3-88
Fourth Stage: Recovery of the uterus after delivery of the placenta
What You Need: 1% Lidocaine without epinephrine (approx. 20-30cc), sterile gloves (several pairs), gauze-
bandages and prep solution, 2-0, 3-0, and 4-0 absorbable suture (Vicryl or Chromic) for the repair, scissors or
a scalpel to make the episiotomy incision, sterile (or clean) towels, suction device (bulb syringe), suture forceps,
and needle holders
What to Do:
During the First Stage of Labor:
- Assess mother’s gestational age by asking the date of the first day of her last normal menstrual period,
subtracting 3 months and adding 7 days (40 weeks +/- 2 weeks). Palpate and measure the height of
the uterine fundus (top) from the pubic bone. Up to about 36 weeks, this distance in centimeters
approximates gestational age (i.e., 32 cm from pubic bone to top of fundus equals approx. 32 weeks
gestational age). If not >36 weeks by dates or measurement, see Preterm Labor section. - Listen for fetal heart tones. Normal rate is approximately 160 beats/minute. Periodically reassess during
labor. The rate normally decreases during contractions but should recover. - Encourage the mother to walk as gravity and motion will encourage cervical dilation.
- Read this section and others related to birth (Episiotomy, Breech Delivery, etc.).
- Periodically assess progression of labor by timing contractions. Eventual delivery is likely when
contractions are <3 minute apart. - Check the birth canal with a sterile gloved hand once before birth to ensure the cervix is fully dilated
and effaced.
During the Second Stage of Labor: (see figures 3-6 & 3-7)
- As the cervix progresses to complete dilation, place the patient in the dorsal lithotomy position (patient
is on her back with her thighs flexed on the abdomen). Women from some cultures may prefer to squat. - With each contraction the patient should be urged to push and the care provider should perform perineal
massage. - As the fetal head crowns (i.e., distends the vaginal opening), consider an episiotomy if massage has
failed to stretch the tissue adequately. An episiotomy facilitates delivery of a large infant, or one with
shoulder dystocia. It is better to cut an episiotomy than to have the baby tear the perineal tissue into the
rectum. See Episiotomy Procedure guide. - As crowning continues, it is very important to support the fetal head via a modified Ritgen maneuver.
This is accomplished by placing one hand over the fetal head while the other exerts pressure through
the perineum onto the fetal chin. Use a sterile towel to avoid contamination of this hand
by the anus. - After the head is delivered, suction the nose and mouth with the bulb syringe.
- Check the neck for the presence of a umbilical cord around it, which should be reduced if possible.
If the cord is too tight, it should be doubly clamped and cut. - Place your hands on the chin and head, applying gentle downward pressure, delivering the anterior
shoulder. Avoid injury to the brachial plexus; avoid excessive pressure on the neck. - Deliver the posterior shoulder by upward traction on the fetal head.
- Delivery of the body should occur easily (see figure 3-8).
- Cradle the fetus in your arms, suction once again and the umbilical cord is clamped and cut. If no clamps
are available, suture may be used. - To avoid significant heat loss, dry the newborn completely and wrap in towels or blankets.
- If the mother (or another person) can hold the baby safely, put the baby to the mother's breast. This
will help the uterus contract.
During the Third Stage of Labor:
- Soon after delivery of the infant, the placenta will follow. Placental delivery is iminent when the uterus
rises in the abdomen, the umbilical cord lengthens, and a “gush” of blood is noted. AVOID excessive
traction on the umbilical cord to avoid uterine inversion (pulling the uterus “inside-out”) which will cause
profound blood loss and shock. Instead, wait up to 30 min. for spontaneous delivery of the placenta.