Management of Fourth Stage of labor

It is the fourth stage of observation following placental ejection (after birth). During this time, the woman's overall health and the uterus's activities must be closely monitored.

• Maintain a comfortable position for the mother.
• Give her a warm drink, such as milk, soup, or juice.
• Check the uterus for contractions; if not, massage the uterus abdominally and instruct the mother to do the same.
• Check the genitalia for PV bleeding and replace the pad if wet; frequent pad changes indicate vaginal hemorrhage; if bleeding is excessive, save all pads to evaluate bleeding. More than 500 mL of bleeding indicates postpartum hemorrhage.
• Evaluate the maternal state by obtaining vital signs; if any irregularities are discovered, notify a senior or a doctor.
• Encourage the mother to empty her bladder on a regular basis; a woman may have pee retention due to muscle overstretching and pain from a cut or bruise.
• Fundal height should be measured and recorded. After birth, the uterine fundus was discovered beneath the umbilicus.
• Examine the baby's cord for any seeping or blood. If any symptoms of bleeding are observed. Clean it thoroughly with a spirit swab and ligature the chord.
• Clean the breasts and place a baby on them.
• If the mother is receiving an oxytocin infusion, it should be continued for at least one hour after the placenta is delivered.
• Encourage the mother to undergo postnatal exercise, particularly pelvic floor muscle training, and advise her to do it twice a day for 6-8 weeks to prevent uterovaginal prolapse later in life.
• Examine the identification mark on the baby's wrist.
• Identify any congenital anomalies.
• Keep track of the baby's weight, as well as whether or not urine and meconium were passed.
• Complete all reports and documentation.
• If everything is ok, move the mother and baby to the postnatal ward.
• Educate the mother on the warning symptoms of both mother and child.

Danger signs of mother:

• Heavy vaginal bleeding, soaked more than two pads in 30 minutes
• Seizures/loss of consciousness
• Severe headache/vision blur
• Perineum swelling and discomfort
• Abdominal pain that is unbearable
• Calf pain with or without swelling

Danger Signs of Baby

• Sucking poorly
• Rapid breathing
• Intense chest indrawing
• Grunting
• Lethargy or movement only in response to stimulus
• Unconscious: hot eyes, edema, and pus discharge from the eyes
• Weak and ineffective wail
• A body's yellow coloring.

Initial Rapid Newborn Assessment

When danger indicators are detected, conduct a fast assessment to evaluate the newborn's degree of illness, the need for emergency care/stabilization, and the immediate course of action that must be taken:

1. Place the infant on a warm, well-lit surface.
2. Examine the baby for the following indications of respiratory distress:
   - Not breathing
   - Gasping
   - Abnormal breathing(60 breaths per minute.
   - Indrawing of chest grunting on expiration.
   - Central cyanosis (blue tongue and lips)
3. Perform resuscitation if the baby is not breathing, is gasping, or has a low respiratory rate before proceeding to the following step.
4. If the baby exhibits any other signs of breathing trouble, or if there are no indicators of breathing difficulties, move to the next rapid initial examination.
5. Determine the baby's heart rate.
   - If the baby has a rapid heart rate (more or equal to 180 beats per minute. Assess for other signs of shock, which may include:
   - Pallor
   - Central cyanosis
   - Rapid breathing (>60 breaths/ mins)
   - Unconscious or nearly unconscious
6. If the baby is not in shock, act promptly and arrange for an urgent referral/transfer:
   - Assess for bleeding if the baby is bleeding, press on the bleeding site with a sterile compress and confirm compression before and during transfer.
   - Keep the baby warm through the assessment and care.
7. Assess the baby for convulsions and spasm:
   - If the baby is having convulsions or spasms, arrange for an urgent referral or transfer and administer a single dosage of Inj. 20mg/kg body weight IM phenobarbitol.
8. Examine the newborn for indications of sepsis and administer antibiotics in the form of Ampicillin 50mg/kg body weight IM PLUS Gentamycin 5mg/kg body weight IM.
9. Manage the baby in accordance with any single danger sign.

Record and Reporting

Always recording and reporting are so crucial that they are occasionally used for statistical purposes and obstetrical research. As a result, facts and data must be recorded appropriately. As soon as labor is completed, the chart should be completed, including the date. The record includes:

• Maternal chart recording

1. Presentation, fetal position, membrane rupture timing, and amniotic fluid color
2. Normal childbirth, normal delivery with episiotomy, vaccum delivery, forceps delivery, cesarean section, and so on.

• Date and time of delivery

1. Local, epidural, and general anesthesia were employed.
2. Placenta delivery time: how many minutes after baby delivery.
3. Completeness of placenta, membrane, cord anomalies, etc. If there is any symptom of incompleteness, investigation and testing are required to determine that there is no retention of a placenta.

• When quantifying blood loss in milliliters, the amount should be computed as clotted, soaked pad containing blood in the teles pad; if blood loss exceeds 500ml, the condition is known as PPH.
• Cervix, vagina, and perineum for any laceration or tear present, as well as the condition of the tear and its depth.

1. Any episiotomy wound and suture should be noted, and if non-absorbable thread is used, the number of sutures should be counted and recorded.
2. During labor, the mother is administered any prescription or substance. It should accurately record the name, dose, route, time, and signature of the giving staff.
3. The chart should record the mother and baby's transfer ward after birth, such as postnatal ward, NICU, baby care, and so on.

• Any aberrant condition or complication during childbirth, as well as its management, should be properly documented.
• The delivery should be documented with the clear name and designation of the on-duty staff, sister in charge, on-duty doctor, student nurse, or ANM present.
• Mother's vital sign upon birth. It depicts the mother's normal and abnormal states. These vital signs should be taken every four hours.

1. If a mother has voided or not after birth, the amount of urine and time of delivery should be noted since urine retention can be measured by the voiding time following delivery.

• Fundal height should be measured and recorded correctly after birth.
• If oxytocin is used for labor induction or active management of the third stage of labor. It should be properly documented.
• Record of baby’s chart

1. Sex of the baby
2. APGAR score of 1min, 5min and 15 min

• Baby’s weight, height, head circumference should be taken and recorded.

1. Baby's temperature, pulse (heart rate), and respiration.
2. Any congenital defects or birth traumas in the newborn.
3. If the baby is given medication, the medication name, dose, route, time, and drug provided should be recorded.

• Any unusual condition.
• Any resuscitation measure is used on the baby, such as oxygenation, suction, endotracheal tube placement, and so on.
• Transfer of the baby from the labor room to another location, such as a pediatric baby unit, neonatal care unit, incubator ward, pediatric intensive care unit, neonatal intensive care unit, and so on.