Delivery of the placenta

1. The placenta usually separates spontaneously from the uterine wall within 5 minutes of delivery. Gentle fundal massage and gentle traction on the cord facilitates delivery of the placenta.

2. The placenta should be examined for missing cotyledons or blind vessels. The cut end of the cord should be examined for 2 arteries and a vein. The absence of one umbilical artery suggests a congenital anomaly.

3. Prophylaxis against excessive postpartum blood loss consists of external fundal massage and oxytocin (Pitocin), 20 units in 1000 mL of IV fluid at 100 drops/minute after delivery of the placenta. Oxytocin can cause marked hypotension if administered as a IV bolus.

4. After delivery of the placenta, the birth canal is inspected for lacerations.

Delivery Note

1. Note the age, gravida, para, and gestational age.

2. Time of birth, type of birth (spontaneous vaginal delivery), position (left occiput anterior).

3. Bulb suctioned, sex, weight, APGAR scores, nuchal cord, and number of cord vessels.

4. Placenta expressed spontaneously intact. Describe episiotomy degree and repair technique.

5. Note lacerations of cervix, vagina, rectum, perineum.

6. Estimated blood loss:

7. Disposition: Mother to recovery room in stable condition. Infant to nursery in stable condition.

Routine Postpartum Orders

Transfer: To recovery room, then postpartum ward when stable.

Vitals: Check vitals, bleeding, fundus q15min x 1 hr or until stable, then q4h.

Activity: Ambulate in 2 hours if stable

Nursing Orders: If unable to void, straight catheterize; sitz baths prn with 1:1000 Beta-dine prn, ice pack to perineum prn, record urine output. Diet: Regular

IV Fluids: D5LR at 125 cc/h. Discontinue when stable and taking PO diet. Medications:

Oxytocin (Pitocin) 20 units in 1 L D5LR at 100 drops/minute or 10 U IM. FeS04 325 mg PO bid-tid. Symptomatic Medications:

Acetaminophen/codeine (Tylenol #3) 1-2 tab PO q3-4h prn OR Oxycodone/acetaminophen (Percocet) 1 tab q6h prn pain. Milk of magnesia 30 mL PO q6h prn constipation. Docusate Sodium (Colace) 100 mg PO bid. Dulcolax suppository PR prn constipation. A and D cream or Lanolin prn if breast feeding. Breast binder or tight brazier and ice packs prn if not to breast feed. Labs: Hemoglobin/hematocrit in AM. Give rubella vaccine if titer <1:10.

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