3 promotion of comfort in the second stage a applying

3. Promotion of Comfort in the Second Stage
a. Applying cool cloths to the face and forehead may help
cool the woman involved in the intense physical exertion of
pushing.
b. The nurse should encourage the woman to rest and relax all
muscles during the periods between contractions.
4. Assisting During Birth
a. Nurses who will be in direct contact with the mother at the
time of birth need to wear protective clothing such as an
apron or gown with a splash apron, disposable gloves, and
eye covering.
b. Care should be taken to preserve her privacy during the
transfer.
5. Cleansing the Perineum
a. After the woman has been positioned for the birth, her
vulvar and perineal areas are cleansed to increase her
comfort and to remove any bloody discharge. .
ii. ATI:
1. Nursing Actions
a. Continue to monitor the client/fetus
b. Assist in positioning the client for effective pushing
c. Assist in partner involvement with pushing efforts and in
encouraging bearing down effort during contractions
d. Promote rest between contractions
e. Provide comfort measures such as cold compresses
f. Cleanse the pt’s perineum as needed if fecal material is
expelled during pushing
g. Prepare for episiotomy, if needed
h. Provide feedback on labor progress to the client
i. Prepare for care of the neonate. A nurse trained in neonatal
resuscitation should be present at delivery
i. Check oxygen flow and tank on warmer
ii. Prehear radiant water
iii. Lay out newborn stethoscope and bulb syringe.
iv. Have resuscitation equipment in working order
(resuscitation bag, laryngoscope) and emergency
medications available
v. Check suction apparatus

3. T hird Stage – (Delivery of Placenta) Description of Stage 3 – London pg. 335; ATI pg. 95
a. Assessment of woman in the third stage of labor – ATI pg. 95
1. ATI:
a. Third Stage Assessment
i. Lasts from the birth of the fetus until the placenta is
delivered
ii. Assessment
1. BP, pulse, and respiration measurements every 15
min
2. Clinical findings of placental separation from the
uterus as indicated by
a. Fundus firmly contracting
b. Swift gush of dark blood from introitus
c. Umbilical cord appears to lengthen as
placenta descends
d. Vaginal fullness on exam
b. Assessment of Pain – London pg. 337-338; ATI pg. 79
1. ATI:
a. Sources of Pain During Labor
i. Third Stage
1. Pain with expulsion of the placenta is similar to the
pain experienced during the first stage
2. Pain causes:
a. Uterine contractions
b. Pressure and pulling of pelvic structures
2. Book:
a. Pain during the third stage results from uterine contractions and
cervical dilation as the placenta is expelled. This stage of labor is
short, and after it anesthesia is needed primarily for episiotomy
repair.

c. Nursing Care of patient in the third stage of labor – London pg. 385-
386; ATI pg. 95
1. ATI:
a. Nursing Actions
i. Instruct the client to push once findings of placental
separation are present. Keep mother/parents informed of
progress of placental expulsion and perineal repair if
appropriate.