6 курс / Неонатология / Интегрированное_Ведение_Беременности_и_Родов_Уход_во_время_беременности

First do Rapid assessment and management

.Thenusethischarttoassessthewoman’sandfetalstatusanddecidestageoflabour.

ASK,CHECK RECORD

LOOK,LISTEN,FEEL

Historyofthislabour:

Observethewoman’sresponseto

Whendidcontractionsbegin?

contractions:

Howfrequentarecontractions?

Õ Isshecopingwellorisshe

Howstrong?

distressed?

Haveyourwatersbroken?Ifyes,

Õ Isshepushingorgrunting?

when? Weretheyclearorgreen?

Check abdomenfor:

Haveyouhadanybleeding?

Õ caesareansectionscar.

Ifyes,when? How much?

Õ horizontalridgeacrosslower

Isthebabymoving?

abdomen(ifpresent,emptybladder

Doyouhaveanyconcern?

andobserveagain).

Checkrecord,orifnorecord:

Feelabdomenfor:

Askwhenthedeliveryisexpected.

Õ contractionsfrequency,duration,

Determineifpreterm

anycontinuouscontractions?

(lessthan8monthspregnant).

Õ fetallie—longitudinalortransverse?

Reviewthebirthplan.

Õ fetalpresentation—head,breech,

Ifpriorpregnancies:

other?

Numberofprior

Õ morethanonefetus?

pregnancies/deliveries.

Õ fetalmovement.

Anypriorcaesareansection,forceps,

Listentothefetalheartbeat:

orvacuum,orothercomplication

Õ Countnumberofbeatsin1minute.

suchaspostpartum haemorhage?

Õ Iflessthan100beatsperminute,

Anypriorthirddegreetear?

ormorethan180,turnwoman on

Currentpregnancy:

herleftsideandcountagain.

RPRstatus

.

Measurebloodpressure.

Hbresults

.

.

Measuretemperature.

Tetanusimmunizationstatus

Lookforpallor.

HIVstatus

.

.

Lookforsunkeneyes,drymouth.

Infantfeedingplan

Pinchtheskinoftheforearm:doesit

gobackquickly?

CARE

FIRSTSTAGE OF LABOUR: NOTIN ACTIVE LABOUR

UsethischartforcareofthewomanwhenNOTIN ACTIVE LABOUR,when cervixdilated0-3cmandcontractionsareweak,lessthan2in10minutes.

POSTPARTUM

MONITOR EVERY HOUR:

MONITOR EVERY 4 HOURS:

Foremergencysigns,usingrapidassessment(RAM)

.

Bloodpressure .

.

Cervicaldilatation

Frequency,intensityanddurationofcontractions.

Unlessindicated,DO NOTdovaginalexaminationmorefrequentlythanevery4hours.

Fetalheartrate .

Temperature.

IMMEDIATEAND

Mood and behaviour(distressed,anxious) .

Pulse .

ASSESS PROGRESS OF LABOUR

TREATAND ADVISE,IF REQUIRED

RecordfindingsregularlyinLabourrecordandPartograph

.

Recordtimeofruptureofmembranesandcolourofamnioticfluid.

GiveSupportivecare

.

Neverleavethewomanalone.

LABOUR,DELIVERYCHILDBIRTH:

After8hoursif:

Refer the woman urgentlytohospital .

Õ Contractionsstrongerandmorefrequentbut

Õ Noprogressincervicaldilatationwithorwithoutmembranesruptured.

After8hoursif:

Dischargethewoman and advisehertoreturnif:

Õ noincreaseincontractions,and

Õ pain/discomfortincreases

Õ membranesarenotruptured,and

Õ vaginalbleeding

Õ noprogressincervicaldilatation.

Õ membranes rupture.

Cervicaldilatation4cmorgreater.

Beginplottingthepartograph and managethewomanasin Activelabour .

DECIDE STAGE OF LABOUR

D3

ASK,CHECK RECORD

LOOK,LISTEN,FEEL

SIGNS

CLASSIFY

MANAGE

Explaintothewomanthat

Lookat vulvafor:

Bulgingthinperineum,vagina

IMMINENT DELIVERY

Seesecondstageoflabour

.

youwillgiveheravaginal

Õ bulgingperineum

gapingandheadvisible,ful

Recordinpartograph .

examinationandaskforher

Õ anyvisiblefetalparts

cervicaldilatation.

consent.

Õ vaginalbleeding

Cervicaldilatation:

LATEACTIVE LABOUR

Seefirststageoflabour–activelabour .

Õ leakingamnioticfluid;ifyes,isitmeconium

stained,foul-smelling?

Õ multigravida ≥5 cm

Startplottingpartograph .

Õ warts,keloidtissueorscarsthatmayinterfere

Õ primigravida ≥6 cm

Recordinlabourrecord .

withdelivery.

Cervicaldilatation ≥4cm.

EARLYACTIVE LABOUR

Performvaginalexamination

Cervicaldilatation:0-3cm;

NOTYETIN ACTIVE

Seefirststageoflabour—notactivelabour .

DO NOTshavetheperinealarea.

Prepare:

contractionsweakand

LABOUR

Recordinlabourrecord .

Õ cleangloves

<2in10minutes.

Õ swabs,pads.

Washhandswithsoapbeforeandaftereach

examination.

Washvulvaandperinealareas.

Putongloves.

Positionthewomanwithlegsflexedandapart.

DO NOTperformvaginalexaminationifbleeding

noworatanytimeafter7monthsofpregnancy.

Performgentlevaginalexamination(donotstart

duringacontraction):

Õ Determinecervicaldilatationincentimetres.

Õ Feelforpresentingpart.Isithard,roundand

smooth(thehead)?Ifnot,identifythe

presentingpart.

Õ Feelformembranes–aretheyintact?

Õ Feelforcord–isitfelt?Isitpulsating?Ifso,

actimmediatelyason .

NEXT:Respondtoobstetricalproblemsonadmission.

Decidestageoflabour

D3

Respondtoobstetricalproblemsonadmission

D4

D4

RESPOND TO OBSTETRICAL PROBLEMS ON ADMISSION

Usethischartifabnormalfindingsonassessingpregnancyandfetalstatus

.

SIGNS

CLASSIFY

TREATAND ADVISE

Transverselie.

OBSTRUCTED LABOUR

Ifdistressed,insertanIVlineandgivefluids .

Continuouscontractions.

Ifinlabour>24hours,giveappropriateIM/IV

Constantpainbetweencontractions.

antibiotics .

Sudden and severeabdominalpain.

Referurgentlytohospital .

Horizontalridgeacrosslower

abdomen.

Labour>24hours.

FOR ALLSITUATIONSINREDBELOW,REFER URGENTLYTO HOSPITALIFINEARLYLABOUR,MANAGE ONLYIFINLATELABOUR

Ruptureofmembranesandanyof:

UTERINE AND

GiveappropriateIM/IVantibiotics .

Õ Fever >38˚C

FETAL INFECTION

Iflatelabour,deliverandrefertohospital

Õ Foul-smellingvaginaldischarge.

afterdelivery .

Plantotreatnewborn .

Ruptureofmembranesat

RISK OF UTERINE AND

GiveappropriateIM/IVantibiotics .

<8 monthsofpregnancy.

FETAL INFECTION

Iflatelabour,deliver

.

Discontinueantibioticformotherafterdeliveryifno

signsofinfection.

Plantotreatnewborn .

Diastolicbloodpressure>90mmHg.

PRE-ECLAMPSIA

Assessfurtherandmanageason .

Severepalmarandconjunctival

SEVERE ANAEMIA

Manageason .

pallorand/orhaemoglobin<7g/dl.

Breechorothermalpresentation .

OBSTETRICAL

Followspecificinstructions

Multiplepregnancy .

COMPLICATION

(seepagenumbersinleftcolumn).

Fetaldistress .

Prolapsedcord .

MONITOR EVERY 30 MINUTES:

MONITOR EVERY 4 HOURS:

D9

Foremergencysigns,usingrapidassessment(RAM)

.

Cervicaldilatation

.

Frequency,intensityanddurationofcontractions.

Unlessindicated,donot dovaginalexaminationmorefrequentlythanevery4hours.

Fetalheartrate .

Temperature.

Mood and behaviour(distressed,anxious) .

Pulse .

Bloodpressure .

RecordfindingsregularlyinLabourrecordandPartograph

.

Recordtimeofruptureofmembranesandcolourofamnioticfluid.

GiveSupportivecare

.

Neverleavethewomanalone.

ASSESS PROGRESS OF LABOUR

TREATAND ADVISE,IF REQUIRED

Partographpassestotherightof ALERTLINE.

Reassesswomanandconsidercriteriaforreferral.

Callseniorpersonifavailable.Alertemergencytransportservices.

Encouragewomantoemptybladder.

Ensureadequatehydrationbutomitsolidfoods.

Encourageuprightpositionandwalkingifwomanwishes.

Monitorintensively.Reassessin2hoursandreferifnoprogress.Ifreferraltakesalongtime,refer

immediately(DONOTwaittocrossactionline).

Partographpassestotherightof ACTIONLINE.

Referurgentlytohospital

unlessbirthisimminent.

Cervixdilated10cmorbulgingperineum.

Manageasin Secondstageoflabour

.

Firststageoflabour(2): whenthewomanisinactivelabour

D9

Secondstageoflabour:deliverthebabyandgiveimmediatenewborncare(1)

D10

D10

SECOND STAGE OF LABOUR: DELIVER THE BABY AND GIVE IMMEDIATE NEWBORN CARE

Usethischartwhencervixdilated10cmorbulgingthinperineumandheadvisible.

MONITOR EVERY 5 MINUTES:

Foremergencysigns,usingrapidassessment(RAM)

.

Frequency,intensityanddurationofcontractions.

Fetalheartrate .

Perineumthinningandbulging.

Visibledescentoffetalheadorduringcontraction.

Mood and behaviour(distressed,anxious) .

RecordfindingsregularlyinLabourrecordandPartograph(pp.N4-N6).

GiveSupportivecare

.

Neverleavethewomanalone.

DELIVER THEBABY

TREATAND ADVISEIFREQUIRED

Ensurealldeliveryequipmentandsupplies,includingnewbornresuscitationequipment,are

available,andplaceofdeliveryiscleanandwarm (25°C) .

Ensurebladderisempty.

Ifunabletopassurineandbladderisfull,emptybladder .

Assistthewomanintoacomfortablepositionofherchoice,asuprightaspossible.

DO NOTletherlieflat(horizontally)onherback.

Staywithherandofferheremotionalandphysicalsupport

.

Ifthewomanisdistressed,encouragepaindiscomfortrelief .

Allowhertopushasshewisheswithcontractions.

DO NOTurgehertopush.

If,after30minutesofspontaneousexpulsiveefforts,theperineumdoesnotbegintothinandstretch

withcontractions,doavaginalexaminationtoconfirmfulldilatationofcervix.

Ifcervixisnotfullydilated,awaitsecondstage.Placewomanonherleftsideanddiscourage

pushing.Encouragebreathingtechnique .

Waituntilheadvisibleandperineumdistending.

Ifsecondstagelastsfor2hoursormorewithoutvisiblesteadydescentofthehead,callforstaff

Washhandswithcleanwaterandsoap.Putonglovesjustbeforedelivery.

trainedtousevacuumextractoror referurgentlytohospital .

SeeUniversalprecautionsduringlabouranddelivery .

Ifobviousobstructiontoprogress(warts/scarring/keloidtissue/previousthirddegreetear),doa

generousepisiotomy.DO NOTperformepisiotomyroutinely.

Ifbreechorothermalpresentation,manageason .

SIGNS

CLASSIFY

TREATAND ADVISE

D5

Warts,keloidtissuethatmay

RISK OF OBSTETRICAL

Doagenerousepisiotomyandcarefullycontrol

interferewithdelivery.

COMPLICATION

deliveryofthehead

.

Priorthirddegreetear.

Bleedinganytimeinthirdtrimester.

Iflatelabour,deliver

.

Priordeliveryby:

Havehelpavailableduringdelivery.

Õ caesareansection

Õ forcepsorvacuumdelivery.

Agelessthan14years.

Labourbefore8completedmonths

PRETERM

Reassessfetalpresentation(breechmorecommon).

ofpregnancy(morethanonemonth

LABOUR

Ifwomanislying,encouragehertolieonherleftside.

beforeestimateddateofdelivery).

Callforhelpduringdelivery.

Conductdeliveryverycarefullyassmallbabymaypop

outsuddenly.Inparticular,controldeliveryofthehead.

Prepareequipmentforresuscitationofnewborn

.

Fetalheartrate

POSSIBLE FETAL

Manageason

.

<120or>160beatsperminute.

DISTRESS

Ruptureofmembranesatterm and

RUPTURE OF

GiveappropriateIM/IVantibioticsifruptureof

beforelabour.

MEMBRANES

membrane >18 hours

.

Plantotreatthenewborn

.

Iftwoormoreofthefollowingsigns:

DEHYDRATION

Giveoralfluids.

.

Õ thirsty

Ifnotabletodrink,give1litreIVfluidsover3hours

Õ sunkeneyes

Õ drymouth

Õ skinpinchgoesbackslowly.

HIVtestpositive.

HIV-POSITIVE

EnsurethatthewomantakesARVdrugsassoonas

Counselledon ARVtreatmentand

labourstarts

.

.

infantfeeding.

Supportherchoiceofinfantfeeding

Nofetalmovement,and

POSSIBLE FETAL DEATH

Explaintotheparentsthatthebabyisnotdoingwel.

Nofetalheartbeaton

NEXT:Givesupportivecarethroughoutlabour

repeatedexamination

Respondtoobstetricalproblemsonadmission

D5

Givesupportivecarethroughoutlabour

D6

D6

GIVE SUPPORTIVE CARE THROUGHOUT LABOUR

Usethischarttoprovideasupportive,encouragingatmosphereforbirth,respectfulofthewoman’swishes.

Communication

Eating,drinking

Explainallprocedures,seekpermission,anddiscussfindingswiththewoman.

Encouragethewomantoeatanddrinkasshewishesthroughoutlabour.

Keepherinformedabouttheprogressoflabour.

Nutritiousliquiddrinksareimportant,eveninlatelabour.

Praiseher,encourageandreassureherthatthingsaregoingwel.

Ifthewomanhasvisibleseverewastingortiresduringlabour,makesuresheeatsanddrinks.

Ensureandrespectprivacyduringexaminationsanddiscussions.

Breathingtechnique

IfknownHIVpositive,findoutwhatshehastoldthecompanion.Respectherwishes.

Cleanliness

Teachhertonoticehernormalbreathing.

Encouragehertobreatheoutmoreslowly,makingasighingnoise,andtorelaxwitheachbreath.

Ifshefeelsdizzy,unwel,isfeelingpins-and-needles(tingling)inherface,handsandfeet,encourage

Encouragethewomantobatheorshowerorwashherselfandgenitalsattheonsetoflabour.

Washthevulvaandperinealareasbeforeeachexamination.

hertobreathemoreslowly.

Washyourhandswithsoapbeforeandaftereachexamination.Usecleanglovesforvaginal

Topreventpushingattheendoffirststageoflabour,teachhertopant,tobreathewithanopen

examination.

mouth,totakein2shortbreathsfollowedbyalongbreathout.

Ensurecleanlinessoflabourandbirthingarea(s).

Duringdeliveryofthehead,askhernottopushbuttobreathesteadilyortopant.

Cleanupspillsimmediately.

Painanddiscomfortrelief

DO NOTgiveenema.

Mobility

Suggestchangeofposition.

Encouragemobility,ascomfortableforher.

Encouragecompanionto:

Encouragethewomantowalkaroundfreelyduringthefirststageoflabour.

Supportthewoman’schoiceofposition(leftlateral,squating,kneeling,standingsupportedbythe

Õ massagethewoman’sbackifshefindsthishelpful.

companion)foreachstageoflabouranddelivery.

Õ holdthewoman’shandandspongeherfacebetweencontractions.

Urination

Encouragehertousethebreathingtechnique.

Encouragewarmbathorshower,ifavailable.

Encouragethewomantoemptyherbladderfrequently.Remindherevery2hours.

Ifwomanisdistressedoranxious,investigatethecause

.

.

Ifpainisconstant(persistingbetweencontractions)andverysevereorsuddeninonset

Birthcompanion

D7

DELIVER THEBABY

TREATAND ADVISE,IFREQUIRED

D11

CARE

Ensurecontrolleddeliveryofthehead:

Ifpotentiallydamagingexpulsiveefforts, exertmorepressureonperineum.

Keeponehandgentlyontheheadasitadvanceswithcontractions.

Discardsoiledpadtopreventinfection.

ÕÕ Supportperineumwithotherhandandcoveranuswithpadheldinpositionbysideofhandduringdelivery.

Õ Leavetheperineumvisible(betweenthumbandfirstfinger).

POSTPARTUM

Õ Askthemothertobreathesteadilyandnottopushduringdeliveryofthehead.

Ifdelayindeliveryofshoulders:

Awaitspontaneousrotationofshouldersanddelivery(within1-2minutes).

Õ Encouragerapidbreathingwithmouthopen.

Feelgentlyaroundbaby’sneckforthecord.

Ifcordpresentandloose,deliverthebabythroughtheloopofcordorslipthecordoverthebaby’shead;if

Checkifthefaceisclearofmucusandmembranes.

cordistight,clampandcutcord,thenunwind.

Gentlywipefacecleanwithgauzeorcloth,ifnecessary.

IMMEDIATE

Applygentledownwardpressuretodelivertopshoulder.

Õ DO NOTpanicbutcallforhelpandaskcompaniontoassist

Assessbaby’sbreathingwhiledrying.

Ifthebabyisnotbreathingorgasping (unlessbabyisdead,macerated,severelymalformed):

Thenliftbabyup,towardsthemother’sabdomentodeliverlowershoulder.

Õ Manageasin Stuckshoulders

.

Placebabyonabdomenorinmother’sarms.

Ifplacingnewbornonabdomenisnotacceptable,orthemothercannotholdthebaby,placethebabyin

Notetimeofdelivery.

aclean,warm,safeplaceclosetothemother.

Thoroughlydrythebabyimmediately.Wipeeyes.Discardwetcloth.

DO NOTleavethebabywet-she/hewillbecomecold.

AND

Ifthebabyisnotcrying,observebreathing:

Õ Cutcordquickly:transfertoafirm,warmsurface;startNewbornresuscitation

.

Õ breathingwell(chestrising)?

CALLFORHELP-onepersonshouldcareforthemother.

Õ notbreathingorgasping?

LABOUR,DELIVERY

Õ observeforoozingblood.

Ifsecondbaby,DO NOTgiveoxytocinnow.GET HELP.

Excludesecondbaby.

.

Palpatemother’s abdomen.

Deliverthesecondbaby.Manageasin Multiplepregnancy

Give10IUoxytocinIMtothemother.

Ifheavybleeding,repeatoxytocin10UIM.

Watchforvaginalbleeding.

Changegloves.Ifnotpossible,washglovedhands.

Ifbloodoozing,placeasecondtiebetweentheskinandthefirsttie.

Clampandcutthecord.

DO NOTapplyanysubstancetothestump.

Õ puttiestightlyaroundthecordat2cmand5cmfrombaby’s abdomen.

DO NOTbandageorbindthestump.

Õ cutbetweentieswithsterileinstrument.

CHILDBIRTH:

Leavebabyonthemother’schestinskin-to-skincontact.Placeidentificationlabel.

Ifroomcool(lessthan25°C),useadditionalblankettocoverthemotherandbaby.

Coverthebaby,covertheheadwithahat.

Encourageinitiationofbreastfeeding

.

IfHIV-positivemotherhaschosenreplacementfeeding,feedaccordingly.

Check ARVtreatmentneeded

.

Secondstageoflabour:deliverthebabyandgiveimmediatenewborncare(2)

D11

CARE

Thirdstageoflabour:delivertheplacenta

D12

D12

THIRD STAGE OF LABOUR: DELIVER THE PLACENTA

Usethischartforcareofthewomanbetweenbirthofthebabyanddeliveryofplacenta.

MONITOR BABY EVERY 15 MINUTES:

POSTPARTUM

MONITOR MOTHER EVERY 5 MINUTES:

Timesincethirdstagebegan(timesincebirth).

.

Breathing:listenforgrunting,lookforchestin-drawingandfastbreathing

.

Foremergencysigns,usingrapidassessment(RAM)

Feelifuterusiswellcontracted.

Warmth:checktoseeiffeetarecoldtotouch

.

Mood and behaviour(distressed,anxious)

.

IMMEDIATE

Recordfindings,treatmentsandproceduresin Labourrecordand Partograph (pp.N4-N6).

TREATAND ADVISEIFREQUIRED

DELIVER THEPLACENTA

GiveSupportivecare

.

Neverleavethewomanalone.

AND

Ensure10IUoxytocinIMisgiven

.

If,after30minutesofgivingoxytocin,theplacentaisnotdeliveredandthewomanis NOTbleeding:

Awaitstronguterinecontraction(2-3minutes)anddeliverplacenta bycontrolledcordtraction:

Õ Emptybladder

LABOUR,DELIVERY

Õ Placesideofonehand(usuallyleft)above symphysispubiswithpalmfacingtowardsthemother’s

Õ Encouragebreastfeeding

umbilicus.Thisappliescountertractiontotheuterusduringcontrolledcordtraction.Atthesame

DO NOTexertexcessivetractiononthecord.

Õ Repeatcontrolledcordtraction.

time,applysteady,sustainedcontrolledcordtraction.

Ifwomanisbleeding,manageason

Õ Ifplacentadoesnotdescendduring30-40secondsofcontrolledcordtraction,releasebothcord

Ifplacentaisnotdeliveredinanother30minutes(1hourafterdelivery):

tractionandcountertractionontheabdomenandwaituntiltheuterusiswellcontractedagain.

Õ Removeplacentamanually

.

Thenrepeatcontrolledcordtractionwithcountertraction.

Õ GiveappropriateIM/IVantibiotic

Õ Astheplacentaiscomingout,catchinbothhandstopreventtearingofthemembranes.

Ifin1hourunabletoremoveplacenta:

Õ Ifthemembranesdonotslipoutspontaneously,gentlytwistthemintoaropeandmovethemup

Õ Referthewomantohospital

anddowntoassistseparationwithouttearingthem.

Õ InsertanIVlineandgivefluidswith20IUofoxytocinat30dropsperminute

duringtransfer

.

CHILDBIRTH:

DO NOTsqueezeorpushtheuterustodelivertheplacenta.

Checkthatplacentaandmembranesarecomplete.

Ifplacentaisincomplete:

.

Removeplacentalfragmentsmanually

GiveappropriateIM/IVantibiotic

.

D13

CARE

DELIVER THEPLACENTA

TREATAND ADVISE,IF REQUIRED

Checkthatuterusiswellcontractedandthereisnoheavybleeding.

Ifheavybleeding:

Repeatcheckevery5minutes.

Massageuterustoexpelclotsifany,untilitishard

.

POSTPARTUM

Giveoxytocin10IUIM

.

ContinueIVfluidswith20IUofoxytocinat30dropsperminute.

Callforhelp.

,add20IUofoxytocintoIVfluidsandgiveat60dropsperminute

.

StartanIVline

Emptythebladder

.

Ifbleedingpersistsanduterusissoft:

Continuemassaginguterusuntilitishard.

Applybimanualoraorticcompression

.

IMMEDIATE

Refer woman urgentlytohospital

.

Examineperineum,lowervaginaandvulvafortears.

Checkafter5minutes.Ifbleedingpersists,repairthetear

.

.

Ifthirddegreetear(involvingrectumoranus),referurgentlytohospital

Forothertears:applypressureoverthetearwithasterilepadorgauzeandputlegstogether.

DO NOTcrossankles.

AND

Collect,estimateandrecordbloodlossthroughoutthirdstageandimmediatelyafterwards.

Ifbloodloss ≈250ml,butbleedinghasstopped:

Õ Plantokeepthewomaninthefacilityfor24hours.

LABOUR,DELIVERY

Keepthemotherandbabyindeliveryroomforaminimumofonehourafterdeliveryofplacenta.

Õ BP,pulse

Õ vaginalbleeding

Õ uterus,tomakesureitiswellcontracted.

Õ Assistthewoman whenshefirstwalksafterrestingandrecovering.

Õ Ifnotpossibletoobserveatthefacility,refertohospital

.

Cleanthewomanandtheareabeneathher.Putsanitarypadorfoldedcleanclothunderherbuttocks

tocollectblood.Helphertochangeclothesifnecessary.

CHILDBIRTH:

Disposeofplacentainthecorrect,safeandculturallyappropriatemanner.

Ifdisposingplacenta:

Õ Usegloveswhenhandlingplacenta.

Õ Putplacentaintoabagandplaceitintoaleak-proofcontainer.

Õ Alwayscarryplacentainaleak-proofcontainer.

Õ Incineratetheplacentaorburyitatleast10mawayfromawatersource,ina2mdeeppit.

Thirdstageoflabour:delivertheplacenta

D13