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).
            3. Lowered blood pressure-may reflect significant blood loss during labor/ birth, or occult bleeding.
         3. Pulse-every 15 minutes X 4.
            1. Physiological bradycardia-due to normal vagal response.
            2. Tachycardia-may indicate excessive blood loss during labor/birth, dehydration, exhaustion, or occult bleeding.
      2. Location and tone of fundus-every 15 minutes X 4 to ensure continuing contraction; prevent blood loss due to uterine relaxation.
         1. Fundus-firm; at or slightly lower than the umbilicus; in midline.
         2. May be displaced by distended bladder- due to normal diuresis; common cause of bleeding in immediate postpartum, uterine atony.
      3. Character and amount of vaginal flow.
         1. Moderate lochia rubra.
         2. If perineal pad saturated in 15 minutes, or blood pools under buttocks, excessive loss.
         3. Bright red bleeding may indicate cervical or vaginal laceration.
      4. Perineum.
         1. Edema.
         2. Bruising-due to trauma.
         3. Distention/hematoma, rectal pain.
      5. Bladder fullness/voiding-to prevent distention.
      6. Rate of IV, if present; response to added medication, if any.
      7. Intake and output-to evaluate hydration.
      8. Recovery from analgesia/anesthesia.
      9. Energy level.
      10. Verbal, nonverbal interaction between woman and significant other.
          1. Dialogue.
          2. Posture.
          3. Facial expressions.
          4. Touching.
      11. Interactions between parent(s) and newborn; signs of bonding.
          1. Eye contact with newborn.
          2. Calls by name.
          3. Explores with fingertips, strokes, cuddles.
      12. Signs of postpartal emergencies:
          1. Uterine atony, hemorrhage.
          2. Vaginal hematoma.
   2. Analysis/nursing diagnosis:
      1. Fluid volume deficit related to excessive intrapartal blood loss, dehydration.
      2. Altered urinary elimination related to intrapartal bladder trauma, dehydration, blood loss.
      3. Impaired skin integrity related to episiotomy, lacerations, cesarean birth.
      4. Altered family processes related to role change.
      5. Altered parenting related to interruption in bonding secondary to:
         1. Compromised maternal status.
         2. Compromised neonatal status.
      6. Knowledge deficit related to self-care procedures.
      7. Fatigue related to sleep disturbances and anxiety.
      8. Anxiety regarding status of self and infant.
      9. Altered nutrition, less than body requirements, related to decreased food and fluid intake during labor.
   3. Nursing care plan/implementation:
      1. Goal: comfort measures.
         1. Position, pad change.
         2. Perineal care-to promote healing; to reduce possibility of infection.
         3. Ice pack to perineum; as ordered-to reduce edema, discomfort, and pain related to hemorrhoids.
      2. Goal: nutrition/hydration. Offer fluids, foods as tolerated.
      3. Goal: urinary elimination.
         1. Encourage voiding-to avoid bladder distention.
         2. Record: time, amount, character.
         3. Anticipatory guidance related to nocturnal diuresis and increased output.
      4. Goal: promote bonding.
         1. Provide privacy, quiet; encourage sustained contact with newborn.
         2. Encourage: touching, holding baby; breastfeeding (also promotes involution).
      5. Goal: health teaching.
         1. Perineal care-front to back, labia closed (after each void/bowel movement).
         2. Hand washing-before and after each pad change; after voiding, defecating; before and after baby care.
         3. Signs to report:
            1. Uterine cramping.
            2. Increased vaginal bleeding, passage of large clots.
            3. Nausea, dizziness.
   4. Evaluation/outcome criteria:
      1. Expresses comfort, satisfaction in fourth stage.
      2. Vital signs stable, fundus contracted, moderate lochia rubra, perineum undistended.
      3. Tolerates food and fluids well.
      4. Voids in adequate amount.
      5. Demonstrates eye contact with infant, cuddles.
      6. Verbalizes abnormal signs to report to physician.
      7. Returns demonstration of appropriate perineal care.
      8. Ambulates without pain, dizziness, numbness of legs.