Page 68 - 2023 Elctronic Book (3) Normal Labor_Neat

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
• Alteration in comfort: pain related to uterine involution and

. episiotomy
• . Sleep pattern disturbance

• Alteration in nutrition to less than body requirement.
• Knowledge deficit related to physiological changes of normal postpartum,
newborn care, and self-care.

• Potential for infection related to trauma and episiotomy during delivery.
Planning and Implement ation
The nurse should remain beside the patient.

• Check and record the maternal vital signs every 15 minutes, or as necessary.
• Check the uterus to ensure that it is well contracted to prevent bleeding.

• Observe the amount of lochia.
• Inspect the perineum for edema and hematoma.

• Encourage the woman to pass urine. A full bladder will prevent proper uterine
contractions, and cause uterine atony and severe postpartum hemorrhage.
• Clean the woman, change her clothes, swab the perineum and apply clean pad.

• Give the woman a drink or light snack if she is hungry.
• Show the mother her newborn infant.

• Put the infant to the breast as soon as possible because the infant is very alert and
sucking reflex is very strong at this time.
• . Encourage rest and sleep

• Observe the infant's cord clamp, skin color, respiration and temperature.
• Detect and treat complications early.

• Complete the records for woman and infant.
• Transfer the woman to postnatal ward.

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