PHYSIOLOGY AND MANAGEMENT OF NORMAL LABOUR

MIDWIFERY LEVEL 200

GROUP 7

1. NARTEY GRACE NARKOUR PUMW/22210133

2. TETTEH VALENTINA ELLIS PUMW/22210085

3. CHRISTABEL HANSON PUMW/22210111
4. BOADU MATILDA AHWIRENMEA PUMW/22210077
5. AGNES APPIAH PUMW/22210141
6. ASARE PATIENCE MUSAH PUMW/22210036
7. SARKODIE PRISCILLA AKYAMAH PUMW/22210078
8. TETTEH GLORIA PUMW/22210099
9. AMPEA VANESSA AKOSUA PUMW/ 22210043
10. TETTEH PATIENCE NUERKIE PUMW/22210121
11. ASARE JENNIFER BOAFO PUMW/22210181

12. RUTH AIDOO PUMW/22217205

13. ADU ASIEDUWAA ESTHER PUNS/22210296
THE FOURTH STAGE OF LABOUR
The fourth stage of labor, which begins after delivery of the placenta and ends when the mother's
system has stabilized, usually 1-4 hours later. It describes the maternal assessment during this
stage, including evaluation of pain, the uterus, inspection of the placenta and repairs if needed.
Potential complications are also discussed as well as neonatal observations like Apgar scoring and
vital signs measurements of the newborn.The fourth stage of labor is a physiologic and clinical
entity.The physiology of the fourth stage of labor is postulated, the two main physiologic phases
being:I.The Contractile Phase,II.The Hemorrhagic Phase.
The contractile phase refers to the initial period following childbirth where the uterus actively
contracts to help separate the placenta and regain its normal tone, essentially the phase where the
uterus is still actively pushing out any remaining tissue, while also experiencing some bleeding,
which is considered part of the "hemorrhagic phase" within the 4th stage; both phases occur
simultaneously and are considered part of the body's natural recovery process after delivery.
GENERAL /PHYSICAL EXAMINATION OF THE 4TH STAGE OF LABOUR
A general examination during the fourth stage of labor primarily focuses on monitoring the
mother's vital signs, uterine tone, amount and character of lochia (postpartum bleeding), assessing
for any perineal lacerations or episiotomy site complications, and ensuring proper recovery from
anesthesia, while also promoting bonding between the mother and newborn and initiating
breastfeeding; essentially, this stage is about closely observing the mother's physical stability post-
delivery and providing necessary support. 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 .During the fourth stage of labor, the uterus should
be firm, midline, and located roughly at the level of the umbilicus, indicating good uterine tone
and a size that is gradually shrinking back to its pre-pregnancy state; this is considered the ideal
position and condition for the uterus in the immediate postpartum period. The tone is Firm and
well-contracted, meaning it effectively clamps the placental site to prevent excessive bleeding. The
size is approximately the size of a grapefruit, gradually decreasing as it involutes.The location is
at the midline in the abdomen, at or slightly below the level of the umbilicus. 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.
THE 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 .The nurse should compare
the vital signs to predelivery vital signs and look for subtle changes to report to the physician.Blood
pressure: normal values range between 90/60 mmHg to below 140/90 mmHg.Maternal pulse rate:
normal range is 80-100 beats/minute, but should not be greater than 110 beats/minute in a woman
in labour.Temperature: average 37oC; if it is between 37.5-38.4oC the woman has a low grade
fever; if it is 38.5oC or above, she has a high grade fever.Breathing: listen for grunting, look for
chest in-drawing and fast breathing in the baby. Warmth: check to see if feet are cold to touch in
the baby.

STATE OF THE UTERUS

Contraction and Firming: After the baby is delivered, the uterus continues to contract, which helps
to stop any bleeding by compressing blood vessels in the placental site. The uterus becomes firmer
and smaller as it contracts to expel the placenta and return to its pre-pregnancy size.
Control of Bleeding: The uterine muscles constrict around the blood vessels at the placental
attachment site to reduce blood loss. After the placenta is delivered, the uterus should feel firm
and contracted to minimize bleeding.
Involution: The uterus starts to contract back to its pre-pregnancy size through a process called
involution. Over the next few weeks, the uterus will continue to shrink and return to a size similar
to its original form.
During the fourth stage of labor, the healthcare team monitors the mother closely for any signs of
excessive bleeding (postpartum hemorrhage) and ensures the uterus remains contracted and firm.
Atonic uterus

This is a failure of the myometrium at the placental site to contract and retract and to compress
torn blood vessels and control blood loss by a living ligature action. When
the placenta is attached, the volume of blood flow at the placental site is approximately 500–800
ml/min. Upon separation, the efficient contraction and retraction of uterine muscle will staunch
the flow and prevent a haemorrhage, which can otherwise ensue with horrifying speed .

BLEEDING
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. 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.
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.Inspect
the perineal pad, underpad, or any material used to collect lochia.
Note the color, amount, consistency, and odor of the discharge;rubra,serosa and alba .Weigh the
lochia on all materials.Using a scale, weigh the soiled perineal pads, underpads, and linen.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.Convert the weight in grams to milliliters (1 g = 1
mL).Assess the odor of lochia. Lochia typically has a mild, musky odor. Any foul or unpleasant
smell may indicate infection.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.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.Excessive pain may indicate the development of a hematoma.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 repairsThe nurse also informs the incharge of
any deviations from normal.
FLUID INPUT AND OUTPUT
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 . 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.Encourage the woman to empty her bladder frequently. Remind her every 2 hours.If the
mother cannot pass urine or the bladder is full (swelling over lower abdomen) and she is
uncomfortable, help her by gently pouring water on vulva.

Fluid input and output are closely monitored to ensure the mother's hydration, kidney function,
and to prevent complications such as hemorrhage or shock.
Fluid Input:
IV Fluids: If the mother has received an IV drip during labor (especially if she had a cesarean
section or complications), fluids may continue to be given in the fourth stage. This is to maintain
hydration and replenish lost fluids, especially if there was significant blood loss.
Oral Fluids: Once the mother is stable and alert, she may be allowed to drink clear fluids like water,
electrolyte solutions, or juice to maintain hydration.
Medications and Analgesia: Any medications administered through an IV or subcutaneously (such
as pain relief or uterotonics) are also considered part of fluid input.
Fluid Output:
Urine Output: Urinary output is carefully monitored in the first few hours postpartum.
Dehydration, urinary retention, or excessive blood loss can impact urine output. Normal urine
output should be at least 30 mL per hour. If urine output is significantly lower or higher, it may
signal complications such as kidney issues or hemorrhage.
Blood Loss: Blood loss during the fourth stage of labor should be carefully assessed. Normal blood
loss is up to 500 mL for a vaginal delivery or up to 1,000 mL for a cesarean section. Any excessive
blood loss (more than 500 mL vaginally or more than 1,000 mL cesarean) could indicate
postpartum hemorrhage and may require immediate intervention.
Monitoring fluid input and output during the fourth stage is crucial to ensuring the mother's
recovery and detecting any potential issues early.
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Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. American
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postnatal period.
Pairman S, Pincombe J, Thorogood C, et al. Midwifery: preparation for practice.
Elsevier: Marrickville, Australia; 2006