NORMAL LABOR

AND DELIVERY
Gener al Dat a
Patient MB, 21 year old , G3P2 (2-0-0-2) Pregnancy
Uterine 38 Weeks & 1 Day AOG, married, Roman
Catholic, from San Andres Bukid, Manila; Admitted for
the first time at Ospital ng Maynila Medical Center last
March 18, 2014, 2:45 PM.


Chief Complaint:
Hypogastric Pain
History of Present Pregnancy
LMP: June 24, 2013
PMP: May 28, 2013
AOG: 38 weeks and 1 day
EDC: March 31, 2014
1
st
Trimester:
Without nausea and vomiting
No maternal illness
Confirmed pregnancy via
pregancy test: July 30, 2013
Taken multivitamins & ferrous
sulfate daily
Did not take folic acid
Prenatal Check-up : 1
st

Prenatal at Libertad Health
Center


Diagnostics done:
1. CBC
2. Urinalysis
3. BT-RH: O+
4. VDRL- RPR (Non-
reactive)
5. HBsAg (Non-reactive)
6. Transvaginal
Ultrasound





2
nd
Trimester
No nausea and vomiting
Quickening (October 2013)
No maternal illness
Continuous intake of
multivitamins and ferrous
sulfate daily
Second and third prenatal
check-up at Libertad Health
Center


Diagnostics done:
1. Pelvic Ultrasound





3
rd
Trimester:
Has good fetal movement
No maternal illness
No labor pains
No bloody, watery, mucoid
discharge
Fourth up to sixth Prenatal
Check up at OMMC.


Diagnostics done:
1. BPS with Biometry





Pain localized on hypogastric
area
Crampy, non-radiating, 8 out of 10,
intermittent, every 45-60 minutes
With good fetal movement
With mucoid discharge from the
vagina
Absence of watery and bloody
discharge

History of Present Pregnancy
Persistence of pain
9 out of 10, every 20-40
minutes
Noted bloody discharge
No watery discharge
Past Medical History
No history of Hypertension, Cerebrovascular Accident,
Diabetes Mellitus , Bronchial Asthma, Goiter, Bronchial
Asthma
No allergy in medication/ food
No previous hospitalization/ operation
No history of illicit drug use
Tetanus toxoid: 2 doses

Family History
Diabetes mellitus (paternal side)
No Hypertension, Cerebrovascular Accident, Goiter/
Thyroid problems, Bronchial Asthma, Cervical
Cancer
A high school graduate
Housewife
Currently she lives with her husband at San
Andres Manila, in a studio type apartment with
good ventilation but with polluted air from
vehicles passing by.
She is a non-smoker, and non-alcoholic drinker;

MENSTRUAL HISTORY
Age of Menarche: 14 years old
Regular interval : 25-29days
Duration: 3-5 days duration
Amount: 2-4 pads used per day (moderately soaked)
Symptom: With day 1 dysmenorrhea, non-
progressive
Last normal menstrual period (LNMP):
May 28, 2013
Previous menstrual period (PMP):
June 26, 2013

Age of 1
st
Coitus: 17 year old
With 2 sexual partners
Contraception:
No use OCP, injectables
Her male partner uses condom
No history of post-coital bleeding, dyspareunia, &
STI

OB/GYNE HISTORY

YEAR SEX OUTCOME MODE PLACE FETOMATERNAL
COMPLICATION
G1 2010 M Full Term NSD Home None
G2 2013 M Full Term NSD Paranaque
Hospital
None
G3 PP (2014)
G3P2 (2002)
REVIEW OF SYSTEM
General: no weight loss, no weight gain
HEENT: no headache, no blurring of vision, no tinnitus
Respiratory: no cough, no colds, no DOB
Cardiovascular: no palpitations, no PND, no orthopnea
REVIEW OF SYSTEM
Abdominal: no abdominal pain, no change in bowel movement,
no nausea, no vomiting, no melena
GUT: no dysuria, no hematuria, no frequency, no incontinence
Endocrinologic: no polydipsia, no polyphagia, no polyuria
Hematologic: no easy bruisability, no prolonged bleeding, no
cyanosis
Psychiatric: No significant mental and behavioral conditions.

PHYSICAL EXAMINATION
General Survey: Conscious, coherent, oriented to 3
spheres, not in distress
Vital Signs: BP= 110/70 mmHg, HR= 89 bpm RR= 20
bpm Temp=36.9C
o

SHEENT: Anicteric sclera, Pink palpebral
Conjunctiva, no nasoaural discharge, no
tonsillopharyngeal congestion, no cervical
lymphadenopathy
PHYSICAL EXAMINATION
Chest/Lungs: Adynamic precordium, normal rate
and rhythm, no murmurs

Abdomen: globular, soft, nontender
Fundic Height: 29 cm
FHR





130s
Internal examination: 4cm, 50% effaced,
Cephalic, intact BOW, Station -2

Estimated Fetal weight:
Johnsons Rule: (Fundic Height 12) x 155
= (29 12) x 155
= 2,635 grams
DIAGNOSIS
Assessment: G3P2 (2-0-0-2) Pregnancy
Uterine 38 Weeks & 1 Day AOG, Cephalic
in Labor
Plan: for vaginal delivery
FREIDMANS CURVE
Cervix: 4cm
dilated, 50%
effaced
Station -2
Station -2
Cervix: 5cm
dilated, 60%
effaced
Cervix: 6 cm
dilated, 80%
effaced
Station -1
Station 0
Cervix: 7 cm
dilated, 80%
effaced
Cervix: 9 cm
dilated, 100%
effaced
Station +1
Cervix: 10 cm
dilated, 100%
effaced
Station +3
CBC: (OMMC,
3/18/14)
Urinalysis: 3/18/14
Color: Dark Yellow
Transparency: Turbid
Epithelial cells: Many
WBC: 1-2/hpf
RBC: Many/hpf
Albumin: Trace
Sugar: Negative
Specific Gravity: 1.015
COURSE IN THE WARDS
1
st
HOSPITAL DAY
The patient was awake, conscious, coherent, oriented in 3
spheres and not in distress.
She was afebrile, freely voiding, and able to pass flatus but
without passage of stool. She had minimal vaginal
spotting.
Her vital signs were 100/70 mmHg, 80 bpm, 20 bpm, 36.4
C
O
Her head and neck, chest and lung, cardiac were
essentially normal
1
st
HOSPITAL DAY
Abdominal finding: flabby abdomen, soft, nontender,
normoactive bowel sounds with well-contracted uterus
Upon internal examination: her cervix is closed with
minimal vaginal discharge



1
st
HOSPITAL DAY
She was on a soft diet and encouraged to increase fluid.
She was maintained on heplock.
Her medications were co-amoxiclav 625 mg/tab, every 12
hours for 7 days; mefenamic acid 500mg/capsule, every 6
hours for pain medication on full stomach; multivitamins
tablet, 1 tablet every day; ferrous sulfate tablet, 1 tab
everyday
Daily body and perineal hygeine was advised
1
st
HOSPITAL DAY
Vital signs monitoring was every 4 hours.
Patient was referred accordingly for any problem.


2
nd
HOSPITAL DAY
The patient was awake, afebrile, freely voiding, and
able to pass flatus and stool. She had minimal
vaginal discharge. Her vital signs were 110/70
mmHg, 83 bpm, 19 bpm, 36.4 C
O
2
nd
HOSPITAL DAY
Her head and neck, chest and lung, cardiac findings
were essentially normal
Abdominal finding: flabby abdomen, soft,
nontender, normoactive bowel sounds with well-
contracted uterus
2
nd
HOSPITAL DAY
Her diet was as tolerated and was encouraged to
increase fluid; heplock was already removed.
Her medications were continued and was advised on
body and perineal hygeine.
Patient was sent home.
DISCUSSION
PARTURITION
Parturition, the bringing forth of
young, requires multiple
transformations in both uterine and
cervical function.
LABOR
The process that begins with regular uterine
contractions that results into:
Cervical dilatation
Cervical effacement
Delivery of the baby and other products of
conception
PARAMETERS OF LABOR
FACTORS OF LABOR
3Ps of Labor
Passenger: infant size, fetal
presentation, etc
Passages: size, shape, and
adequacy of pelvis
Power: uterine contractility,
contractions at the onset of labor

PASSENGER
FETAL LIE
FETAL POSITION
FETAL PRESENTATION
FETAL ATTITUDE
FETAL LIE
FETAL LIE
The relation of the fetal long axis to that of the
mother is termed fetal lie and is either longitudinal
or transverse.
FETAL LIE
LONGITUDINAL LIE
the long axis of the fetus
parallels the longitudinal axis of
the uterus
could be cephalic or breech
present in 99% of labors

FETAL LIE
TRANSVERSE LIE
the fetus lies in the transverse
plane of the uterus
FETAL LIE
Predisposing factors for transverse lie
multiparity
placenta previa (placenta implanted in the
cervix/internal OS or is partially in the cervix)
hydramnios
uterine anomalies (e.g. myomas)

FETAL LIE
OBLIQUE LIE
a variant of the transverse lie
axis cross at a 45 angle
unstable and converts to longitudinal or
transverse during the course of labor


FETAL
PRESENTATION
FETAL PRESENTATION
part of fetus lying over the pelvic inlet

PRESENTING PART
portion of the fetal body that is either foremost within the birth
canal or in closest proximity to it.
can be felt through the cervix on vaginal examination

Landmarks to check for presentation:
Sutures (sagittal suture)
Fontanels
FETAL PRESENTATION
Anterior
fontanel/bregma
diamond shaped,
Posterior fontanel
triangular
FETAL PRESENTATION
IN LONGITUDINAL LIES
the presenting part is either the
fetal head or breech

IN TRANSVERSE LIES
the fetus lies with the long axis
transversely,
the shoulder is the presenting
part

CEPHALIC PRESENTATION
fetal head is felt through the cervix
depends on the flexion/extension of the fetal
head
VERTEX
(OCCIPUT)
the head is flexed
sharply so that the
chin is in contact with
the thorax
PP: occiput/posterior
fontanel
FACE
the neck is sharply
extended so that the
occiput and back
come in contact
PP: face
SINCIPUT
military attitude
head is partially flexed
PP: anterior fontanel/
bregma
BROW
fetal head is partially
extended
the occipitomental plane
being the longest
anteroposterior diameter
is presented
PP: brow
As labor progresses:
Sinciput Vertex
Brow Face

BREECH PRESENTATION
FRANK
BREECH
thighs are flexed on the
abdomen and the legs are
extended over the anterior
surfaces of the body
Lower extremities are flexed at
the hips and extended at the
knees, thus, the feet lie in close
proximity to the head (U-shaped)
COMPLETE

thighs are flexed on
abdomen and legs are
flexed over the thighs
the feet present at the
level of the buttocks
(Indian sit)
INCOMPLETE
or
FOOTLING
BREECH
one or both feet, one or both
knees are lowermost
one or both hips are not
flexed and one or both feet or
knees lie below the breech
such that a foot or a knee is
lowermost in the birth canal
CAUSES OF BREECH PRESENTATION
Hydrocephalus
Uterine septum
Extension of fetal vertical column seen in
Frank breeches
Placenta is the lower uterine segment
Abnormal fetal tone and movement

SHOULDER PRESENTATION
the acromion/ scapula is
the portion of the fetus
arbitrarily chosen to orient
it with the maternal pelvis
usually presented into the
pelvic inlet in the
transverse lie

FETAL POSITION
FETAL POSITION
the relation of an arbitrarily chosen portion of
the fetal PP to the RIGHT (R) or LEFT (L) side of
the maternal pelvis/ birth canal
O (occiput) vertex presentation
M (mentum/chin) face mento
S (sacrum) breech sacro
A (acromion/ scapula) shoulder dorso-acromion

Nomenclature: Presenting part in each of the
2 positions and directed anteriorly, transverse
or posteriorly.
Example: Right occiput anterior

Vertex Presentation: ROA
Vertex Presentation: ROP
Vertex Presentation: LOA
Vertex Presentation: LOP
Vertex Presentation: ROT
Vertex Presentation: LOT
Face Presentation: RMA
Face Presentation: RMP
Face Presentation: LMA
Face Presentation: LMP
Face Presentation: RMT
Face Presentation: LMT
Breech Presentation: RSA
Breech Presentation: RSP
Breech Presentation: LSA
Breech Presentation: LSP
Breech Presentation: RST
Breech Presentation: LST
DIAGNOSIS OF FETAL PRESENTATION
AND POSITION
Leopolds maneuver (LM) abdominal
palpation with the examiner facing the
patients face except for LM 4

LM 1: Fundal Grip
What fetal part
occupies the fundus?
Breech: irregular,
nodular
Cephalic: round
LM 2: Umbilical Grip
Which side is the
fetal back?
Back: linear, convex,
bony ridge
Small Parts:
numerous
nodulations
LM 3: PawliksGrip
What fetal part lies
above the pelvic inlet?
Head not engaged-
round ballotable,
easiliy displaced
Head engaged- felt as
relatively fixed,
knoblike part
LM 3: Pelvic Grip
Which side is the
cephalic prominence?
Flexion: cephalic
prominence same side
as fetal parts
Extension: same side as
fetal back
VAGINAL EXAMINATION
VE before labor is inconclusive because you cant palpate
(closed cervix)
Vertex: palpate for the posterior fontanel, anterior
fontanel, direction of the sagittal suture
(swipe upward to differentiate anterior from posterior fontanel)

FACE BREECH
(-) muscular resistance (R) (+) muscular R
(-) meconium (+) meconium
Mouth & malar eminences form a
triangular shape
Anus & ischial tuberosities are in a straight
line
AUSCULTATION

Cephalic midway bet. symphysis pubis and umbilicus
Breech slightly above the umbilicus
Occiput Anterior a short distance from the midline
Right or Left Occiput Transverse more laterally
Occiput Posterior back in the flanks

SONOGRAPHY
involves exposing part of the body to high-
frequency sound waves to produce pictures of
the inside of the body

FETAL ATTITUDE
FETAL ATTITUDE
Posture/Habitus: the relation of the fetal parts
to one another
Normal habitus: fetus forms an
ovoid mass that corresponds to
the shape of the uterine cavity
bent upon itself in a manner that
the head is flexed, the back
becomes convex, thighs are
flexed over the abdomen

The legs are bent at the
knees,
and arches of the feet
rest upon the anterior
surfaces of the legs
arms are usually crossed
over
The Bony Pelvis
1. (2) innominate
bones (ilium, ischium,
pubis)
2. Sacrum
3. Coccyx


Boundaries of
the Pelvis
1. True Pelvis
2. False Pelvis


PLANES OF THE PELVIS
Pelvic inlet
superior strait
Pelvic outlet
inferior strait
Pelvic midplane
AP DIAMETER
OBSETRIC CONJUGATE
DIAGONAL CONJUGATE
TRUE/ANATOMIC CNJUGATE


TRANVERSE DIAMETER
OBLIQUE DIAMETER

OBSTETRIC CONJUGATE

shortest distance between
the promontory of the
sacrum and symphysis pubis
(NV>10cm)
shortest diameter/narrowest
portion of the pelvic inlet
OC = DC-1.5 to 2.0 cm


DIAGONAL CONJUGATE

distance from the lower
margin of the pubis to the
sacral promontory
(NV>11.5 cm)
only AP diameter that
can be measured
clinically by doing an
internal examination (IE)


TRUE CONJUGATE
distance from the
upper margin of the
pubis to the sacral
promontory
(NV>11cm)
TC = DC-1.2 cm

TRANSVERSE DIAMETER
greatest distance
between linea
terminalis on either
side (NV>13.5cm)
between the two
farthest points of the
pelvic brim over
iliopectineal line


OBLIQUE DIAMETER
Right and left obliques:
extend from one the
sacroiliac synchondrosis
to the iliopectineal
prominence of the
opposite side of the
pelvis (NV=13cm)


- level of ischial spine

Interspinous Diameter
AP Diameter
Posterior Sagittal Diameter


ANTEROPOSTERIOR (AP)
DIAMETER : 11.5 cm
POSTERIOR SAGITTAL
DIAMETER : 4.5 cm
diameter between the sacrum and
the line created by the IS diameter

INTERSPINOUS DIAMETER (IS) : 10.5 cm
shortest inlet of pelvic cavity

BASIS FOR STATION
PELVIC OUTLET
AP Diameter
(NV=9.5-11.5cm)
extends from lower
margin of pubis to tip of
sacrum
Consists of 2 approximately triangular areas having a common base

Transverse
diameter
(NV=11 cm)
distance between
inner edges of ischial
tuberosities
Posterior
Sagittal
Diameter
(NV>7.5 cm)
extends from tip of
sacrum to a right angle
intersection with a line
between ischial
tuberosities
POWERS
Refer to the force generated by the uterine
musculature
Force of uterine contractility
Force of pelvis and perineal floor
POWERS
NORMAL CONTRACTION
greatest and longest myometrial activity at fundus
15 mm Hg - lower limit of contraction pressure required to
dilate
Normal spontaneous contraction = 60 mmHg
Clinical labor starts when uterine activity: ~ 80-120
Montevideo units (cutoff: 180 MVU)
MONTEVIDEO UNITS (MVU)
increase in uterine pressure above the baseline in a
10-minute period
180 MVU = uterine contraction is adequate
<180 MVU = uterine contraction is inadequate
Cervix: 4cm
dilated, 50%
effaced
Station -2
Station -2
Cervix: 5cm
dilated, 60%
effaced
Cervix: 6 cm
dilated, 80%
effaced
Station -1
Station 0
Cervix: 7 cm
dilated, 80%
effaced
Cervix: 9 cm
dilated, 100%
effaced
Station +1
Cervix: 10 cm
dilated, 100%
effaced
Station +3

GENERAL CONDITIONS OF
MOTHER AND FETUS SHOULD BE
ASSESSED
MATERNAL CONDITION
HISTORY AND PE
BP
Temperature
Pulse
Weight
RR

MATERNAL CONDITION
UTERINE CONTRACTIONS
Frequency (from the start
of a contraction to the
start of another
contraction)
Duration (time from the
start of contraction to the
end of the same
contraction )
Intensity (mild,
moderate, strong)
FETAL CONDITION
1) HR, Presentation, Fetal Size
Fetal HR: should be checked especially at
the end of contraction and immediately
thereafter to identify any pathological
conditions
Get FHR after the contractions, NOT during
FETAL CONDITION
2) Status of Fetal Membranes:
note if there are any watery vaginal
discharge (might be ruptured bag of
water already)


ELECTRONIC ADMISSION TEST
Non-stress Test (NST)
Contraction Stress Test (CST)

INTERNAL EXAMINATION
INTERNAL EXAMINATION
A. Cervix
B. Bag of Waters/ Amniotic Fluid
C. Presenting Part
D. Station
E. Pelvic Architecture
CERVIX
1. Cervical Dilatation
Estimate the average diameter of the
original opening
Expressed in cm
10 cm fully dilated
As in Friedman curve

CERVIX
2. Degree of Effacement
The obliteration or taking up of the cervix
Shortening of the cervical canal from the length of
about 2 cm to mere circular orifice with almost paper
thin edges
When the length of the cervix is reduced to its
original, it is 50% effaced
CERVIX
3. Softness
4. Position of Cervix
Relationship of cervical os to fetal head
Categorized as posterior, midposition, or
anterior

AMNIOTIC FLUID
Assessed via Speculum Exam

SIGNIFICANCE OF RUPTURED
MEMBRANE:
If presenting part is not fixed into the pelvis,
the possibility of cord prolapse and cord
compression is greatly increased causes
fetal distress, death
SIGNIFICANCE OF RUPTURED
MEMBRANE:
Labor is likely to occur soon if pregnancy is at
or near term.
If delivery is delayed for 24 hours or more,
after the membrane ruptures, there is
increased likelihood of serious uterine infection
(chorioamnionitis).
DETECTION OF RUPTURED
MEMBRANE:
Pooling of amniotic fluid in the posterior fornix
or clear fluid passing from the cervical canal is
conclusive.
pH: Vaginal Secretion: 4.5-5.5
Amniotic Fluid: 7.0-7.5 (alkaline)


DETECTION OF RUPTURED
MEMBRANE
Nitrazine test
False (+): blood, semen, bacterial vaginosis
False (-): minimal amount of fluid
(+) - blue ; (-) yellow

DETECTION OF RUPTURED
MEMBRANE
Arborization or Ferning of
Vaginal Fluid
Suggest amniotic rather than
cervical fluid
Injection of dyes into
amniotic sac via abdominal
amniocentesis
PRESENTING PART
May be breech or cephalic

STATION
Level of the presenting
part in the birth canal
described in relationship
to the ischial spine which
is halfway between the
pelvic inlet and the outlet

STATION
Lowermost portion of the presenting part is at
the level of the ischial spine = Station 0
Long axis of the birth canal above the ischial
spine was arbitrarily divided into thirds
STATION
Adopted Classification of Gestation (ACOG):
new classification, divides the long axis into
fifths instead of the thirds in the old system

STAGES OF LABOR
4 STAGES OF LABOR
1. 1
st
Stage: From onset of labor Full cervical
dilatation
2. 2
nd
Stage: Full cervical dilatation delivery of
the baby
3. 3
rd
Stage: Delivery of baby Delivery of placenta
4. 4th Stage: Delivery of the placenta an hour after
delivery of placenta
1
st
STAGE
From regular uterine contractions to full
cervical dilatation (10 cm)

Duration is variable
Nulliparous: 7hours
Multiparous: 4hours
1
st
STAGE
1st phase of labor has started if:
(+) contraction
(+) bloody show
(+) water breaking

1
st
STAGE
FHT MONITORING
Should be taken after contractions [because tone
cannot be appreciated during contractions]
Normal: 110-160 bpm
If there are no FHT abnormalities, check every 30
mins by auscultation or continue electronic
monitoring
1
st
STAGE
every 30 mins 1st stage
every 15 mins 2nd stage
In high risk pregnancy: check FHT every
15minutes during the 1st stage and every
5 minutes during the 2nd stage of labor

TO PREVENT PROLONGED LABOR
1. AMNIOTOMY (uses an amniotome)
Artificial rupture of bag of waters

Presumed benefits:
More rapid labor
Earlier detection of meconium-stained amniotic
fluid
TO PREVENT PROLONGED LABOR
2. OXYTOCIN
Promotes uterine contraction
2
nd
STAGE
Full cervical dilatation to delivery of baby
Pushing or bearing down stage

DURATION VARIES:
Nulliparous: 50 minutes
Multiparous: 20 minutes

2
nd
STAGE
Episiotomy
before it is a routine procedure
but today it is only restricted
(only with indication eg:large
baby)
Incision of the pudenda
2
ND
STAGE
Disadvatage of Median episiotomy: rectal
orifice may be cut
Performed when the head circumference is
visible during a contraction to a diameter of 3
to 4 cm

2
ND
STAGE
Ritgen maneuver
Allows control of the delivery of the head
LACERATIONS OF THE BIRTH CANAL
1st DEGREE
fourchette, perineal skin,
vaginal mucosa lacerated
but not underlying fascia
or muscle
also includes periurethral
lacerations


LACERATIONS OF THE BIRTH CANAL

2nd DEGREE
up to fascia and
muscle of perineal
body

LACERATIONS OF THE BIRTH CANAL
3rd DEGREE
up to anal sphincter (extends
from the vaginal mucosa,
perineal skin and fascia up to
anal sphincter, but not rectal
mucosa)
risk of fecal incontinence


LACERATIONS OF THE BIRTH CANAL

4th DEGREE
up to rectal mucosa
but not rectal
muscle repair
properly, give stool
softener
risk of fistula

3
RD
STAGE
From delivery of the infant to the
delivery of placenta
Placenta appears within 1-5 mins after
delivery of the baby
Deliver the placenta
3
RD
STAGE
Signs of Placental Separation:
Uterus glabrous and firmer; earliest sign
(Calkins sign)
Sudden gush of blood
Uterus rises to the abdomen
Umbilical cord lengthens (protrudes farther
out the vagina)


MECHANISM OF PLACENTAL
SEPARATION
1. DUNCAN (Dirty)
Blood from the implantation site escapes
immediately
Maternal side, cotyledons appear first

2. SCHULTZE (Shiny or smooth)
Bleeding may be concentrated behind the
placenta and membranes until the placenta is
delivered
Fetal side


PLACENTAL DELIVERY
1. Modified Credes Maneuver
a technique for aiding the expulsion of
the placenta. The uterus is pushed toward the
birth canal by pressure exerted by the thumb of
one hand on the posterior surface of the
abdomen and the other hand on the anterior
surface.

PLACENTAL DELIVERY
2. Brandt Andrews Maneuver
Brandt-Andrews maneuver,
which involves applying firm
traction on the umbilical cord
with one hand while the other
applies suprapubic
counterpressure
4
th
STAGE
An hour after delivery of placenta
Critical period
Placenta membranes and cord should be
examined for completeness and anomalies
Uterus must be evaluated
Vaginal and perineal area should be inspected for
lacerations
4
th
STAGE
Prompt identification of abnormal bleeding
Identification if there is post-partum bleeding give
oxytocic agents: oxytocin, ergonovine,
methylergonovine
Never leave patient unattended
Monitor every 15 minutes, especially, in the 1st 2 hours
Breathing and warmth check for grunting, look for
chest indrawing and fast breathing