STAGE IV (FIRST 4 HOURS FOLLOWING DELIVERY OF
CLIENT ASSESSMENT DATA BASE
May appear “energized” or fatigued/exhausted, sleepy
Pulse usually slow (50–70 beats per minute [bpm], owing to vagal hypersensitivity).
Blood pressure (BP) variable; may be lower in response to analgesia/anesthesia, or elevated in response to oxytocin
administration or pregnancy-induced hypertension (PIH).
Edema, if present, may be dependent (e.g., confined to lower extremities); or may include upper extremities and facies,
or may be generalized (signs of PIH).
Blood loss during labor and delivery up to 400–500 ml for vaginal delivery or 600–800 ml for cesarean birth.
Emotional reactions regarding birth experience varied and changeable, e.g., excitation, disinterest (exhausted), or
May express concern or apologize for intrapartal behavior or loss of control; may express fears regarding condition of
newborn and immediate neonatal care
Hemorrhoids often present and protruding.
Bladder may be palpable over symphysis pubis, or urinary catheter may be in place.
Diuresis may occur if pressure of presenting part obstructs urinary flow, and/or intravenous (IV) fluids are
administered during labor and delivery.
May report thirst, hunger, or nausea
Sensation and movement of lower extremities decreased in presence of spinal anesthesia or caudal/epidural analgesia.
Hyperreflexia may be present (suggests developing or persistent hypertension, especially in diabetic, adolescent, or
May report discomfort from various sources; e.g., afterpains, tissue trauma/episiotomy repair, bladder fullness, or
feeling cold/muscle tremors with “chills”
Slight temperature elevation initially (exertion, dehydration).
Episiotomy/laceration repair intact, with tissue edges closely approximated.
Perineum free of redness, edema, ecchymosis, or discharge.
Striae may be present on abdomen, thighs, and breasts.
Fundus firmly contracted, midline, and located at the level of the umbilicus
Moderate amount of vaginal drainage or lochia, dark red, with only a few small clots at most (up to small plum size)