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Show Notes
1. SECOND & THIRD STAGES OF LABOR (10 cm Dilated to Placenta Delivery)
- Maternal Positioning: Promote upright, squatting, or lateral positions to maximize pelvic space and use gravity for fetal descent. Never use supine or dorsal positions, which compress the inferior vena cava, reduce placental perfusion, and prolong labor.
- Active Pushing: Wait until the fetus descends (0 station) and the client actually feels the urge to push (delay up to 2 hours for epidural clients). Encourage open glottis (natural) pushing over closed glottis (Valsalva/breath-holding) to reduce maternal fatigue, hemorrhage, and perineal tearing.
- Placental Delivery (Third Stage): The 3 hallmark signs of placental separation are a gush of blood from the vagina, lengthening of the umbilical cord, and a globular-shaped fundus. Actively manage this stage to prevent Postpartum Hemorrhage (PPH) using uterotonic medications.
- High-Yield Uterotonics: Oxytocin (first-line; adverse effect: tachysystole); Carboprost (contraindicated in hepatic/pulmonary/renal disease); and Methylergonovine (strict contraindication: hypertension).
2. FOURTH STAGE OF LABOR (Immediate Postpartum & Hemorrhage Priorities)
- The Hemorrhage Priority: A boggy (soft) fundus means the uterus is not contracting properly (atony) and the client is at severe risk for hemorrhage. Your immediate priority action is fundal massage.
- Bladder Distention Exam Trap: If the fundus is firm but deviated to the right or left, the bladder is full. A full bladder prevents uterine contraction and increases blood loss. The priority action is to assist the client to void immediately.
- Lochia & Blood Loss: Accurately quantify blood loss by weighing pads (1 gram = 1 mL of blood). Total blood loss exceeding 1,000 mL is classified as a PPH. Assess the perineum constantly for hidden bleeding or perianal hematomas (discoloration/bulging).
3. NEWBORN TRANSITION & SAFETY (First 2 Hours of Life)
- Apgar Scoring: Assessed at 1 and 5 minutes post-birth based on Heart rate, Breathing effort, Muscle tone, Reflex irritability, and Color. Scores of 7–10 are expected. Exam Trap: A score of 1 for color is completely normal because acrocyanosis (blue hands/feet) is an expected benign finding. However, cyanosis around the mouth (central cyanosis) is a medical emergency.
- Expected Newborn Vitals: Heart rate: 110–160 beats/min; Respiratory rate: 40–60 breaths/min; Axillary temp: 36.5°–37.5°C (97.7°–99.5°F). Look for red flags of respiratory distress: nasal flaring, grunting, and retractions.
- Thermoregulation: Place the newborn skin-to-skin immediately to prevent heat loss, stabilize breathing, and prevent newborn hypoglycemia. Understand the 4 types of heat loss: Evaporation (wet baby), Conduction (cold surfaces), Convection (drafts), and Radiation (near cold windows).
- Priority Newborn Meds: Administer Erythromycin ophthalmic ointment within 1 hour to prevent blinding neonatal ophthalmia from vaginal bacteria. Administer Phytonadione (Vitamin K) IM within 1 hour to prevent fatal Vitamin K Deficiency Bleeding (VKDB), as newborns are born with sterile guts and cannot synthesize their own clotting factors yet