy and dignity throughout the assessment, using drapes or blankets as needed.
- Position: Ensure the birthing person is in a comfortable and appropriate position (legs apart and knees bent) for assessment, such as lying on their back or sitting up at less than 45 degrees.
- Use gloves: Wear disposable gloves to minimize the risk of infection when handling lochia.
- Inspection: Inspect the perineal pad, underpad, or any material used to collect lochia.
Note the color, amount, consistency, and odor of the discharge.- Color: Lochia progresses through different color phases:
- Lochia rubra: This is the initial discharge and is typically bright red, resembling menstrual blood. Lochia rubra is expected for the first 4 days.
- Lochia serosa: This is the second phase and is typically pink or brownish in color. Lochia serosa is expected for up to another 10 days.
- Lochia alba: This is the third phase and is typically whitish or yellowish and may continue for several weeks.
- The transition from rubra to serosa to alba indicates the normal healing process of the site where the placenta was attached in the uterus.
- Amount:
- Visually estimate the amount of lochia by assessing whether it is:
- (a) Scant: A small amount, less than 1 inch on a perineal pad.
- (b) Light: Approximately 1 to 4 inches on a pad.
- (c) Moderate: Approximately 4 to 6 inches on a pad.
- (d) Heavy: Saturating a pad within 1 hour or less.
- Weigh the lochia on all materials (quantification of blood loss* [QBL])
- (a) Using a scale, weigh the soiled perineal pads, underpads, and linen.
- (b) Subtract the dry weight of all materials (perineal pad, underpad, and linen) from the soiled weight. This equals the weight of the lochia in grams.
- (c) Convert the weight in grams to milliliters (1 g = 1 mL).
- (d) Add the mL of lochia to the QBL at the delivery (and any previous lochia in the postpartum period).
- Visually estimate the amount of lochia by assessing whether it is:
- Consistency: Note the consistency of lochia; it should be similar to that of mucus or watery. Clots may be present but should not be larger than a quarter.
- Odor: Assess the odor of lochia. Lochia typically has a mild, musky odor. Any foul or unpleasant smell may indicate infection.
- Color: Lochia progresses through different color phases:
- Abnormal findings: Report any abnormal findings, such as heavy bleeding (hemorrhage), foul odor, or large clots, to the health-care provider immediately, as these can be signs of complications.
- Documentation: Document the findings of the lochia assessment accurately in the birthing person’s medical record, including color, amount, consistency, and odor.
Perineum
The delivery of the newborn may result in lacerations or edema of the perineum. Lacerations are repaired by the provider, ensuring skin approximation. The nurse will assess the perineum for edema, bruising, laceration approximation, and pain when assessing vital signs and when indicated (Milton, 2024). Excessive pain may indicate the development of a hematoma. (See Chapter 20 Postpartum Care and Chapter 21 Postpartum Complications for more information.)
Nursing Actions in the Fourth Stage of Labor
In addition to assessing the patient who just delivered, nursing care during the fourth stage of labor includes assisting the health-care provider, monitoring the physiologic and psychologic responses of the birthing person, and assisting with breast-feeding. During this period, the nurse also continues to monitor the birthing person for complications.
Assisting the Health-Care Provider
During the fourth stage of labor, the nurse assists the health-care provider as needed and provides updates on any deviations from normal. Nursing actions may include cleaning the perineum, massaging the fundus, and providing any assistance and supplies for perineal repairs (Milton, 2024). The nurse also informs the HCP of any deviations from normal.
Pharmacology Connections
Lidocaine
Patients requiring suturing for a perineal laceration or repair of an episiotomy may require lidocaine. Lidocaine is a local anesthetic that is administered under the skin and to the area under the wound edge to relieve the pain associated with the repair. Lidocaine temporarily numbs the area and allows the health-care provider time to complete the repair while the patient remains comfortable.
Lidocaine (Xylocaine)
- Indications: pain relief during repair of postpartum perineal tears
- Mechanism of Action: Lidocaine provides local anesthesia by nerve blockade at various sites in the body by stabilizing the neuronal membrane by inhibiting the ionic fluxes required for the initiation and conduction of impulses, thereby effecting local anesthetic action.
- Adverse Effects: dizziness, tinnitus, confusion, tachycardia, anxiety, chest pain, dyspnea, hives
- Contraindications:
- known hypersensitivity to lidocaine or other local anesthetics of the amide type
- complete heart block
- hypovolemia
- Patient Education:
- Classification: Local anesthetics
- Route/Dosage: 10 to 15 mL of lidocaine 1 percent along the edges of the perineal tear or episiotomy
(Vallerand & Sanoski, 2002)
Monitoring the Physical Response during the Fourth Stage of Labor
Following the delivery of the newborn, the nurse should obtain vital signs of the birthing person every 15 minutes for the first hour and every 30 minutes for the second hour. During this period, the nurse will also assess the birthing person’s fundus, ensuring that it is contracting and that the birthing person’s lochia is small to moderate. The nurse also monitors the birthing person’s bladder immediately after delivery because of any IV fluid intake during labor. A full bladder interferes with uterine involution, increasing the risk of PPH (Milton, 2024). The nurse will need to assist the birthing person to void when needed. It is important for the nurse to monitor the birthing person’s level of pain and to provide comfort measures or analgesia.
Monitoring the Emotional Response during the Fourth Stage of Labor
The emotional changes that occur for the birthing person during the fourth stage of labor reflect the physical challenges and changes that the birthing person’s body has undergone. Immediately following birth, some birthing persons may feel shocked or disconnected from reality; others may feel wide awake and euphoric. As the intensity of labor wears off, the birthing person may become exhausted and interested in sleeping or resting. The role of the nurse is to support the emotional needs of the birthing person and reassure them that their feelings are normal, all while encouraging bonding with the newborn (Milton, 2024).
Promoting Breast-Feeding
In most cases, the newborn will be placed skin-to-skin with the birthing person. This allows for bonding between the birthing person and the newborn and the initiation of early breast-feeding. Following the birth of the newborn, the nurse may need to educate the birthing person on the importance of breast-feeding and the newborn’s feeding cues. The nurse can support the birthing person by keeping the newborn at the bedside for physical and emotional closeness, and to recognize feeding cues more easily (WHO, 2024). The nurse can assist the birthing person with proper positioning of the infant and attaining a proper latch during feeding. Early assistance with breast-feeding can increase the success of long-term breast-feeding (Couto, 2020). (See Chapter 22 Immediate Care of the Newborn for more information on breast-feeding.)
Link to Learning
Toronto Metropolitan Maternity Series: Labor and Delivery includes four games that examine the role of the nurse in preconception and prenatal care. These games promote the application of knowledge and skills related to assessment and intervention, highlight the important components of a comprehensive postpartum assessment, and introduce the nurse to the care of the newborn.
Monitoring for Complications during the Fourth Stage of Labor
The nurse should perform frequent assessments of the uterine fundus, including tone, location, and position. The fundus should be firm and well contracted, with the uterus located midline. Initially, the fundus will be located between the umbilicus and the symphysis pubis, slowly rising to the level of the umbilicus during the first hour after birth.
Fundal massage is performed at regular intervals to assess and maintain the firmness of the uterus. If the uterus becomes boggy at any point, additional fundal massage may be warranted. Any deviation of the fundus to the right or left of the midline requires further assessment and may require additional interventions to promote involution of the uterus. The nurse must continually assess for bladder distention, a common contributor to uterine atony, lack of muscle tone in the uterus following birth, a leading cause of postpartum hemorrhage.
The birthing person’s lochia should be frequently assessed during the fourth stage (Figure 18.7). An increase in lochia is one of the hallmark signs of potential postpartum hemorrhage. When observed, the cause should be investigated and corrected immediately. As previously mentioned, quantitative measurements of blood loss should be obtained, and treatment of postpartum hemorrhage should be a priority for nurses following every delivery (Milton, 2024).
Monitoring Parent-Newborn Attachment
The nurse can continue to encourage skin-to-skin contact between the newborn and the birthing person and support person throughout the fourth stage of labor. The nurse educates the birthing person and support person on the importance of skin-to-skin. The nurse evaluates the interactions between the birthing person and newborn and the support person and newborn. Lack of parental interaction, such as minimal holding, touching, and discussing the infant, has been linked with an increase in risk for abuse and neglect of the newborn (Safari et al., 2022).
Patient Education during the Fourth Stage of Labor
The fourth stage of labor is a time of great importance for patient teaching. The nurse should include teaching about care of the birthing person and the newborn. Fundal massage can be very uncomfortable, and birthing persons may push the nurse away. Educating the birthing person on the importance and need for fundal massage, including a decreased risk of PPH, can improve the birthing person’s acceptance of the intervention. The nurse should educate the birthing person and their partner or support person on the benefits of early skin-to-skin contact with the newborn (Safari et al., 2022) by mentioning how it
- promotes calm and relaxation for both parent and newborn;
- regulates the newborn’s heart rate and breathing, helping with the transition to extrauterine life;
- stimulates digestion and an interest in feeding;
- regulates the newborn’s temperature;
- protects against infection via colonization of the newborn’s skin with the birthing person’s bacteria; and
- stimulates maternal hormones to support breast-feeding and parenting.
Cultural Context
Cultural Considerations about Privacy
The needs and expectations when having a baby vary based on the patient’s social, religious, and cultural background. The health-care team should make every effort to understand, respect, and implement the cultural requests of the patient when appropriate. Privacy among cultures may vary, with some patients requesting no male providers or staff at the bedside. The nurse should notify the health-care team of the patient’s requests and provide staff that meet the patient’s needs. When it is not possible to meet the privacy needs of the patient, the nurse should have a discussion with the patient on how to maximize the patient’s privacy.