LABOR Stage III (Placental Expulsion)

LABOR Stage III (Placental Expulsion) - LABOR Stage...

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LABOR: Stage III (Placental Expulsion) Stage III of labor begins with the birth of the baby and is completed with placental separation and expulsion.  Lasting anywhere from 1–30 min, with an average length of 3–4 min in the nullipara, and 4–5 min in the multipara,  this stage is the shortest. Careful management and monitoring are necessary, however, to prevent short- and long-term  negative outcomes. CLIENT ASSESSMENT DATA BASE Activity/Rest Behaviors may range from excitement to fatigue. Circulation BP increases as cardiac output increases; then returns to normal levels shortly thereafter. Hypotension may occur in response to analgesics and anesthetics. Pulse rate slows in response to change in cardiac output. Food/Fluid Normal blood loss is <500 ml. Pain/Discomfort May complain of leg/body tremors/chills, leg cramps Safety Manual inspection of uterus and birth canal determines presence of tears or lacerations. Extension of the episiotomy or birth canal lacerations may be present. Sexuality Dark vaginal bleeding beginning as a trickle occurs as the placenta separates from the endometrium, usually within 1–5  min after delivery of the infant. Umbilical cord lengthens at vaginal introitus. Uterus changes from discoid to globular shape and rises in abdomen. NURSING PRIORITIES 1. Promote uterine contractility. 2. Maintain circulating fluid volume. 3. Promote maternal and newborn safety. 4. Support parental-infant interaction. NURSING DIAGNOSIS: Fluid Volume risk for deficit Risk Factors May Include: Lack/restriction of oral intake, vomiting, diaphoresis, increased  insensible water loss, uterine atony, lacerations of the birth canal,  retained placental fragments Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an  actual  diagnosis]
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DESIRED OUTCOMES/EVALUATION  Display BP and heart rate WNL, palpable pulses. CRITERIA—CLIENT WILL: Demonstrate adequate contraction of the uterus with blood loss  WNL. ACTIONS/INTERVENTIONS RATIONALE Independent Instruct the client to push with contractions; help  Client attention is naturally on the newborn; in  direct her attention toward bearing down. addition, fatigue may affect individual efforts, and  she may need help in directing her efforts toward  assisting with placental separation. Bearing down  helps promote separation and expulsion, reduces  blood loss, and enhances uterine contraction. Assess vital signs before and after administering  Hypertension is a frequent side effect of oxytocin.
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LABOR Stage III (Placental Expulsion) - LABOR Stage...

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