FORCEPS DELIVERY (MANAGEMENT) & PUERPERIUM / POSTPARTUM

STAGE
Monday, September 12, 2022 2:32 PM

FORCEPS DELIVERY

C. THIRD STAGE OF LABOR = STAGE OF PLACENTAL EXPULSION

- Begins with the delivery of the infant to the delivery of the placenta.

Signs of placental separation

1. Calkin’s sign – uterus becoming round & firm & globular again, rising high to the level of the umbilicus. ( Earliest
sign of placental separation)

2. Sudden gush of blood from the vagina

3. Lengthening of the cord from the vagina

Types of placental separation:

1. Schultz – if the placenta separates first at its center & last at its edges, it tends to fold on itself like an umbrella & presents
the fetal surface which is shiny. 80% of placentas separate this way; “ Shiny for Schultz”
2. Duncan – if the placenta separates first at its edges, it slides along the uterine surface & presents at the vagina with the
maternal surface which is raw, red, & irregular with the ridges or cotyledons that separate blood collection spaces showing.
Only about 20% of placentas separate this way. “ Dirty for duncan”

Nursing care:

○ Do not hurry the expulsion of the placenta by forcefully pulling out the cord or doing vigorous fundal push as this can
cause uterine inversion.

○ Tract the cord slowly, winding it around the clamp until the placenta spontaneously comes out ,rotating it slowly so
that no membranes are left inside the uterus. A method called “ Brandt Andrew’s maneuver

○ Take note of the time of placental delivery. It should be delivered within 15 to 20 minutes after the delivery of the
baby, otherwise refer immediately to the physician as this can cause severe bleeding in the mother.

*If bleeding occurs & the placenta cannot be delivered, manual extraction of the placenta is indicated

○ Inspect for completeness of cotyledons; any placental fragment retained can also cause severe bleeding & possible
death. ( First nursing action in the 3rd stage of labor).

○ Palpate the uterus to determine degree of contraction. If relaxed, boggy or non-contracted; the first nursing action is
to massage gently & properly. An ice cap over the abdomen will also help contract the uterus since cold causes
vasoconstriction.

○ Inject oxytoxics, methergin or syntocinon IM to maintain uterine contractions, thus prevent hemorrhage.

Note: oxytoxics are not given before placental delivery because placental entrapment could occur. Do not give
methergin if bp is 130/100 or above.

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○ Inspect the perineum for lacerations. Anytime the uterus is firm following placental delivery, yet bright red vaginal
bleeding is gushing forth from the vaginal opening, suspect lacerations.

Categories of lacerations

i. First degree – involves the vaginal mucus membranes & skin of the perineum & the fourchette.

ii. Second degree – involves not only the vaginal mucus membranes & skin but also the muscles.

iii. Third degree – involves not only the rectal sphincter of the rectum, muscles, vaginal mucus membranes & skin
but also the mucus membranes of the rectum.

D. FOURTH STAGE OF LABOR – STAGE OF PUERPERIUM / STAGE OF VIGILANCE

-Said to be the most critical for the mother because of unstable vital signs.

- Starts immediately after the delivery of the fetus up to 4 hours & is completed when the reproductive tract has returned to its
non-pregnant condition

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PUERPERIUM / POSTPARTUM STAGE

Puerperium / postpartum - refers to the six to eight week period after the delivery of the baby.

Involution - the return of the reproductive organs to their pre-pregnant state ( 6 weeks)

Assessment:

a. Fundus - should be checked every 15 minutes for 1 hour then every 30 minutes for the next 4 hours. Fundus should
be firm, in the midline, & during the first 12 hours postpartum, is a little above the umbilicus.

b. Lochia – uterine discharge consisting of blood, deciduas, WBC, & mucus. Should be moderate in amount.

Pattern of lochia:

 Rubra = 0-3 days , dark red & moderate in amount, small clots, fleshy stale odor.

 Serosa = 4 -7 days ; pink or brownish in color, no clots, no odor ( unless poor hygiene)

 Alba = 1 – 3 weeks; cream to yellowish in color; minimal in amount; no odor; no clots

Notes on lochia:

 Pattern should not reverse

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 It should approximate menstrual flow

 It has the same fleshy odor as menstrual blood.

 It should never be absent, regardless of the method of delivery. ( NSD OR CS)

c. Bladder - a full bladder is evidenced by a fundus which is right to the midline

d. Perineum – is normally tender , discolored (ecchymotic) & edematous. ( Apply ice bag to the perineum immediately).
It should be clean with intact sutures.

e. Rooming – in concept – ( primarily to promote bonding).

f. Blood pressure – taken every 15 minutes for 1st hr; then every 30 minutes during the 2nd hour

IMMEDIATE MEDICAL INTERVENTION IS NECESSARY IF ANY OF THE FOLLOWING OCCURS:

1. Marked bleeding persists – blood soaks a perineal pad in 15 minutes regardless of whether the bleeding is accompanied
by a change in vital signs, maternal color or behavior.

2. Complaints of lightheadedness & blurring of vision.

3. Ashen color / pallor

4. Exhibits air hunger

5. Cold clammy skin

6. Restlessness

7. Decreased blood pressure

8. Increased blood pressure

9. Increased PR & RR

Emergency mx & intervention:

1. Call for help

2. Turn woman to her left & check fundus of the uterus for firmness

3. Increase IV flow & add oxytocin as per doctors order

4. Elevate the foot part of the bed to allow the fast return of the blood to the upper part of the body

5. Administer oxygen

g. Genital changes – uterine involution is assessed by measuring the fundic height by fingerbreadths (=1 cm). On
postpartum day 1 ( PPD 1) = fundus is one fingerbreadth below the umbilicus; on PPD 2, 2 fingerbreadths below the

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*To encourage return of the uterus to its usual anteflexed position, prone & knee chest positions are advised.

h. Afterpains / afterbirth pains - strong uterine contractions felt more particularly by multis, those who delivered large
babies, & those who breastfeed because of oxytocin production. It will be relieved in 3 -4 days.

Postpartum psychological adaptation:

1. Taking- in phase - 1 – 3 days postpartum when mother relies on others to care for her & her newborn. Preoccupied with self &
own needs ( food & sleep), client may verbalize her feelings regarding recent delivery. Hesitant about making decisions.

2. Taking – hold phase - 4 – 7 days postpartum when mother begins to initiate actions & decisions; dependency /independency;
ready for mothering role; post-partum blues – (an overwhelming feeling of sadness that cannot be accounted for) may be
observed. Could be due to hormonal changes, fatigue or feelings of inadequacy in taking care of a new baby.

Mx:

- Explain that it is normal & that crying could be therapeutic. But if postpartum blues extend beyond two weeks, it could
lead to postpartum depression & postpartum psychosis ;therefore constant monitoring should be done to the mother.

Implication: provide psychological support .

3. Letting – go phase - 10 days; Woman attains complete independence; assuming new roles and responsibilities

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