Page 71 - 33Elctronic Book (3) Normal Labor

cord is thick and the umbilical cord clamp cannot be applied, the cord is ligated by two

thick silk ligatures.

4- The infant is examined for injuries and congenital anomalies as imperforate anus.

5- Vernix caseosa is removed from the neck, maxilla and groins and a bath is not

necessary.

6- The infant is weighted, gestational age is determined, dressed and bracelets is applied
for identification.

7- Penicillin eye drops or ointment is used to protect against gonococcal ophthalmia

neonatorum. Tetracycline or erythromycin ointment can be used.

8- Vitamin k1 is given to all infant immediately after delivery as 1gm IM or is given orally
as 1gm at birth and the dose is repeated at the end of the first and third week (3 oral dose).

In high-risk infants who are liable, to develop hemorrhage as preterm as asphyxiated
infants, the first dose is given IM and then two oral dose are given as above.

Fourth stage of labor:

Definition:

It is the stage of early recovery. Begins immediately after expulsion of the placenta

and membranes and lasts for one hour. During which careful observation for the patient

particularly the signs of postpartum hemorrhage. Uterine massage is usually done every 5

minute during this period.

Nursing Management of the Fourth Stage of Labor

Assessment
• . Check maternal vital sign :

• . Check uterine contraction
• . Observe lochia

• Assess the condition of the urinary bladder.
• Assess the condition of the perineum.
Nursing Diagnosis

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