RUFAIDA COLLEGE OF NURSING

JAMIA HAMDARD

LESSON PLAN ON
4th STAGE OF LABOR

SUBMITTED TO: SUBMITTED BY:

Somibala Thockom Shaheen Parveen
Assistant Professor [Link] Nursing Ist Year
RCON RCON
Jamia Hamdarad Jamia Hamdard
Name of student teacher; Ms. Shaheen Parveen

Subject: Obstetrics and Gynecology

Topic: 4th Stage Of labour

Group: [Link]. (H) Nursing 3RD Year

Date: 7/03/2025

Duration: 45 minutes

Method of teaching: Lecture Cum Discussion

Language: English

Venue; [Link] (H) Nursing 3rd Year Classroom

A.V. aids: Flash cards, Chart

Previous Knowlodge: Studens has some previous knowledge about 4th stage of labour.
GENERAL OBJECTIVES:

STUDENTS POINT OF VIEW:

At the end of class the students will be able to understand about the 4th stage of labour.

STUDENT TEACHER POINT OF VIEW:

 The student teacher would be able to take effective planned teaching.
 The student teacher will develop confidence in the students and delivering class.
 The student teacher acquire skills in effective use of A.V. aids.
Time Specific Content Teaching Evaluation
Objective Learning
Activity/ A.V.
aids
Introduce the topic INTRODUCTION;
The 4th stage of labor
is the immediate
period following the
delivery of the
placenta, typically
lasting around one to
two hours, where the
mother’s body
recovers from
childbirth, including
uterine contractions
to stabilize and
potential repair of
any tears or
incisions, while also
allowing for skin-to-
skin contact and
initial breastfeeding
desired.
It’s a crucial time for
close monitoring of
vital signs and
potential
complications like
postpartum
hemorrhage.
At the end of the Announcement of
class the students the topic;
will be able to: Today we will
discuss about events
in 4th stage of labor.
Define 4th stage of DEFINITION; Student teacher Define 4th
labor This is the period from the delivery of the afterbirth to the define 4th stage of stage of
time when women is examined and then transferred to her labor by lecture cum labor.
room. discussion method
It is the stage of observation for at least one-two hours after
expulsion of placenta.
Explain maternal MATERNAL ASSESSMENT AND OBSERVATION;
assessment Maternal assessment during this stage is crucial to monitor
for complications such as excessive bleeding, uterine
contraction, and sign of infection. Here’s an overview of the
key aspects of maternal assessment during this stage:

VITAL SIGNS:
Regular monitoring of temperature, pulse, blood pressure,
and respiration. It’s common for the mothjer’s pulse and
blood pressure to stabilize within this period, but any signs
of shock (tachycardia, hypotension) should be immediately
addressed.

PAIN MANAGEMENT:
Assess pain levels and manage appropriately with
medications or other comfort measures.

LEVEL OF CONSCIOUSNESS AND MENTAL

STATUS:
Monitor for any signs of confusion or altered consciousness,
which may indicate complications such as hemorrhage or
infection.

EMOTIONAL WELL BEING:

Some mothers may experience a range of emotions; support
and encouragement are essential during this time.

2. FUNDAL HEIGHT AND UTERINE CONSISTENCY:

 FUNDAL HEIGHT: The fundus should be palpated
every 15 minutes during the first hour. It should be
firm, at or near the level of the umbilicus
immediately postpartum, and gradually descend
(about 1 cm per day).
 UTERINE CONSISTENCY: The uterus should be
feel firm and contracted. A boggy (soft uterus may
indicate uterine atony, which is a risk factor for
postpartum hemorrhage. If the uterus is soft, gentle
massage and administration of uterotonic agents may
be required.

3. URINE OUTPUT:
 Monitoring Urine Output: The bladder should be
assessed for distention, as a full bladder can interfere
with contraction, increasing the risk of hemorrhage.
 Normal Output: Urinary output typically increases
in the first few hours post delivery due to dieresis
(fluid shift after labor). Ideally, urine output should
be at least 150-200 ml per hour.
 Signs of Retention: if the mother has difficulty
voiding or reports discomfort, a catheterization may
be required to relieve urinary retention.

4. BLOOD LOSS:
 Assessment of blood loss: Normal blood loss during
 fourth stage should be minimal, typically about 200-
500 ml. excessive bleeding (greater than 500 ml in a
vaginal birth) may indicate postpartum hemorrhage.
 Signs of Hemorrhage: Keep an eye out for sign of
excessive bleeding such as soaking pad in less than
15 minutes, large clots, or signs of shock (pale skin,
tachycardia, hypotension, dizziness).
 Uterine Massage: If bleeding is more than expected,
fundal massage may help stimulate contraction and
reduce bleeding.

EVALUATION AND INSPECTION;

 Pain
 Evaluation of the uterus
 Inspection of cervix and upper vaginal vault
 Inspection and evaluation of the placenta,
Membranes and Umbilical cord.
 Repairs
 Perineal cleansing and positioning of legs

PAIN:
 Assess the type, location and intensity of pain.
 Look for sign of discomfort.

EVALUATION OF THE UTERUS:

 After the delivery of the placenta, the uterus is
normally found in the midline of the abdomen
approximately two third to three fourths of the way
up between the symphysis pubis and umbilicus.
 A uterus found the above the umbilicus is indicative
of blood clots inside, which need to be expressed and
expelled.
 A uterus found above umbilicus and one side usually
 the right side usually the right side indicate a full
bladder.
 The uterus is assessed every 15 minutes for the first
hour. The women is positioned with knee flexed and
flat.
 The nurse use one hand to stabilize the uterus just
above the symphysis pubis and outer edge of the
other hand to locate the fundus.
 Position of the fundus is noted in relation to the
umbilicus and recorded as centimeters above or
below the umbilicus.
 During the fourth stage, the fundal height usually is
at the level of the umbilicus.
 Placement of the uterus also is noted in relation to
midline.
 Consistency is noted. If the uterus is not firm, it is
referred to as boggy, and the fundus is massaged
gently in a circular motion until the uterus contracts
and becomes firm.

INSPECTION OF THE CERVIX AND UPPER

VAGINAL VAULT:
 The uterus is well contracted but there continues to
be steady trickle or flow of blood from vagina.
 The mother was pushing prior to complete dilatation
of the cervix.
 The labor and delivery were rapid and ptrecipitous.

INSPECTION AND EVALUATION OF THE

PLACENTA AND MEMBRANES AND UMBILICAL
CORD:
 They are done before repairing any laceration or
episiotomy.
  This is because, if during the examination of the
placenta, the midwife determines that the uterus
needs to exposed manually because of a retained
placenta fragment, it needs to be done as soon as
possible since it has the potential for causing
hemorrhage.

REPAIRS:
The repairs of any laceration or an episiotomy is done after
the examination of the placenta and membranes. If a uterine
exploration for retained placenta fragments is necessary, it is
done prior to the repair. The uterus is checked again for
consistency and repair is begun.

PERINEAL CLEANSING AND POSITIONING OF

LEGS:
 The next nursing action is wash off the mother,s
entire perineum, vulva, inner thighs, buttocks and the
rectal area.
 A perineal pad is then placed against the perineum
and mother assisted to put her legs together.

CONTINUING CARE AND MONITORING:

 Vital signs check
 Palpation of the fundus of the uterus for contractility
 Massage of the fundus, and exprtession of the clots
and free bloom from the uterus
 Measurement of the fundus in relation to the
umbilicus
 Inspection of the perineum for discoloration and
swelling
 Inspection of the perineal pad and change, if
necessary
  Offering food and fluids if allowed and comfort and
safety measures

Explain DOCUMENTATION AND RECORD OF

documentation and BIRTH;
record of birth Documentation and record-keeping are the critical for
ensuring that both the mother and baby remain stable and
receive appropriate care following delivery.
1. Maternal Recovery:
 Vital Sign: Record maternal blood pressure, heart
rate, temperature, and respiratory rate. These should
be monitored At regular intervals(e.g., every 15
minutes during the first hour)
 Uterine tone: Document the fundal height and the
tone of uterus. The uterus should be firm to prevent
postpartum hemorrhage.
 Bleeding: Note the amount of vaginal bleeding
(lochia). The color and amount of bleeding should be
documented to identify potential complications such
as hemorrhage.
 Perineal assessment: Check for tears, episiotomy, or
lacerations. Document any stitches or repairs made.
 Pain Management: Record the type and
effectiveness of pain relief (e.g., medications given
for postpartum pain such as ibuprofen,
acetaminophen, or opoids).
2. Baby’s Condition:
 Apgar Score: Record the baby’s Apgar score at 1
and 5 minutes after birth to assess the newborn’s
immediate condition (appearance, pulse, grimace,
activity, respiration)
 Identification and Bonding: Ensure that the baby is
properly indentified (e.g., ID bands placed), and note
 the early skin-to-skin contact with the mother.
 Feeding: Record whether the baby initiates
breastfeeding and if the baby has latched. If there are
difficulties, document them.
 Physical Examination: Note any immediate
physical assessments performed, such as checking
the baby’s heart rate, respiratory rate, and
temperature.
 Newborn Screening: Record any early screenings
performed, such as the vitamin K injection or
hepatitis B vaccine.
3. Placenta and Membranes:
 Placental Delivery: Document the time of placental
delivery. The placenta should typically be delivered
within 30 minutes of the birth.
 Placental Inspection: Confirm and document that
the placenta is complete (no retained tissue) and that
the membranes are intact.
 Blood Loss: Note the amount of blood lost during
the delivery of the placenta. Typically, blood loss of
300-500 ml is normal, but greater amounts may
indicate complications.
4. Emotional and Psychological Well-being:
 Emotional State: Document the mother’s emotional
state (e.g., happy, anxious, in pain) and any support
measures provided.
 Postpartum Mental Health Screening: Any signs
of distress, confusion, or overwhelming sadness
should be noted. Standard tools for screening, like
the Edinburgh Postnatal Depression Scale (EPDS),
could be used if applicable.
5. General Notes:
 Timing: Document the time of birth, placental
 delivery, and any significant events that occur during
this stage (e.g., excessive bleeding or medical
interventions).
 Interventions: Note any medical interventions (e.g.,
administration of uterotonics like oxytocin to prevent
hemorrhage).
 Nursing Interventions: Any specific actions taken
by the healthcare team, including monitoring,
adjustments to position, or additional support
provided to the mother or baby.

Discuss Alternative Alternative and complimentary therapies in fourth stage

and Complimentary of labour:
therapies in fourth 1. Aromatherapy:
stage of labour  Purpose: Aromatherapy uses essential oils to
promote relaxation, reduce pain, and balance
emotions.
 How it helps: Certain oils like lavender, chamomile,
or frankincense can help soothe the mother and
create a calm environment. They can also be used to
ease discomfort or support emotional well-being in
the post-birth period.
2. Massage and Acupressure:
 Purpose: Massage can help relieve tension, promote
relaxation, and support physical recovery.
Acupressure may help alleviate pain or discomfort,
balance energy, and ease emotional stress.
 How it helps: Postpartum massage can help with
uterine contraction, relieve sore muscles, and
improve circulation. Acupressure points, such as
those on the hands or feet, can help with milk flow,
emotional stability, and pain relief.
3. Herbal Remedies:
 Purpose: Herbal treatments can be used to promote
healing, relieve afterbirth pains, and enhance milk
production.
 How it helps: Herbs like raspberry leaf, ginger or
chamomile can be used as teas or in sitz bath to
promote healing, reduce inflammation, and support
uterine contractions.
4. Breathing and Relaxation Techniques:
 Purpose: Breathing exercise and relaxation
techniques can help reduce stress and anxiety,
support emotional health, and enhance physical
recovery.
 How it helps: Deep breathing, meditation, and
mindfulness practices, can help the mother feel more
relaxed, reduce pain perception, and promote
emotional healing.
5. Homeopathy:
 Purpose: Homeopathic remedies are sometimes used
to help with pain relief, emotional healing, or
physical recovery after childbirth.
 How it helps: Remedies like Arnica Montana can be
used to relieve soreness or bruising, while
Staphysagria can be considered for emotional
healing, especially after a difficult birth experience.
6. Chiropractic Care:
 Purpose: Chiropractic adjustments may support
physical recovery, address pelvic misalignment, and
help ease discomfort related to the birth process.
 How it helps; Chiropractic care may alleviate back
pain, realign the pelvis, and promote the body’s
overall recovery after childbirth.
7. Hydrotherapy (Water Therapy)
 Purpose: Soaking in warm water, such as in a sitz
 bath, can help with healing, pain relief, and
emotional relaxation.
 How it helps: Hydrotherapy can reduce perineal
discomfort, promote healing of any tears or stitches,
and provide relaxation and pain relief.
8. Sound Therapy and Music:
 Purpose: Music and sound therapy can support
emotional healing, relaxation, and bonding with the
newborn.
 How it helps: Listening to calming music or sounds
can help reduce stress and anxiety and improve
overall emotional well-being.

Explain Breastfeeding and Lactation in The Fourth Stage of

Breastfeeding and Labor
Lactation in the 1. Immediate Skin-to-Skin Contact:
Fourth Stage of  Encouraged immediately after birth, skin-to-skin
Labor contact between the mother and baby helps initiate
breastfeeding. The warmth and closeness of the
mother’s body provide comfort to the newborn.
 It also stimulates the baby’s natural reflexes, like
rooting and sucking, which help with latch and
suckling during breastfeeding.
2. First Feeding:
 The first breastfeeding often happens within the first
hour after birth. This is crucial for stimulating the
release of hormones like oxytocin, which helps the
uterus contract back to its pre-pregnancy size and
minimizes bleeding.
 The baby may be quite alert at this time, and some
babies latch instinctively within minutes.
3. Colostrums:
 The first milk the mother produces is called
 colostrums, a thick, yellowish fluid that is nutrient
and full of antibodies. Colostrums provides the
newborn with essential immune protection.
 The baby’s small stomach capacity is ideal for
colostrum, and frequent breastfeeding sessions in the
fourth stage help establish milk supply.
4. Hormonal Changes:
 Oxytocin plays a major role in lactation as well as in
uterine contraction during this stage. Suckling helps
release oxytocin, which not only supports milk
production but also helps in reducing postpartum
bleeding.
 Prolactin, the hormone responsible for milk
production, gradually increases in response to
breastfeeding during the first hour and days.
5. Breast Engorgement:
 After the first few days, the mother may experience
breast engorgement as milk begins to come in more
fully (typically within 2-5 days postpartum).
 \it is important that the breastfeeding is frequent and
effective during the fourth stage to avoid
complications like engorgement or issues with milk
supply.s