Department of Obstetrics and Gynecology
October 15. 2012
24 years old
Gravida 2 Para 1 (1000)
admitted for the first time on November 11, 2011
General Data:
Birthdate: October 7, 1987 Birthplace: Manila Status: Single Religion: Roman Catholic Occupation: Sales agent Habits: Non-smoker, non alcohol
drinker Attitude: Cooperative Availability of relatives: Near
Patient’s Profile:
LMP: March 7, 2011 PMP: February, 2011 AOG: 37 weeks and 2 days EDC: November 26, 2011
History of the Present Pregnancy:
Usual symptoms of early pregnancy – nausea and vomiting
First month of missed menses (April 2011) self PT = positive Consult with obstetrician in a government
hospital
History of the Present Pregnancy: First Trimester
Complete Blood Count – Normal Urinalysis - Normal Blood Typing – “O” positive Hepatitis B – nonreactive Transvaginal Ultrasound – single
intrauterine pregnancy compatible with 10 weeks age of gestation
Pap Smear – bacterial vaginosis
Bacterial vaginosis
Metronidazole, 500mg/tab, twice a day
for 7 days (taken regularly)
GRAM STAIN of cervicovaginal discharge (after completion of
antibiotics) –NORMAL RESULTS
History of the Present Pregnancy: First Trimester No history of dysuria, hypogastric
pain, vaginal spotting or bleeding and fever
Quickening – 5th month of pregnancy Regular prenatal check-up Regular intake of:
Multivitamins, 1 tablet once a day Ferrous sulfate, 1 tablet once a day Calcium tablet, 1 tablet twice a day Prenatal milk, 1 glass twice a day
History of the Present Pregnancy: Second Trimester
Ultrasound (7th month of pregnancy) – single, live, intrauterine pregnancy compatible with 29 weeks age of gestation
No history of dysuria, hypogastric pain, vaginal spotting or bleeding and fever
History of the Present Pregnancy: Second Trimester
Regular prenatal check-up at our OB OPD
Regular intake of: Multivitamins, 1 tablet once a day
Ferrous sulfate, 1 tablet once a day
Calcium tablet, 1 tablet twice a day
Prenatal milk, 1 glass twice a day
History of the Present Pregnancy: Third Trimester
No history of dysuria and fever
History of the Present Pregnancy: Third Trimester
3 hours prior to admission: The patient went to the OPD for her weekly
prenatal check-up
Crampy, intermittent, hypogastric pain, radiating to the lumbosacral area, associated with scanty, bloody vaginal discharge
History of the Present Pregnancy: Third Trimester
ADMISSION
Mumps and chicken pox during childhood
Non-diabetic, non-asthmatic No history of accidents, trauma,
major illnesses, operations and exposure to radiation or toxic chemicals
Past Medical History
Father: 50 years old, separated from patient’s family since childhood
Mother: 48 years old, apparently well 1 sibling No heredofamilial diseases, such as
hypertension, diabetes mellitus, asthma, and diseases of the breast, thyroid, heart, lung and/or kidney.
Family History
Eldest among 2 College graduate Sales agent Lives with partner (24 years old) for 7
years Non-smoker, non-alcohol beverage
drinker No food preference No known allergy to food and drugs
Personal and Social History
Lasted for 5 days Moderate in flow Consumed 5
napkins per day No
dysmenorrhea
Reproductive History: Gynecologic
28-30 days interval
Lasting for 5 days Consuming 3-5
napkins per day No associated
dysmenorrhea
MENARCHE: 14 years oldSUBSEQUENT MENSES:
regular
Reproductive History: Obstetric
Gravida 2 Para 1 (1000)Gravi
daHow Where Outcome Remarks
1
Normal spontane
ous delivery
Hospital
No fetomater
nal complicati
ons
After a month, baby died due to
sudden infant death syndrome
2 Present pregnancy
Coitarche – 17 years old 1 sexual partner No dyspareunia, post coital bleeding,
and leucorrhea No sexually transmitted disease
Sexual History
Oral contraceptive pills for 6 years after giving birth
Method of Contraception
CONSTITUTIONAL : no fever, no chills HEMATOLOGY: no rashes CENTRAL NERVOUS SYSTEM: no headache, no
dizziness, no loss of consciousness, no seizure
HEENT: no blurring of vision, no hearing loss RESPIRATORY: no difficulty of breathing, no
cough and colds CARDIOVASCULAR: no chest pain, no orthopnea GASTROINTESTINAL: no nausea, vomiting,
diarrhea and constipation GENITOURINARY: no dysuria, no frequency, no
urgency NEUROMUSCULAR: no arthralgia, no myalgia, no
numbness
Review of Systems
Physical Examination General Survey
Conscious, coherent, afebrile, not in cardiorespiratory distress
BP: 120/80
CR: 89 bpm
RR: 19 cpm
Temperature: 36.7 0C
Physical Examination HEENT
Pink palpebral conjuctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion
Neck Supple, no neck vein engorgement, no
cervicolymphadenopathy
Physical Examination Chest Symmetrical chest expansion, no retractions,
no lagging
Lungs Vesicular breath sounds, no crackles, no
wheezes
Heart Adynamic precordium, normal rate, regular
rhythm, no murmur
Physical Examination Abdomen Globularly enlarged, with fundic height of 32
cm, fundus occupied by breech, fetal back on the right, fetal small parts on the left, unengaged, cephalic, fetal heart tone of 130s bpm, best heart at the right lower quadrant with estimated fetal weight of 3000 to 3200 grams
Physical Examination Extremities
No gross deformities, full and equal pulses
Skin No active dermatoses
Speculum Not done
Physical Examination Internal Exam Normal looking external genitalia, parous
introitus, and vagina admits 2 fingers with ease, cervix is 4cm dilated, beginning effacement, intact bag of waters, unengaged, cephalic, and station 2
Physical Examination Clinical Pelvimetry Adequate
Sacral promontory not reached at 11.5 cm
Sacrosciatic notch average
Ischial spines not prominent
Sacrum deep and well-curved
Sidewalls not convergent
Pubic arch wide
Complete Blood Count – Normal resultsRESULT NORMAL VALUES
RBC count 4.62 x1012/L 4.5-5.5 x1012/L
Hemoglobin 13.6 x g/d 12-14 x g/d
Hematocrit 0.38 L/L 0.37-0.47 L/L
MCV 83.9 fl. 80-100 fl.
MCH 29.4 pg. 27-33 pg.
MCHC 35.1 % 32-38 %
Platelet Count 247 x 109/L 160-380 x 109/L
WBC Count 8.84 x 109/L 5-10 x 109/L
Color: Yellow Character: HazyBilirubin: Negative Urobilinogen: NormalProtein: Negative Nitrite: NegativepH: 7.0 Specific Gravity: 1.010
Blood: NegativeKetone: NegativeGlucose: NegativeLeukocytes: Negative
Casts: None /lpf Pus cells: 0-1 /hpfCrystals: None A. Urates/Phosphates: RareRed Blood Cell: None Bacteria: Rare
Urinalysis – Normal results
ADMISSION DIAGNOSIS:Gravida 2 Para
1 (1000)Pregnancy Uterine 37
weeks, Cephalic In Labor
PLAN For complete blood count,
urinalysis, and baseline cardiotocogram
For amniotomy Awaits spontaneous vaginal
delivery
ADMISSION
Salient Features 24 year old, Gravida 2 Para 1 (1000) Lives with partner (24 years old) for
7 years LMP: March 7, 2011 PMP: February, 2011 AOG: 37 weeks and 2 days EDC: November 26, 2011
Salient Features First Trimester
Usual symptoms of early pregnancy – nausea and vomiting
Self PT = positive Bacterial vaginosis = urinalysis and pap smear;
treated Transvaginal Ultrasound – single intrauterine
pregnancy compatible with 10 weeks age of gestation
Blood Typing – “O” positive Hepatitis B – nonreactive
Salient Features Second Trimester
Quickening – 5th month of pregnancy
Ultrasound (7th month of pregnancy) – single, live, intrauterine pregnancy compatible with 29 weeks age of gestation
Third Trimester Crampy, intermittent, hypogastric pain,
radiating to the lumbosacral area, associated with scanty, bloody vaginal discharge
Salient Features Physical Examination: Abdomen Globularly enlarged, with fundic height of 32 cm,
fundus occupied by breech, fetal back on the right, fetal small parts on the left, unengaged, cephalic, fetal heart tone of 130s bpm, best heart at the right lower quadrant with estimated fetal weight of 3000 to 3200 grams
Physical Examination: Internal Exam Normal looking external genitalia, parous introitus,
and vagina admits 2 fingers with ease, cervix is 4cm dilated, beginning effacement, intact bag of waters, cephalic, and station 2
NORMAL LABOR AND DELIVERY At the onset of labor, the position of the
fetus with respect to the birth canal is critical to the route of delivery.
Fetal orientation relative to the maternal pelvis is described in terms of FETAL LIE, PRESENTATION, ATTITUDE, AND POSITION.
Fetal Lie – relation of the long axis of the fetus to that of the mother Longitudinal Transverse Oblique
Fetal Lie – relation of the long axis of the fetus to that of the mother Longitudinal Transverse Oblique
present in over 99 percent of labors at term
Fetal Lie – relation of the long axis of the fetus to that of the mother Longitudinal Transverse Oblique
PERPENDICULAR
Predisposing factors:
Multiparity
Placenta previa
Hydramnios
Uterine anomalies
Fetal Lie – relation of the long axis of the fetus to that of the mother Longitudinal Transverse Oblique
fetal and the maternal axes cross at a 45-degree angle
unstable and always becomes longitudinal or transverse during the course of labor
Fetal Presentation presenting part is that portion of
the fetal body that is either foremost within the birth canal or in closest proximity to it
Fetal Presentation Cephalic
A.VERTEX OR OCCIPUT PRESENTATION
B.SINCIPUTC.BROWD.FACE
Fetal Presentation Breech
A.FRANKB.COMPLET
EC.INCOMPL
ETE/FOOTLING
Fetal Attitude “habitus” characteristic posture fetus forms an ovoid mass that
corresponds roughly to the shape of the uterine cavity – characteristic posture results from the mode of fetal growth and its accommodation to the uterine cavity.
Fetal Attitude
Abnormal exceptions to this attitude occur as the fetal head becomes progressively more extended from the vertex to the face progressive change in fetal attitude from a convex (flexed) to a concave (extended) contour of the vertebral column
Fetal Position relationship of an arbitrarily chosen
portion of the fetal presenting part to the right or left side of the birth canal
with each presentation there may be two positions — right or left
Fetal Position
Leopold’s Maneuver diagnosis of fetal presentation and
position
L1, L2, L3 – examiner stands at the side of the bed that is most convenient and faces the patient
L4 – examiner reverses this position and facesher feet for the last maneuver
Leopold’s Maneuver Examiner gently
palpates the fundus with the tips of the fingers of both hands to define which fetal pole is present in the fundus
Breech – gives the sensation of a large, nodular body
Cephalic – head feels hard and round and is more freely movable and balottable
Fundus occupied by breech
Leopold’s Maneuver The palms are placed
on either side of the abdomen and gentle but deep pressure is exerted
Back – hard, resistant structure
Extremities – numerous small, irregular and mobile parts
Fetal back on the right
Fetal small parts on the left
Leopold’s Maneuver Using the thumb and
fingers on one hand, the lower portion of the abdomen is grasped just above the symphysis pubis
If the presenting part is not engaged, a movable body will be felt, usually the head
unengaged
Leopold’s Maneuver If the cephalic prominence is on
the same side as the small parts, the head must be flexed, and therefore the vertex is the presenting part
When the cephalic prominence of the fetus is on the same side as the back, the head must be extended
If the presenting part is deeply engaged, however, the findings from this maneuver are simply indicative that the lower fetal pole is fixed in the pelvis, the details are then defined by the last maneuver
unengaged
Leopold’s Maneuver The examiner faces the
mother’s feet and, with the tips of the first 3 fingers of each hand, exerts deep pressure in the direction of the axis of the pelvic inlet.
cephalic
Leopold’s Maneuver Vertex Presentation –
the prominence is on the same side as the small parts
Face Presentations – on the same side as the back
cephalic
Leopold’s Maneuver A transverse lie: Inspection: abdomen is unusually wide, whereas
the uterine fundus extends to only slightly above the umbilicus
No fetal pole is detected in the fundus, and the ballottable head is found in one iliac fossa and the breech in the other.
Back is anterior = hard resistance plane extends across the front of the abdomen; Back is posterior = irregular nodulations are felt through the abdominal wall.
Labor Uterine contractions that bring about
demonstrable effacement and dilatation of the cervix
PREPARATORY DIVISION DILATATIONAL DIVISION PELVIC DIVISION
Labor: First Stage
PREPARATORY DIVISION cervix dilates little, its connective tissue
components change considerably; sedation and conduction analgesia are capable of arresting this division of labor
DILATATIONAL DIVISION PELVIC DIVISION
Labor: First Stage
PREPARATORY DIVISION, DILATATIONAL DIVISION dilatation proceeds at its most rapid rate
unaffected by sedation or conduction analgesia.
PELVIC DIVISION
Labor: First Stage
PREPARATORY DIVISION, DILATATIONAL DIVISION PELVIC DIVISION commences with the deceleration phase of
cervical dilatation
engagement, flexion, descent, internal rotation, extension, and external rotation principally take place
Labor: First Stage
the point at which the mother perceives regular contractions
for most women ends at between 3 and 5 cm of dilatation
may be clinically useful, for it defines cervical dilatation limits beyond which active labor can be expected
PROLONGED: exceeding 20 hours in the nullipara or 14 hours in the multipara
Labor: First Stage—Latent Phase
cervical dilatation of 3 to 5 cm or more, in the presence of uterine contractions, can be taken to reliably represent the threshold for active labor.
Labor: First Stage—Active Labor
Contractions occur at regular interval Intervals gradually shorten Intensity gradually increases Discomfort is in the back and abdomen Cervix dilates Discomfort is not stopped by sedation
Labor: True
irregular intervals long intervals intensity remains unchanged Discomfort is chiefly in lower abdomen Cervix does not dilate Discomfort is usually relieved by
sedation
Labor: False
Labor: True vs False
Amniotic fluid seen pooling in the posterior fornix or clear fluid passing from the cervical canal
Testing the pH of the vaginal fluid: Normal pH = 4.5-5.5 whereas the amniotic fluid: 7.0-7.5
pH above 6.5 is consistent with ruptured membranes
Detection of Ruptured Membranes
Nitrazine simple and fairly reliable
test papers impregnated with dye
color of the reaction is interpreted by comparison with a standard color chart
Detection of Ruptured Membranes
Other Tests : arborization or ferning of vaginal fluid – suggests
amniotic rather than cervical fluid
detection of alpha-fetoprotein in the vaginal vault to identify amniotic fluid
injection of various dyes into amniotic sac via abdominal amniocentesis ex. Evans Blue, Methylene Blue, Indigo Carmine, or Fluorescein
Detection of Ruptured Membranes
Cervical Dilation Estimating the average diameter of the cervical opening
expressed in cms
10 cms – fully dilated
Cervical Effacement Expressed in terms of length of cervical canal compared
to uneffaced cervix
If reduced by ½ - 50% effaced
If thin as the adjacent lower uterine segment – completely or 100% effaced
Cervix
Cervical Position Relationship of cervical as to fetal lie categorized as
posterior, midposition or anterior
Cervix
The level—or station—of the presenting fetal part in the birth canal is described in relationship to the ischial spines, which are halfway between the pelvic inlet and the pelvic outlet.
When lowermost portion of presenting part is at level of ischial spines designated as ZERO STATION
Station
The American College of Obstetricians and Gynecologists classified stations dividing the pelvic above and below the spines into fifths represent centimeters above and below the spines into fifths
Station
Station +5 corresponds to fetal head visible at the introitus
If the head is unusually molded, or if there is an extensive caput formation, or both, engagement might not have taken place even though the head appears to be at 0 station
Station
Monitoring fetal well-being during labor
Fetal heart rate stethoscope or any Doppler ultrasound devices fetal heart auscultated after contraction fetal jeopardy FHR <100/min
Management of theFirst Stage of Labor
American College of OB-GYNE recommends
1. First Stage of Labor
FHR checked after contraction at least every 30 minutes then every 15 minutes during second stage
Management of theFirst Stage of Labor
American College of OB-GYNE recommends
2. High Risk Pregnancies
Continuous electronic monitoring evaluation oftracing
o Every 15 minutes : 1st stage of labor
o Every 5 minutes : 2nd stage of labor
Management of theFirst Stage of Labor
American College of OB-GYNE recommends
2. High Risk Pregnancies
Uterine contractions
o Evaluate frequency, duration quantified as to degree
o of firmness or resistance to indentation
Management of theFirst Stage of Labor
American College of OB-GYNE recommends
2. High Risk Pregnancies
Continuous electronic monitoring evaluation of tracing
o Every 15 minutes : 1st stage of labor
o Every 5 minutes : 2nd stage of labor
Management of theFirst Stage of Labor
Subsequent vaginal examinations Vary during the 1st stage
When membranes rupture – examination repeated expeditiously if fetal head was not definitely engaged at the previous vaginal examination
FHR checked immediately and during the next uterine contraction to detect an occult umbilical cord compression
Maternal Monitoring
Oral intake – NPO Food withheld during active labor and delivery
Gastric emptying time is prolonged once labor is established and analgesics are administered
Intravenous fluids – D5LR 1L x 8 hours Advantageous during the immediate puerperium to
administer Oxytocin prophylactically and at times therapeutically when uterine atony persists
With longer labors, administration of glucose, sodium, and water at a rate of 60-120 mL/hr to prevent dehydration and acidosis
Maternal Monitoring
begins when cervical dilatation is complete and ends with fetal delivery
Median duration ~ 50 minutes for nulliparas and about 20 minutes for multiparas – can be highly variable
Labor: Second Stage
10
8
6
4
2
0
-3
-2
-1
0
+1
+2
+3
+4
+52 4 6 8
Amniotomy done(clear amniotic
fluid)
Oxytocin 6 units
incorporated to IVF
Outcome: Baby Girl, live, term, delivered via Normal Spontaneous Delivery
with an AS: 9 & 10; BW: 3130g; BL: 47cm; BS: 37 weeksAppropriate for gestational age
Mean length of first- and second-stage labor ~
9 hours in nulliparous women without regional analgesia, and that the 95th percentile upper limit was 18.5 hours
for multiparous women, about 6 hours with a 95th percentile maximum of 13.5 hours
Identification Full cervical dilatation
Bearing down efforts lasting 1 ½ minutes
Descent of presenting part with urge to defecate
Labor: Second Stage
May be prolonged due to: large fetus
with conduction analgesia
intense sedation
Labor: Second Stage
Labor: Cardinal Movements The positional changes in the presenting
part required to navigate the pelvic canal constitute the mechanisms of labor.
The cardinal movements of labor are engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion
EngagementDescentFlexion Internal rotationExtensionExternal rotationExpulsion
Labor: Cardinal Movements
Labor: Cardinal Movements EngagementDescentFlexion Internal
rotationExtensionExternal
rotationExpulsion
Labor: Cardinal Movements EngagementDescentFlexion Internal
rotationExtensionExternal
rotationExpulsion
Labor: Cardinal Movements EngagementDescentFlexion Internal
rotationExtensionExternal
rotationExpulsion
Labor: Cardinal Movements EngagementDescentFlexion Internal
rotationExtensionExternal
rotationExpulsion
Labor: Cardinal Movements EngagementDescentFlexion Internal
rotationExtensionExternal
rotationExpulsion
Labor: Cardinal Movements EngagementDescentFlexion Internal
rotationExtensionExternal
rotationExpulsion
Labor: Cardinal Movements EngagementDescentFlexion Internal
rotationExtensionExternal
rotationExpulsion
Labor: Cardinal Movements EngagementDescentFlexion Internal
rotationExtensionExternal
rotationExpulsion
Labor: Cardinal Movements EngagementDescentFlexion Internal
rotationExtensionExternal
rotationExpulsion
Fetal heart rate Low risk fetus auscultation every 15 minutes
High risk fetus every 5 minutes interval
Slowing of FHR can be induced by head compression
Descent may likely tighten a loop or loops of umbilical cord around the fetus especially the neck
Management of theSecond Stage of Labor
Coaching Legs = half-flexed so that she can push with them against
the mattress
Intruct = Take a deep breath as soon as the next uterine contraction begins, and with her breath held, to exert downward pressure exactly as though she were straining at stool
While actively bearing down, the fetal heart rate immediately after the contraction is likely to be slow, but should recover to normal range before the next expulsive effort.
Management of theSecond Stage of Labor
The occiput is being kept close to the symphysis by moderate pressure to the fetal chin at the tip of the maternal coccyx
RITGEN MANUEVER OR MODIFIED RITGEN MANUEVER
Forward pressure on the chin of the fetus through the perineum just in front of the coccyx, at the same time, the other hand exerts pressure superiorly against the occiput
Labor: Second Stage—Delivery of the Head
EPISIOTOMY – right mediolateral Prevents pelvic relaxation ex. Cystocele, rectocele,
urinary incontinence
Shoulder dystocia or Breech delivery
Forceps or vacuum extractor operations
Occiput posterior positions
Instances where failure to perform episiotomywill result in perineal rupture
Labor: Second Stage—Delivery of the Head
Labor: Second Stage—The Cord
Labor: Second Stage—The Cord Clamping the Cord The umbilical cord is cut between two clamps placed 4 to 5
cm from the fetal abdomen, and later an umbilical cord clamp is applied 2 to 3 cm from the fetal abdomen
After delivery the newborn is placed at or below the level of the vaginal introitus for 3 minutes and the fetoplacental circulation is not immediately occluded by cord clamping, an average of 80 mL of blood may be shifted from the placenta to the neonate
This provides approximately 50 mg of iron, which reduces the frequency of iron deficiency anemia later in infancy
delivery of infant to expulsion of placenta
Watchful waiting until the placenta is separated as long as the uterus remains firm and there is no unusual bleeding
Hand is rested on the fundus frequently to make certain that the organ does not become atonic and filled with blood behind a separate placenta
Labor: Third Stage
signs of placental separation Calkin’s Sign – the uterus becomes globular and, as a
rule, firmer; earliest to appear
Sudden gush of blood
the uterus rises in the abdomen
Lengthening of the umbilical cord
Labor: Third Stage
Expression of the placenta should never be forced before placental separation lest the uterus becomes inverted
Traction on the umbilical cord must not be used to pull the placenta out of the uterus.
Uterine inversion is one of the grave complications associated with delivery, and it constitutes an emergency requiring immediate attention
Labor: Third Stage—Placenta
Manual removal
brisk bleeding
placenta cannot be delivered by these techniques
This is especially common in cases of preterm delivery
Labor: Third Stage—Placenta
UTERINE MASSAGE following placental delivery is recommended by many to prevent postpartum hemorrhage.
OXYTOCIN, ERGONOVINE, AND METHYLERGONOVINE are all employed widely in the normal third stage of labor
If they are given before delivery of the placenta, however, they may entrap an undiagnosed, undelivered second twin
Labor: Third Stage—Placenta
OXYTOCIN (pitocin, syntocinon)
Synthetic form of the octapeptide Oxytocin
Spontaneously laboring uterus very likely to be exquisitely sensitive to Oxytocin
Not effective by mouth
Half-life : 3 minutes (intravenous)
Labor: Third Stage—Placenta
OXYTOCIN (pitocin, syntocinon)
Inappropriate dose uterus may contract so violently as to kill the fetus
Cardiovascular effects :
o Transient fall in arterial blood pressure
o Increase in cardiac output
Antidiuresis
Labor: Third Stage—Placenta
ERGONOVINE AND METHYLERGONOVINE
An alkaloid obtained from ergot
Powerful stimulants of myometrial contraction
Parental administration sometimes initiates transient severe hypertension
Labor: Third Stage—Placenta
Demerol 25mg+Phenergan 25 mg, ½ IM, ½ IV
Meperidine hydrochloride – fast acting opioid analgesic drug
Promethazine- a first-generation antihistamine of the that has anti-motion sickness, antiemetic, and anticholinergic effects, as well as a strong sedative effect; also used to potentiate any opiates
Oxytocin 6 units Carboprost 250mg TIV
Medications
Demerol 25mg+Phenergen 25 mg, ½ IM, ½ IV
Oxytocin 6 units
Carboprost 250mg TIV
Medications
Demerol 25mg+Phenergen 25 mg, ½ IM, ½ IV
Oxytocin 6 units Carboprost 250mg TIV
synthetic prostaglandin analogue of PGF2α (with oxytocic properties)
induces contractions and can trigger abortion in early pregnancy; also reduces postpartum bleeding
Medications
hour immediately following delivery Post partum hemorrhage as the result of
uterine atony is more likely at this time perineum inspected to detect excessive
bleeding
maternal BP and pulse recorded immediately after delivery and every 15 minutes for the 1st hour
Labor: Fourth Stage
Labor: Fourth Stage First degree
laceration
Fourchette
Perineal skin
Vaginal mucous membrane
Labor: Fourth Stage Second
degree laceration
Skin
Mucous membrane
Fascia
Muscles
Perineal body
Labor: Fourth Stage Third degree
laceration
Skin
Mucous membrane
Perineal body
Sphincter
Labor: Fourth Stage Fourth degree
laceration
Extends through the rectal mucosa to expose the lumen of the rectum
Gravida 2 Para 2 (2001)
Pregnancy Uterine 37 weeks Cephalic – Delivered
Amniotomy – Clean Amniotic Fluid
Normal Spontaneous Delivery
Right Mediolateral Episiotomy and Repair
FINAL DIAGNOSES