Nursing Care Plan for Stage III of Labor Placental Expulsion

Stage III of labor begins with the birth of the baby and is completed with placental separation and expulsion. Lasting anywhere from 1–30 min, with an average length of 3–4 min in the nullipara, and 4–5 min in the multipara, this stage is the shortest. Careful management and monitoring are necessary, however, to prevent short- and long term negative outcomes.

NURSING PRIORITIES
1. Promote uterine contractility.
2. Maintain circulating fluid volume.
3. Promote maternal and newborn safety.
4. Support parental-infant interaction.

Nursing diagnosis of Placental Expulsion: Risk for Fluid Volume Deficit may be related to lack/restriction of oral intake, vomiting, diaphoresis, increased insensible water loss, uterine atony, lacerations of the birth canal, retained placental fragments

Desired Outcomes:
1. Display BP and heart rate WNL, palpable pulses.
2. Demonstrate adequate contraction of the uterus with blood loss WNL.

Nursing intervention with rationale:
1. Instruct the client to push with contractions; help direct her attention toward bearing down.
Rationale: Client attention is naturally on the newborn; in addition, fatigue may affect individual efforts, and she may need help in directing her efforts toward assisting with placental separation. Bearing down helps promote separation and expulsion, reduces blood loss, and enhances uterine contraction.

2. Assess vital signs before and after administering oxytocin.
Rationale: Hypertension is a frequent side effect of oxytocin.

3. Palpate uterus; note “ballooning.”
Rationale: Suggests uterine relaxation with bleeding into uterine cavity.

4. Monitor for signs and symptoms of excess fluid loss or shock (i.e., check BP, pulse, sensorium, skin color, and temperature). (Refer to CP: Postpartal Hemorrhage.)
Rationale: Hemorrhage associated with fluid loss greater than 500 ml may be manifested by increased pulse, decreased BP, cyanosis, disorientation, irritability,

5. Place infant at client’s breast if she plans to breastfeed.
Rationale: Suckling stimulates release of oxytocin from the posterior pituitary, promoting myometrial contraction and reducing blood loss.

6. Massage uterus gently after placental explusion.
Rationale: Myometrium contracts in response to gentle tactile stimulation, thereby reducing lochial flow and expressing blood clots.

7. Record time and mechanism of placental separation; i.e., Duncan’s mechanism (placenta separates from the inside to outer margins) versus Schulze’s mechanism (placenta separates from outer margins inward).
Rationale: Separation should occur within 5 min after birth. The Duncan’s mechanism of separation carries increased risk of retained fragments, necessitating close inspection of the placenta. Failure to separate may require manual removal. The more time it takes for the placenta to separate, and the more time in which the myometrium remains relaxed, the greater the blood loss.

8. Inspect maternal and fetal surfaces of placenta. Note size, cord insertion, intactness, vascular changes associated with aging, and calcification (which possibly contributes to abruption).
Rationale: Helps detect abnormalities that may have an impact on maternal or newborn status.

9. Administer oxytocin (Pitocin) through IM route, or dilute IV drip in electrolyte solution, as indicated. IM methylergonovine maleate (Methergine) or prostaglandins may be given at the same time.
Rationale: Promotes vasoconstrictive effect within the uterus to control postpartal bleeding after placental explusion. IV bolus may result in maternal hypertension. Water intoxication may occur if electrolyte-free solution is used. Note: Methergine is contraindicated in presence of hypertension/ hypotension.

10. Elevate fundus by dipping fingers down behind and moving uterine body up away from symphysis pubis.
Rationale: May be requested by practitioner to facilitate internal examination.