Department of Obstetrics and Gynecology

October 15. 2012

General Data:

24 years old
Gravida 2 Para 1 (1000) admitted for the first time on November 11, 2011

Patients Profile:

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

History of the Present Pregnancy:

LMP: March 7, 2011

PMP: February, 2011

AOG: 37 weeks and 2 days EDC: November 26, 2011

History of the Present Pregnancy: First Trimester

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

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

History of the Present Pregnancy: Second Trimester

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: Third 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

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

3 hours prior to admission:

Past Medical History

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

Family History

Father: 50 years old, separated from patients 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.

Personal and Social 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

Reproductive History:
Gynecologic
MENARCHE: 14 years old SUBSEQUENT MENSES: regular

Lasted for 5 days

28-30 days interval Lasting for 5 days Consuming 3-5 napkins per day No associated dysmenorrhea

Moderate in flow
Consumed 5 napkins per day No dysmenorrhea

Reproductive History:
Obstetric
Gravida 2 Para 1 (1000)
Gravida How Where Outcome Remarks After a month, No baby died due to fetomaternal sudden infant complications death syndrome

Normal spontaneous delivery

Hospital

Present pregnancy

Sexual History

Coitarche 17 years old 1 sexual partner No dyspareunia, post coital bleeding, and leucorrhea No sexually transmitted disease

Method of Contraception

Oral contraceptive pills for 6 years after giving birth

Review of Systems

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

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 Vesicular breath sounds, no crackles, no wheezes Adynamic precordium, normal rate, regular rhythm, no murmur

Lungs

Heart

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 results

RESULT NORMAL VALUES

RBC count Hemoglobin Hematocrit MCV MCH MCHC Platelet Count WBC Count

4.62 x1012/L 13.6 x g/d 0.38 L/L 83.9 fl. 29.4 pg. 35.1 % 247 x 109/L 8.84 x 109/L

4.5-5.5 x1012/L 12-14 x g/d 0.37-0.47 L/L 80-100 fl. 27-33 pg. 32-38 % 160-380 x 109/L 5-10 x 109/L

Urinalysis Normal results

Color: Yellow Bilirubin: Negative Protein: Negative pH: 7.0 Blood: Negative Ketone: Negative Glucose: Negative Leukocytes: Negative Casts: None /lpf Pus cells: 0-1 /hpf Crystals: None A. Urates/Phosphates: Rare Red Blood Cell: None Bacteria: Rare Character: Hazy Urobilinogen: Normal Nitrite: Negative Specific Gravity: 1.010

ADMISSION

DIAGNOSIS:

Gravida 2 Para 1 (1000) Pregnancy Uterine 37 weeks, Cephalic In Labor

ADMISSION

PLAN

For complete blood count, urinalysis, and baseline cardiotocogram For amniotomy Awaits spontaneous vaginal delivery

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 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

Physical Examination: Internal Exam

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
PERPENDICULAR

Longitudinal Transverse Oblique

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

[Link] OR OCCIPUT PRESENTATION [Link] [Link] [Link]

Fetal Presentation

Breech

[Link] [Link] [Link]/

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

Leopolds 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

Leopolds 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

Leopolds 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

Leopolds Maneuver

unengaged

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

Leopolds 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

Leopolds Maneuver

cephalic

The examiner faces the mothers 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.

Leopolds Maneuver

cephalic

Vertex Presentation the prominence is on the same side as the small parts Face Presentations on the same side as the back

Leopolds 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

Labor: First Stage

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 StageLatent Phase

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 StageActive Labor

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: True

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: False

irregular intervals

long intervals
intensity remains unchanged Discomfort is chiefly in lower abdomen Cervix does not dilate Discomfort is usually relieved by sedation

Labor: True vs False

Detection of Ruptured Membranes

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

Cervix

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 - 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

Station

The levelor stationof 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

Management of the First Stage of Labor

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 the First 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 the First 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 the First 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 the First 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

Maternal Monitoring

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

Labor: Second Stage

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

Outcome: Baby Girl, live, term, delivered via Normal Spontaneous Delivery with an AS: 9 & 10; BW: 3130g; BL: 47cm; BS: 37 weeks Appropriate for gestational age Oxytocin 6 units incorporated to IVF -3 -2 -1 10 8 6 Amniotomy done (clear amniotic fluid) 0

+1
+2 +3 +4 +5

4
2 0 2 4 6 8

Labor: Second Stage

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 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: 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

Labor: Cardinal Movements

Engagement Descent Flexion Internal rotation Extension External rotation Expulsion

Labor: Cardinal Movements

Engagement Descent Flexion Internal rotation Extension External rotation Expulsion

Labor: Cardinal Movements

Engagement Descent Flexion Internal rotation Extension External rotation Expulsion

Labor: Cardinal Movements

Engagement Descent Flexion Internal rotation Extension External rotation Expulsion

Labor: Cardinal Movements

Engagement Descent Flexion Internal rotation Extension External rotation Expulsion

Labor: Cardinal Movements

Engagement Descent Flexion Internal rotation Extension External rotation Expulsion

Labor: Cardinal Movements

Engagement Descent Flexion Internal rotation Extension External rotation Expulsion

Labor: Cardinal Movements

Engagement Descent Flexion Internal rotation Extension External rotation Expulsion

Labor: Cardinal Movements

Engagement Descent Flexion Internal rotation Extension External rotation Expulsion

Labor: Cardinal Movements

Engagement Descent Flexion Internal rotation Extension External rotation Expulsion

Management of the Second Stage of Labor

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 the Second 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.

Labor: Second Stage

Delivery of the Head

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

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

Labor: Third Stage

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

Calkins 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 Placenta

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

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

Medications

Demerol 25mg+Phenergan 25 mg, IM, 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, IM, IV

Oxytocin 6 units

Carboprost 250mg TIV

Medications

Demerol 25mg+Phenergen 25 mg, IM, IV

Oxytocin 6 units
Carboprost 250mg TIV
synthetic prostaglandin analogue of PGF2 (with oxytocic properties) induces contractions and can trigger abortion in early pregnancy; also reduces postpartum bleeding

Labor: Fourth Stage

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

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

FINAL DIAGNOSES

Gravida 2 Para 2 (2001) Pregnancy Uterine 37 weeks Cephalic Delivered Amniotomy Clean Amniotic Fluid Normal Spontaneous Delivery

Right Mediolateral Episiotomy and Repair