Rana

• Fourth Stage of labor


  The stage started after delivery of placenta & until physical status has stabilized
• Duration of Fourth 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 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. Immediately following the birth of placenta, the uterus contracts to the size of a large grapefruit

  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
• Lochia


  Classified according to its appearance & contents
• Types of Lochia


  • Lochia rubra (dark red, occurs for the 1st 2-3 days)
  • Lochia Serosa (pinkish color, follows from about day 3 until day 10)
  • Lochia Alba (composed leukocytes, decidual cells, epithelial cells, fat, cervical mucus, cholesterol crystals, & bacteria)
• When the lochia flow stops, the cervix is considered closed, & chances of infection ascending from the vagina to the uterus decrease
• An infection does not develop because the organisms involved are relatively nonvirulent
• Total average volume of lochia

  About 225 ml & the daily volume gradually decreases
• The amount of lochia may increase by exertion or breastfeeding
• Evaluation of lochia


  Necessary to determine presence of hemorrhage and to assess uterine involution
• 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
• Vaginal changes


  Following birth the vagina appears edematous & may be bruised, the hymen torn & jagged, heals irregularly, leaving small tags called carunculae myrtiformes
• 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
• Recurrence of ovulation & Menstruation


  In non breastfeeding mothers returns between 4 & 6 weeks after birth, 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) may occur
• Lactation


  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 bowels tend to be sluggish following birth, women who have had an episiotomy, lacerations, or hemorrhoids may tend to delay elimination for fear of increasing their pain
• 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, at risk for over distention, incomplete bladder emptying, & buildup of residual urine
• Vital Signs


  During P-P period, with the exception of the first 24 hrs the woman should be afebrile, a transient rise in both systolic & diastolic blood pressure, which spontaneously returns to the pre-pregnancy baseline over the next few days, puerperal bradycardia with rates of 50 to 70/ bpm commonly occurs during the first 6 to 10 days of the P-P period
• Blood Values


  Nonpathologic leukocytosis often occurs during labor & in the immediate P-P period, with WBCs of 25,000 to 30,000/mm, hemoglobin & hematocrit levels may be difficult to interpret in the first 2 days after birth because of the changing blood volume, platelet levels fall as a result of placental separation then begin to increase by the third to fourth P-P day
• The diameter of deep vein can take up to 6 weeks to return to prepregnant levels, this is why there is a prolonged risk of thromboembolism in the 1st 6 weeks following birth