Fourth Stage of Labor

Some consider the first hour after delivery of the placenta the fourth stage of labor. Risk of uterine atony is highest during this period. The patient should be watched carefully for excessive vaginal bleeding, an enlarging boggy fundus, and hypotension. Massage of the uterine fundus most often is sufficient to return it to a contracted state and stop bleeding. Oxytocin may be added to the IV fluids in doses of 20 or 40 units/L of fluid and the IV rate increased, or if no IV fluid is needed, 20 units of oxytocin can be given intramuscularly (IM). Alternately, methylergonovine (Methergine), 0.2 mg, can be given IM every 20 minutes if the mother is not hypertensive. Finally, if no resolution to bleeding, 250 ^.g of prostaglandin F2a (Hemabate) can be given IM every 15 to 20 minutes as needed for up to 3 doses.

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