preterm labour mine

8/8/2019 Preterm Labour Mine

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PretermPreterm LabourLabour


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DefinitionsDefinitions

LabourLabour is preterm when it occurs in ais preterm when it occurs in apatient whose period of gestation ispatient whose period of gestation isless than 37 completed weeks(lessless than 37 completed weeks(lessthan 259 days) from the first day ofthan 259 days) from the first day ofthe last menstrual period.the last menstrual period.


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IncidenceIncidence

ApproxApprox 55--6% in Australia6% in Australia

More than 10% in the USAMore than 10% in the USA Second leading cause of mortalitySecond leading cause of mortality

after congenitalafter congenital anomaliesanomalies


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DiagnosisDiagnosis

Uterine contractionsUterine contractions-- 4 in 204 in 20 minsmins or 8or 8in 60in 60 minsmins

CervixCervix-- dilated 2 cm or 80% effaceddilated 2 cm or 80% effaced

Serial examinations, preferably by theSerial examinations, preferably by thesame observer, reveal changes in thesame observer, reveal changes in the

cervixcervix

Membranes are rupturedMembranes are ruptured


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Risk Factors (1)Risk Factors (1)

StressStress

Occupational fatigueOccupational fatigue Smoking/substance abuseSmoking/substance abuse

Poor antenatal carePoor antenatal care


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Risk FactorsRisk Factors

Excessive or impaired uterine distension:Excessive or impaired uterine distension:

Multiple pregnancyMultiple pregnancy PolyhydramniosPolyhydramnios

FibroidsFibroids

Uterine anomalyUterine anomaly


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Maternal FactorsMaternal Factors

Maternal diseaseMaternal disease PIHPIH Renal diseaseRenal disease

AppendicitisAppendicitis

Uterine anomaliesUterine anomalies Cervical incompetenceCervical incompetence

History of pretermHistory of preterm labourlabour-- 1 pre term1 pre term-- 2525--50%50%increased riskincreased risk

History of abortionHistory of abortion Socioeconomic statusSocioeconomic status-- Poor nutrition,Poor nutrition,

inadequate prenatal care, low maternal age,inadequate prenatal care, low maternal age,heavy workheavy work


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Cervical factors:Cervical factors:

History of second trimester lossHistory of second trimester loss

Cervical surgeryCervical surgery

Premature cervical dilatationPremature cervical dilatation ororeffacementeffacement


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Infections:Infections:

Systemic infectionsSystemic infections

STD'sSTD's

PyelonephritisPyelonephritis

BacteriuriaBacteriuria Periodontal diseasePeriodontal disease


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Fetal & placental factors:Fetal & placental factors:

Congenital anomaliesCongenital anomalies-- polyhydramniospolyhydramnios (1/3(1/3rdrd

have PTL),have PTL), oligohydramniosoligohydramnios

IUGRIUGR Multiple pregnancyMultiple pregnancy-- 261 days for twins, 246261 days for twins, 246

days for triplets, 236 days for quadrupletsdays for triplets, 236 days for quadruplets

PROMP

ROM

AbruptionAbruption

VaginalVaginal bleedingbleeding

PlacentaPlacenta previaprevia


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Causes of PretermCauses of Preterm LabourLabour

Major focus of O & G research.Major focus of O & G research.

80% spontaneous onset80% spontaneous onset

5050% PTL% PTL

3030% PPROM% PPROM

20% due to20% due to toto intervention forintervention formaternal ormaternal or fetal indicationsfetal indications


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Four Major CategoriesFour Major Categories

Activation ofActivation ofhypothalamic/pituitary/adrenal axis:hypothalamic/pituitary/adrenal axis:

maternal or fetalmaternal or fetal

InflammationInflammation

DecidualDecidual hemorrhagehemorrhage

Uterine overUterine over--distentiondistention


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Activation ofHPAActivation ofHPA

AxisAxis Maternal physical/emotional stressMaternal physical/emotional stress

PlacentalPlacental vasculopathyvasculopathy

Increased secretion of CRHIncreased secretion of CRH fetalfetalACTHACTH

Increased secretion placentalIncreased secretion placentalestrogenestrogen

Increased secretion of placental PG'sIncreased secretion of placental PG's

Activation of myometriumActivation of myometrium


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InflammationInflammation

Both systemic and genital tract infectionsBoth systemic and genital tract infections

ChorioamnionitisChorioamnionitis in 50% of pretermin 50% of preterm labourslabours before 30 weeks' gestationbefore 30 weeks' gestation

Can occur with intact membranesCan occur with intact membranes

Raised cytokines (interleukins, TNF, GSF)Raised cytokines (interleukins, TNF, GSF) Enhanced prostaglandin productionEnhanced prostaglandin production


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BacteriaBacteria

Some organisms have a direct role inSome organisms have a direct role in PTLPTLindependentindependent of inflammatory mediatorsof inflammatory mediators

PseudomonasPseudomonas, staph, strep,, staph, strep, bacteroidesbacteroides,,enterobacterenterobacter produce proteases that canproduce proteases that canbreak downbreak down fetal membranesfetal membranes

Can also produce phospholipase A2Can also produce phospholipase A2 andandendotoxinsendotoxins, stimulating uterine, stimulating uterinecontractionscontractions


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BacteriaBacteria

Increased rates of PTL noted inIncreased rates of PTL noted inwomen withwomen with

GBS, chlamydia and syphilisGBS, chlamydia and syphilis

Risk of PTL reduced by treating:Risk of PTL reduced by treating:

AsymptomaticAsymptomatic bacteriuriabacteriuria

GonorrheaGonorrhea

BV in high risk patients for PTLBV in high risk patients for PTL


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Oral BacteriaOral Bacteria

Increased rates of PTL noted inIncreased rates of PTL noted inwomenwomen with periodontalwith periodontal diseasedisease

? intrauterine infection following? intrauterine infection followingdescent fromdescent from oral cavityoral cavity

CaseCase report:report: BergeyellaBergeyella bacteriumbacterium

isolated fromisolated from both the mouth andboth the mouth andamniotic fluidamniotic fluid of patientof patient with intactwith intactmembranes having PTLmembranes having PTL at 24at 24 weeksweeks


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Vaginal bleeding in more than oneVaginal bleeding in more than onetrimester increasestrimester increases risk of PTL 7risk of PTL 7--foldfold

Placental histopathology: occultPlacental histopathology: occultdecidualdecidual hemorrhagehemorrhage noted in 36noted in 36--38%38%of cases of PTBof cases of PTB

PPROM may be related to highPPROM may be related to highconcentrationsconcentrations of tissueof tissue factorfactor


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DecidualDecidual TF combines withTF combines with FVIIaFVIIa totoactivate FXactivate FX, to generate thrombin, to generate thrombin

Thrombin is a potent inducer ofIL8,Thrombin is a potent inducer ofIL8,causingcausing localisedlocalised inflammatory reactions.inflammatory reactions.

Leads to degradation of fetalLeads to degradation of fetal membranemembrane

extracellularextracellular matrix, PPROMmatrix, PPROM


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Uterine OverUterine Over--distentiondistention

UpUp--regulation of oxytocin receptorsregulation of oxytocin receptors

Formation of gap junctionsFormation of gap junctions

PGE2 andPGE2 and PGFPGF


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UterineUterine OverOver--distensiondistension

PolyhydramniosPolyhydramnios

Multiple pregnancyMultiple pregnancy


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Cervical IncompetenceCervical Incompetence

In most cases a secondary effectIn most cases a secondary effect

CervicalCervical cone biopsycone biopsy

LLETZLLETZ, laser cone, laser cone

Increased risk of PTLIncreased risk of PTL --


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Prevention of PretermPrevention of PretermLabourLabour


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Potentially effectivePotentially effective

interventionsinterventions Progesterone supplementsProgesterone supplements

Smoking cessationSmoking cessation

Avoidance of drugs & alcoholAvoidance of drugs & alcohol

Reduce rate of multiple pregnancyReduce rate of multiple pregnancy

CervicalCervical cerclagecerclage Reduce occupational stressReduce occupational stress

NutritionNutrition

Early diagnosis & treatment of infectionEarly diagnosis & treatment of infection


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Progesterone supplementsProgesterone supplements

Most trials useMost trials use 1717--alphaalpha--hydroxyprogesteronehydroxyprogesteronecaproatecaproate, weekly IMI, weekly IMI

Reduction in PTL rates by 15

Reduction in PTL rates by 15--70%70%

Most effective in women with previous PTLMost effective in women with previous PTL atat


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Stop smokingStop smoking

Cigarette smoking has aCigarette smoking has a dosedose--dependent relationshipdependent relationship with pretermwith preterm

labourlabour

Partially due to smokingPartially due to smoking--relatedrelatedcomplicationscomplications

Cessation of smoking likely to beCessation of smoking likely to bebeneficial,beneficial, but notbut not proven in RCTsproven in RCTs


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Avoidance of drugs andAvoidance of drugs and

alcoholalcohol CocaineCocaine

AlcoholAlcohol

? Cannabis? Cannabis


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Reduction in multipleReduction in multiple

pregnanciespregnancies Multiple pregnancies six times moreMultiple pregnancies six times more

likelylikely to deliverto deliver pretermpreterm

Risk increases with increasing no. ofRisk increases with increasing no. offetusesfetuses

Valid indication before starting ARTValid indication before starting ART

Limit no. of embryosLimit no. of embryos transferrredtransferrred


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CervicalCervical CerclageCerclage

Cervical incompetence based on historyCervical incompetence based on history ororultrasoundultrasound findingsfindings

RCOG study of 1292 womenRCOG study of 1292 women Significant reduction in pretermSignificant reduction in preterm births


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Reduction of WorkReduction of Work

FatigueFatigue Excessive physical demands relatedExcessive physical demands related toto

increasedincreased risk (OR 1.63)risk (OR 1.63)

Working > 42Working > 42 hrshrs/week/week

Standing > 6Standing > 6 hrshrs/day/day

Low job satisfactionLow job satisfaction

No RCTs availableNo RCTs available


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Nutritional interventionsNutritional interventions

No fish consumption linked to excess riskNo fish consumption linked to excess riskof PTLof PTL (OR 19.6)(OR 19.6)

Fish oil supplements: one multiFish oil supplements: one multi--centrecentreRCTRCT in highin high risk women showed arisk women showed asignificant reductionsignificant reduction in PTL (OR 0.54)in PTL (OR 0.54)

Trial withTrial with docosahexanoicdocosahexanoic acidacid

supplements: significantsupplements: significant prolongation ofprolongation ofpregnancypregnancy

CARRDIP trial: marked reduction in riskCARRDIP trial: marked reduction in risk ofofpretermpreterm labourlabour (1/141(1/141 vsvs 11/14911/149


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Early detection and treatment ofEarly detection and treatment of

infectioninfection

AsymptomaticAsymptomatic bacteruriabacteruria: treatment: treatmentsignificantly reducessignificantly reduces risk of PTL or LBWrisk of PTL or LBW

infants (OR 0.60)infants (OR 0.60) ChlamydiaChlamydia, gonorrhea, BV: routine, gonorrhea, BV: routine

screeningscreening not indicatednot indicated

WomenWomen with previous PTL and +with previous PTL and +veve for BVfor BVmay benefitmay benefit from treatmentfrom treatment

TrichomonasTrichomonas: treatment of asymptomatic: treatment of asymptomaticwomenwomen may increasemay increase risk of PTLrisk of PTL


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Tests for Prediction ofTests for Prediction of

Preterm DeliveryPreterm Delivery CervicoCervico--vaginalvaginal fibronectinfibronectin

Ultrasound measurement of cervicalUltrasound measurement of cervicallengthlength


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Treatment of PretermTreatment of Preterm

LaborLabor No generally accepted criteriaNo generally accepted criteria forfor

startingstarting tocolysistocolysis

AboutAbout 3030--50% of threatened50% of threatened pretermpretermlabourslabours spontaneously resolvespontaneously resolve

TreatTreat the underlying cause if possiblethe underlying cause if possible


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General MeasuresGeneral Measures

No proven benefits forNo proven benefits for::

Bed restBed rest

HydrationHydration

SedationSedation


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Objectives ofObjectives of TocolysisTocolysis

Delay delivery so that steroids mayDelay delivery so that steroids may bebegivengiven

AllowAllow safe transport of the mothersafe transport of the mother ififpossiblepossible

ProlongProlong pregnancy when there arepregnancy when there are selfself

limitinglimiting causescauses ofof labourlabour e.g. sepsise.g. sepsis


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Contraindications toContraindications to

TocolysisTocolysis APHAPH with hemodynamic instabilitywith hemodynamic instability

Severe preSevere pre--eclampsiaeclampsia//eclampsiaeclampsia

ChorioamnionitisChorioamnionitis

Severe IUGRSevere IUGR

Evidence of fetal compromiseEvidence of fetal compromise Lethal fetal anomalyLethal fetal anomaly

Fetal demiseFetal demise


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Benefits of AntenatalBenefits of Antenatal

SteroidsSteroids Reduce riskReduce risk of:of:

RDSRDS (RR 0.66)(RR 0.66)

NEC (RR

0.46)NEC (RR

0.46) IVH (RR 0.54)IVH (RR 0.54)

Severe bruisingSevere bruising Systemic infection in the first 48Systemic infection in the first 48 hrhr ofof

life (RR

life (RR

0.56)0.56) Admission to NICU (RR 0.80)Admission to NICU (RR 0.80) Neonatal mortality (RR 0.69)Neonatal mortality (RR 0.69)


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Antenatal SteroidsAntenatal Steroids

Effective in women with SROM andEffective in women with SROM andPETPET

MaximumMaximum effect at 48effect at 48 hrshrs

Betamethasone 12Betamethasone 12 mg IMmg IM 2424 hrshrs apartapart

Beneficial effects wear off after 2Beneficial effects wear off after 2weeksweeks

No significant maternal side effectsNo significant maternal side effects


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TOCOLYTICAGENTSTOCOLYTICAGENTS

BetamimeticBetamimetic agentsagents

NifedipineNifedipine

NSAIDSNSAIDS

AtosibanAtosiban

MagnesiumMagnesium sulphatesulphate


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BETABETA--ADRENERGICADRENERGICRECEPTORAGONISTSRECEPTORAGONISTS


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Mechanism of action:Mechanism of action:

CauseCause myometrialmyometrial relaxation byrelaxation bybinding withbinding with betabeta--2 receptors and2 receptors and

increasing intracellularincreasing intracellular adenyladenyl cyclasecyclase..

DropDrop in intracellular calciumin intracellular calcium

TargetTarget cells eventually becomecells eventually become

desensitized todesensitized to the effect of betathe effect of beta--adrenergicadrenergic agonists (agonists (tachyphylaxistachyphylaxis).).


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BETABETA--ADRENERGICRECEPTORADRENERGICRECEPTORAGONISTS : EFFICACYAGONISTS : EFFICACY

MetaMeta--analyses:analyses:

ReductionReduction in no. of births within 48in no. of births within 48 hrshrs((RR 0.63RR 0.63).).

NoNo decrease in no. of births within 7decrease in no. of births within 7daysdays

NoNo change in perinatal mortalitychange in perinatal mortality

MarginalMarginal decrease in RDS casesdecrease in RDS cases


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BETABETA--ADRENERGICRECEPTORADRENERGICRECEPTORAGONISTS: MATERNALAGONISTS: MATERNAL SIDEEFFECTSSIDEEFFECTS

TachycardiaTachycardia

PalpitationsPalpitations

Lowered blood pressureLowered blood pressure

Shortness of breathShortness of breath

Myocardial ischemiaMyocardial ischemia

PulmonaryPulmonary edemaedema (0.3%)(0.3%)

Hyperglycemia, hypokalemiaHyperglycemia, hypokalemia


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BETABETA--ADRENERGICRECEPTORADRENERGICRECEPTORAGONISTS:AGONISTS:FETALFETAL SIDEEFFECTSSIDEEFFECTS

TachycardiaTachycardia

NeonatalNeonatal hypoglycemiahypoglycemia


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TERBUTALINE:TERBUTALINE:

DOSAGEDOSAGE ContinuousContinuous iv infusioniv infusion (10(10 mcgmcg/min/min

increasedincreased to max. ofto max. of 5050 mcg/min)mcg/min)

S.C.IS.C.I. 25 mg stat. 25 mg stat

StopStop ifHR>120 or symptomaticifHR>120 or symptomatic

MonitorMonitor K+ andK+ and blood sugarsblood sugars


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CALCIUMCHANNELCALCIUMCHANNEL

BLOCKERSBLOCKERS Block the influx ofBlock the influx of CaCa+ through+ through thethe

cellcell membranemembrane

ReductionReduction of intracellular free calciumof intracellular free calcium

InhibitionInhibition of myosin light chainof myosin light chain kinasekinasephosphorylationphosphorylation

RelaxationRelaxation of uterine muscleof uterine muscle


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EFFICACY OF NIFEDIPINEEFFICACY OF NIFEDIPINE

MetaMeta--analysis of 12 RCTs:analysis of 12 RCTs:

Reduction in no. of births within 7 days (RRReduction in no. of births within 7 days (RR

0.760.76)) Reduction in no. of births before 34 weeksReduction in no. of births before 34 weeks

(RR 0.83)(RR 0.83)

Lower risk ofRD

S (RR

0.63), NEC (RR

Lower risk ofRD

S (RR

0.63), NEC (RR

0.23),0.23), IVHIVH (RR(RR 0.59), jaundice (RR 0.73)0.59), jaundice (RR 0.73)

Fewer maternal side effects (RR 0.14)Fewer maternal side effects (RR 0.14)


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NIFEDIPINE :NIFEDIPINE :

MATERNAL SIDEEFFECTSMATERNAL SIDEEFFECTSPeripheral vasodilator:Peripheral vasodilator:

Nausea, flushing, headacheNausea, flushing, headache

PalpitationsPalpitations

Reduction in MAP, reflex tachycardiaReduction in MAP, reflex tachycardia

Rarely severe hypotensionRarely severe hypotension


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FETAL SIDEEFFECTSFETAL SIDEEFFECTSAnimal studies: reduced uterineAnimal studies: reduced uterine andand

umbilicalumbilical blood flowblood flow

No evidence of toxicity in humansNo evidence of toxicity in humans


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CONTRAINDICATIONSCONTRAINDICATIONS KnownKnown allergyallergy

LV dysfunction or cardiac failureLV dysfunction or cardiac failure

Hepatic dysfunctionHepatic dysfunction

Concomitant use ofConcomitant use of magnesium:magnesium:respiratoryrespiratory paralysisparalysis


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MagnesiumMagnesium sulphatesulphate

Prevents influx of calcium into thePrevents influx of calcium into themyometrialmyometrial cellcell

4 g loading dose in 250 ml RL over 204 g loading dose in 250 ml RL over 20minsmins

MaintenanceMaintenance-- 40 g in 1 l RL40 g in 1 l RL-- 50 ml/50 ml/hrhr

(2g/(2g/hrhr)) Serum levelsSerum levels-- 44--8 mg8 mg

Continued for 24Continued for 24-- 48 hours48 hours


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Side effectsSide effects

MaternalMaternal

Patellar reflexes disappearPatellar reflexes disappear-- 1010 meqmeq/l/l

Respiratory depressionRespiratory depression-- 1212--15meq/l15meq/l

Cardiac arrestCardiac arrest-- 15meq/l15meq/l

FetalFetal-- crosses the placentacrosses the placenta

Loss of beat to beat variabilityLoss of beat to beat variability Respiratory depressionRespiratory depression


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IndomethacinIndomethacin ProstaglandinProstaglandin synthetasesynthetase inhibitorinhibitor

100 mg rectal suppository100 mg rectal suppository

Repeat at 8Repeat at 8--12 hour intervals or 25 mg oral12 hour intervals or 25 mg oral

every 6 hoursevery 6 hours UptoUpto 24 hours24 hours

Side effectsSide effects-- Premature closure ofPremature closure of ductusductusarteriosusarteriosus

NeuronalNeuronal micronecrosismicronecrosis OligohydramniosOligohydramnios

Delay in pulmonary maturationDelay in pulmonary maturation


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ROUTINEANTIBIOTICSINPRETERMROUTINEANTIBIOTICSINPRETERMLABOUR WITHINTACTMEMBRANESLABOUR WITHINTACTMEMBRANES

Results of ORACLE and metaResults of ORACLE and meta--analysis:analysis:

No improvement in neonatalNo improvement in neonatal

outcomesoutcomes

Reduction in maternal infection (RRReduction in maternal infection (RR0.74)0.74)

Uncertainty about optimal antibioticsUncertainty about optimal antibioticsand regimeand regime


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MANAGEMENT FOLLOWINGMANAGEMENT FOLLOWINGSUCCESSFULSUCCESSFUL

TOCOLYSISTOCOLYSIS

Optimal approach unknownOptimal approach unknown limitedlimiteddatadata

ProlongedProlonged hospitalisationhospitalisation probably ofprobably ofno valueno value

Bed rest not proven effectiveBed rest not proven effective

Avoid physically demanding workAvoid physically demanding work


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MANAGEMENT FOLLOWINGTOCOLYSIS:MANAGEMENT FOLLOWINGTOCOLYSIS:SEXUAL ACTIVITYSEXUAL ACTIVITY

Observational data onlyObservational data only

HigherHigher mortality amongst infectedmortality amongst infected

infants associatedinfants associated with recent coitus:with recent coitus:11%11% vsvs 2.4%2.4%

IncreasedIncreased rates or RDS, jaundice, lowrates or RDS, jaundice, lowApgar scoresApgar scores (x 2)(x 2)

EffectEffect stronger among preterm birthsstronger among preterm births

PrudentPrudent to suggest avoidance of coitusto suggest avoidance of coitusafter successfulafter successful tocolysistocolysis


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MANAGEMENT FOLLOWINGTOCOLYSIS:MANAGEMENT FOLLOWINGTOCOLYSIS:MAINTENANCETOCOLYSISMAINTENANCETOCOLYSIS

MostRCTs are smallMostRCTs are small

EndogenousEndogenous prostaglandins mayprostaglandins may

increase oxytocinincrease oxytocin receptor densityreceptor density

CochraneCochrane review of maintenance oralreview of maintenance oralbeta agonists: nobeta agonists: no significant benefitssignificant benefits

MayMay be useful for temporary relief ofbe useful for temporary relief ofpainful contractionspainful contractions


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MANAGEMENT FOLLOWINGTOCOLYSIS:MANAGEMENT FOLLOWINGTOCOLYSIS:REPEATED COURSESOF ANTENATALREPEATED COURSESOF ANTENATAL

STEROIDSSTEROIDS

Repeat courses of steroids improveRepeat courses of steroids improve neonatalneonatalpulmonarypulmonary outcomes, especially inoutcomes, especially in earlierearlier

gestationalgestational agesages EvidenceEvidence of delayed neuronal maturationof delayed neuronal maturation

and increasedand increased risk ofIUGR in animal studiesrisk ofIUGR in animal studies

Humans

Humans: reduced birth weight only with 4: reduced birth weight only with 4 orormoremore coursescourses

CatchCatch--upup growth by time of dischargegrowth by time of discharge fromfromhospitalhospital


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MANAGEMENT FOLLOWINGTOCOLYSIS:MANAGEMENT FOLLOWINGTOCOLYSIS:REPEATED COURSESOF ANTENATALREPEATED COURSESOF ANTENATAL

STEROIDSSTEROIDS

LongLong--termterm neuroneuro--developmental datadevelopmental datanot availablenot available

OptimalOptimal number of courses ofnumber of courses of steroidssteroidsunknownunknown

TwoTwo courses probably safecourses probably safe


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MANAGEMENT FOLLOWINGMANAGEMENT FOLLOWINGTOCOLYSIS: RISKTOCOLYSIS: RISKOF IUGROF IUGR

Threatened PTL may be an indication ofThreatened PTL may be an indication offetal stressfetal stress arising fromarising from unfavourableunfavourableintrauterine environmentintrauterine environment..

PlacentalPlacental pathology: increased incidencepathology: increased incidenceof fetalof fetal or maternal vascular lesionsor maternal vascular lesionswithout inflammationwithout inflammation

RiskRisk of giving birth to SGA infant (ORof giving birth to SGA infant (OR

2.2)2.2) NeedNeed closer surveillance with USS forcloser surveillance with USS for

growth andgrowth and Doppler studiesDoppler studies

bb


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LabourLabour

Premature infants tolerate stress andPremature infants tolerate stress andhypoxia less well than term infantshypoxia less well than term infants

Aims ofAims of manangementmanangement

Adequate fetal oxygenation during deliveryAdequate fetal oxygenation during delivery

Prevention of traumatic deliveryPrevention of traumatic delivery

Skilled resuscitative team present at birthSkilled resuscitative team present at birth

Continuous electronic fetal monitoringContinuous electronic fetal monitoring Scalp blood sampling when indicatedScalp blood sampling when indicated


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DeliveryDelivery

Birth should be gentle and slow toBirth should be gentle and slow toavoid rapid compression andavoid rapid compression anddecompression of the headdecompression of the head

Membranes should not be rupturedMembranes should not be rupturedartificiallyartificially

Episiotomy may be indicatedEpisiotomy may be indicated

Low forceps may be used to guide theLow forceps may be used to guide thehead over the perineumhead over the perineum


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THANK YOUTHANK YOU


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preterm labour mine

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