Rana

• Fourth Stage of labor


  The stage started after delivery of placenta & until physical status has stabilized
• Duration of 4th stage

  1. 2 hours after delivery of placenta
• Puerperium


  The period begins immediately after birth & continues for approximately 6 weeks
• Physiological changes of the 4th stage of labor


  Involve the reproductive organs & other major body systems
• Involution of the uterus

  The rapid reduction in size & the return of the uterus to a non-pregnant state
• Involution of the uterus


  1. Decidua of the uterus is irregular, jagged, varied in thickness

  2. Spongy layer of decidua is cast off as lochia

  3. Basal layer of decidua remains in the uterus to become differentiated into two layers
• Involution of the uterus occurs within the first 48 to 72 hours after birth
• The outermost layer becomes necrotic & is sloughed off in the lochia
• The placental site is completed in approximately 3 weeks
• Healing at the placental site occurs gradually over 6 weeks
• Exfoliation


  A very important aspect of involution, if healing of the placenta site leaves a fibrous scar the area available for future implantation is limited & the number of possible pregnancies
• Factors that enhance involution


  • Uncomplicated labor & birth
  • Complete expulsion of the placenta or membranes
  • Breastfeeding
  • Manual removal of the placenta during a cesarean birth
  • Early ambulation
• Factors that slow involution


  • Prolonged labor
  • Anesthesia
  • Difficult birth
  • Grand multiparity
  • Incomplete expulsion of placenta or membranes
  • Infection
  • Over distention of uterus
• Changes in Fundal Position


  1. Fundus is situated in the midline midway between the symphysis pubis & the umbilicus immediately following the birth of placenta

  2. Within 6 – 12 hrs after birth, the fundus rises to the level of the umbilicus

  3. A fundus that is above umbilicus & boggy is associated with excessive uterine bleeding

  4. When fundus is higher than expected on palpation & is not in the midline (usually deviated to the right), distention of the bladder should be suspected
• Involution of the uterus

  1. Immediately after delivery of the placenta, the top of the fundus is in the midline & approximately halfway between the symphysis pubis & the umbilicus

  2. About 6 – 12 hrs after birth the fundus is at the level of the umbilicus

  3. The height of the fundus then decreases about one finger breadth (approximately 1 cm ) each day
• Subinvolution


  Any slowing of descent of the fundus
• Types of Lochia


  • Lochia rubra (dark red, 1st 2-3 days)
  • Lochia Serosa (pinkish, day 3 to 10)
  • Lochia Alba (whitish, after day 10)
• When the lochia flow stops, the cervix is considered closed, & chances of infection ascending from the vagina to the uterus decrease
• Microorganisms are always present in the vaginal lochia, by the 2nd day following birth the uterus is contaminated with the vaginal bacteria
• An infection does not develop because the organisms involved are relatively nonvirulent
• The total average volume of lochia is about 225 ml & the daily volume gradually decreases
• The amount of lochia may increase by exertion or breastfeeding
• Multiparas women usually have more lochia than primiparas, also a C-section birth have less lochia than vaginal
• Persistent discharge of lochia rubra or a return to lochia rubra


  Indicates subinvolution or late postpartal hemorrhage
• Cervical changes


  • Following birth the cervix is flabby, formless, & may appear bruised
  • The lateral aspects of external os are frequently lacerated during birth process
  • The external os is irregular & closes slowly
  • The shape is changed by the first childbearing
• Vaginal changes


  • Following birth the vagina appears edematous & may be bruised
  • The hymen torn & jagged, heals irregularly, leaving small tags called carunculae myrtiformes
  • The size of the vagina decreases & rugae return within 3 – 4 weeks
  • By 6 weeks the non-breastfeeding woman's vagina usually appears normal
• Perineal changes


  • During the early postpartal period the soft tissue in & around the perineum may appear edematous, with some bruising
  • Initial healing of episiotomy or laceration occurs in 2—3 weeks after birth
  • Complete healing up to 4—6 months, perineal discomfort may be present during this time
• Recurrence of ovulation & Menstruation


  1. In non breastfeeding mothers, returns between 4 & 6 weeks after birth

  2. If a mother breastfeeds for less than 1 month, return of Menses & ovulation is similar to non breastfeeding mother

  3. In women exclusively breastfeed, Menses is delayed for at least 3 months
• Abdominal changes


  • The stretched abdominal wall appears loose & flabby, it responds to exercise within 2 – 3 months
  • Diastasis recti abdominis (separation of the abdominal muscle)
  • The striae (stretch marks) gradually fade after a time but remain visible
• Lactation


  • During pregnancy, breast development in preparation for lactation results from the influence of both estrogen & progesterone
  • After birth, the interplay of maternal hormones leads to milk production
• Gastrointestinal system changes


  • Hunger following birth is common, & the mother may enjoy eating a light meal
  • The bowels tend to be sluggish following birth because of the lingering effects of progesterone, decreased abdominal muscle tone & bowel evacuation associated with the labor & birth process
  • Women who have had an episiotomy, lacerations, or hemorrhoids may tend to delay elimination for fear of increasing their pain
• Women with C-section birth may receive clear liquids shortly after surgery, once bowel sounds are present, her diet is quickly advanced to solid food
• Urinary tract changes


  • The postpartal woman has an increased bladder capacity, swelling & bruising of the tissue around the urethra, decreased sensitivity to fluid pressure, & a decreased sensation of bladder filling
  • She is at risk for over distention, incomplete bladder emptying, & buildup of residual urine
  • Immediate postpartal use of oxytocin to facilitate uterine contractions has an anti-diuretic effect
  • Urinary output increases during the early postpartal period (first 12 to 24 hrs) because of puerperal diuresis
• If urine stasis exists, chances for UTI increase because of bacteriuria & the presence of dilated ureters & renal pelves, which persist for about 6 weeks after birth
• A full bladder may also increase the tendency of the uterus to relax by displacing the uterus & interfering with its contractility, leading to hemorrhage
• Vital Signs


  1. During P-P period, with the exception of the first 24 hrs the woman should be afebrile

  2. A maternal Temp of up to 38C may occur after childbirth as a result of the exertion & dehydration of labor

  3. An increase in Temp to between 37.8 & 39C may also occur during the 1st 24 hours after the mother's milk comes in

  4. Immediately following childbirth a transient rise in both systolic & diastolic blood pressure, which spontaneously returns to the pre-pregnancy baseline over the next few days

  5. A decrease in BP may indicate physiologic readjustment to decreased intrapelvic pressure, or related to uterine hemorrhage

  6. BP elevation may result from excessive use of oxytocin or vasopressor medications

  7. Puerperal bradycardia with rates of 50 to 70/ bpm commonly occurs during the first 6 to 10 days of the P-P period

  8. A pulse rate greater than 100/bpm may be indicative of hypovolemia, infection, fear, or pain & requires further assessment
• Blood Values


  1. Nonpathologic leukocytosis often occurs during labor & in the immediate P-P period, with WBCs of 25,000 to 30,000/mm

  2. Hemoglobin & hematocrit levels may be difficult to interpret in the first 2 days after birth because of the changing blood volume

  3. Blood loss averages 400 ml with a vaginal birth & nearly 1000 ml with a C-section birth

  4. A two to three percentage point drop in hematocrit equals a blood loss of 500 ml

  5. After 3 to 4 days, mobilization of interstitial fluid leads to a slight increase in plasma volume

  6. Platelet levels fall as a result of placental separation, then begin to increase by the third to fourth P-P day, returning to normal by the sixth P-P week

  7. The hemostatic system as a whole reaches its normal prepregnant status by 3 to 4 weeks P-P

  8. The diameter of deep vein can take up to 6 weeks to return to prepregnant levels, prolonging the risk of thromboembolism in the 1st 6 weeks following birth