5. Nursing actions during third stage of labor
   1. Assessment:
      1. Time elapsed-average: 5 minutes; prolonged third stage (greater than 25 minutes) may indicate complications (placenta accreta).
      2. Signs of placental separation:
         1. Increase in bleeding from the vagina.
         2. Cord lengthens.
         3. Uterus rises in abdomen, assumes globular shape.
      3. Assess mother’s level of consciousness.
      4. Examine placenta for intactness and number of vessels in umbilical cord (normal: three. Note: two vessels only-associated with increased incidence of congenital anomalies); condition of placenta for calcification, infarcts, etc.
   2. Analysis/nursing diagnosis:
      1. Family coping: potential for growth related to bonding, beginning achievement of developmental tasks.
      2. Fluid volume deficit related to blood loss during third stage.
   3. Nursing care plan/implementation:
      1. Goal: prevent uterine atony. Administer oxytocin, as ordered.
      2. Goal: facilitate parent-child bonding.
         1. While protecting neonate from cold stress, encourage parents to see, hold, touch neonate.
         2. Comment about neonate’s individuality, characteristics, and behaviors.
         3. After neonate is assessed for congenital anomalies (cleft palate, esophageal atresia), encourage breastfeeding, if desired.
      3. Goal: health teaching.
         1. Describe, discuss common neonatal behavior in transitional period (periods of reactivity, sleep, hyperactivity).
         2. Demonstrate removal of mucus by aspiration with bulb syringe.
         3. Demonstrate ways of facilitating breastfeeding.
   4. Evaluation/outcome criteria:
      1. Woman has a successful, uneventful completion of labor.
         1. Minimal blood loss.
         2. Vital signs within normal limits.
         3. Fundus well contracted at level of umbilicus.
      2. Parents express satisfaction with outcome, demonstrate infant attachment.
6. Nursing actions during the fourth stage of labor- 1-2 hours postpartum.
   1. Assessment-every 15 minutes four times; then, every 30 min two times-or until stable-to monitor response to physiological stress of labor/birth.
      1. Vital signs:
         1. Temperature taken once; if elevated, requires follow-up-may indicate infection, dehydration, excessive blood loss. Note, record, report temperature of 100.4°F (38°C).
         2. Blood pressure-every 15 minutes X 4.
            1. Returns to prelabor level-due to loss of placental circulation and increased circulating blood volume.
            2. Elevation may be in response to use of oxytocic drugs or preeclamsia (first 48 hours).