The fetal skull is characterized by a number of landmarks.

Moving from front to back, they include

the following (Figure 9-2):

1. Nasion (the root of the nose)

2. Glabella (the elevated area between the orbital ridges)
3. Sinciput (brow) (the area between the anterior fontanelle and the glabella)
4. Anterior fontanelle (bregma)-diamond shaped
5. Vertex (the area between the fontanelles and bounded laterally by the parietal
eminences)
6. Posterior fontanelle (lambda)-Y- or T-shaped
7. Occiput (the area behind and inferior to the posterior fontanelle and lambdoid sutures)

Diameters

Several diameters of the fetal skull are important (see Figures 9-1 and 9-2). The anteroposterior
diameter presenting to the maternal pelvis depends on the degree of flexion or extension of the
head and is important because the various diameters differ in length. The following measurements
are considered average for a term fetus:

1. Suboccipitobregmatic (9.5 cm), the presenting anteroposterior diameter when the head is well
flexed, as in an occipitotransverse or occipitoanterior position. It extends from the undersurface of
the occipital bone at the junction with the neck to the center of the anterior fontanelle.

2. Occipitofrontal (11 cm), the presenting anteroposterior diameter when the head is deflexed, as
in an occipitoposterior presentation; it extends from the external occipital protuberance to the
glabella.

3. Supraoccipitomental (13.5 cm), the presenting anteroposterior diameter in a brow

presentation and the longest anteroposterior diameter of the head; it extends from the vertex to
the chin.

4. Submentobregmatic (9.5 cm), the presenting anteroposterior diameter in face presentations; it

extends from the junction of the neck and lower jaw to the center of the anterior fontanelle.

The transverse diameters of the fetal skull are as follows:

1. Biparietal (9.5 cm), the largest transverse diameter; it extends between the temporal
bones.
2. Bitemporal (8 cm), the shortest transverse diameter; it extends between the temporal
bones.

The average circumference of the term fetal head, measured in the occipitofrontal plane, is 34.5
cm
Pelvis: está limitada por su parte superior por el estrecho superior de la pelvis. En su parte inferior
por el estrecho inferior de la pelvis, en su parte posterior por el cóccix y en la parte anterior por la
sínfisis del pubis.

La pelvis está compuesta por dos huesos coxales o innonimados, por el sacro y el cóccix.

The sacrum consists of five fused vertebrae. The anterior superior edge of the first sacral
vertebra is called the promontory, which protrudes slightly into the cavity of the pelvis.
The anterior surface of the sacrum is usually concave. It articulates with the ilium at its
upper segment, with the coccyx at its lower segment, and with the sacrospinous and
sacrotuberous ligaments laterally.

The coccyx is composed of three to five rudimentary vertebrae. It articulates with the
sacrum forming a joint, and occasionally the bones are fused.

The pelvis is divided into the false pelvis above and the true pelvis below the linea
terminalis. The false pelvis is bordered by the lumbar vertebrae posteriorly, an iliac fossa
bilaterally, and the abdominal wall anteriorly. Its only obstetric function is to support the
pregnant uterus.

The true pelvis is a bony canal and is forme d by the sacrum and coccyx posteriorly
and by the ischium and pubis late rally and anteriorly. Its internal borders are solid and
relatively immobile. The posterior wall is twice the length of the anterior wall. The true
pelvis is the area of concern to the obstetrician because its dimensions are sometimes not
adequate to permit passage of the fetus.

Pelvic Planes

The pelvis is divided into the following four planes for descriptive purposes :

1. The pelvic inlet

2. The plane of greatest diameter
3. The plane of least diameter
4. The pelvic outlet

These planes are imaginary, flat surfaces that extend across the pelvis at different levels.
Except for the plane of greatest diameter, each plane is clinically significant.

The plane of the inlet is bordered by the pubic crest anteriorly, the iliopectineal line of the
innominate bones laterally, and the promontory of the sacrum posteriorly. The fetal head
enters the pelvis through this plane in the transverse position.

The plane of greatest diameter is the largest part of the pelvic cavity. It is bordered by the
posterior midpoint of the pubis anteriorly, the upper part of the obturator foramina laterally,
and the junction of the 2nd and 3rd sacral vertebrae posteriorly. The fetal head rotates to the
anterior position in this plane.
The plane of least diameter is the most important from a clinical standpoint, because most
instances of arrest of descent occur at this level. It is bordered by the lower edge of the
pubis anteriorly, the ischial spines and sacrospinous ligaments laterally, and the lower
sacrum posteriorly. Low transverse arrests generally occur in this plane.

The plane of the pelvic outlet is formed by two triangular planes with a common base at
the level of the ischial tuberosities. The anterior triangle is bordered by the subpubic angle
at the apex, the pubic rami on the sides, and the bituberous diameter at the base. The
posterior triangle is bordered by the sacrococcygeal joint at its apex, the sacrotuberous
ligaments on the sides, and the bituberous diameter at the base. This plane is the site of a
low pelvic arrest.

Pelvic Diameters

The diameters of the pelvic planes represent the amount of space available at each level.
The key measurements for assessing the capacity of the maternal pelvis include the
following:

1. The obstetric conjugate of the inlet

2. The bispinous diameter
3. The bituberous diameter
4. The posterior sagittal diameter at all levels
5. The curve and length of the sacrum
6. The subpubic angle

The pelvic inlet has five important diameters (Figure 9-3). The anteroposterior diameter is
described by one of two measurements. The true conjugate (anatomic conjugate) is the anatomic
diameter and extends from the middle of the sacral promontory to the superior surface of the
pubic symphysis. The obstetric conjugate represents the actual space available to the fetus and
extends from the middle of the sacral promontory to the closest point on the convex posterior
surface of the symphysis pubis.

The transverse diameter is the widest distance between the iliopectineal lines. Each oblique
diameter extends from the sacroiliac joint to the opposite iliopectineal eminence.

The posterior sagittal diameter extends from the anteroposterior and transverse intersection to
the middle of the sacral promontory

Plane of Greatest Diameter: The plane of greatest diameter has two noteworthy diameters. The
anteroposterior diameter extends from the midpoint of the posterior surface of the pubis to the
junction of the 2nd and 3rd sacral vertebrae.

Plane of Least Diameter (Midplane): The plane of least diameter has three important diameters.
The anteroposterior diameter extends from the lower border of the pubis to the junction of the
fourth and fifth sacral vertebrae. The transverse (bispinous) diameter extends between the ischial
spines. The posterior sagittal diameter extends from the midpoint of the bispinous diameter to
the junction of the fourth and fifth sacral vertebrae.

Pelvic Outlet: The pelvic outlet has four important diameters (Figure 9-4). The anatomic
anteroposterior diameter extends from the inferior margin of the pubis to the tip of the coccyx,
whereas the obstetric anteroposterior diameter extends from the inferior margin of the pubis to
the sacrococcygeal joint. The transverse (bituberous) diameter extends between the inner
surfaces of the ischial tuberosities, and the posterior sagittal diameter extends from the middle of
the transverse diameter to the sacrococcygeal joint

The clinical evaluation is started by assessing the pelvic inlet. The pelvic inlet can be evaluated
clinically for its anteroposterior diameter. The obstetric conjugate can be estimated from the
diagonal conjugate, which is obtained on clinical examination.

La pelvis osea se divide en dos por la línea terminal o ileopectínea y por el promotorio del sacro.

El cóccix se mueve en sentido posterior durante el parto. Todos estos cambios de la pelvis
determinan un aumento de hasta el 10 al 15% de los diámetros (en su mayoría transversales) que
facilitan el paso del feto por el conducto pélvico . El diámetro que no se altera es el verdadero o
conjugado entre el promotorio del sacro y la cara posterosuperior de la sínfisis del pubis.

Bloqueos pudendo e ileoinguinal: Para alviar el dolor del parto se procede a la anestesia del
bloqueo del nervio pudendo, se inyecta un anestésico local en los tejido que rodean el nervio
pudendo. La inyección tiene lugar en el punto donde el nervio pudendo cruza la cara lateral del
ligamento sacroespinoso cerca de su inserción en la espina ciática. Para abolir la sensibilidad de la
parte anterior del perineo se efectua un bloqueo ileoinguinal.

Episiotomia: Incisión quirúrgica del perineo y de la pared inferior y posterior de la vagina para
evitar que el músculo puboccocigeo (parto del m. elevador del ano) se debilite y con ello existan
problemas con las vísceras que sostiene como la vagina, la uretra y el conducto anal.

The anthropoid pelvis resembles that of the anthropoid ape. It is found in approximately
20% of women and has the following characteristics:

1. A much larger anteroposterior than transverse diameter, creating a long narrow oval
at the inlet
2. Side walls that do not converge
3. Ischial spines that are not prominent but are close, owing to the overall shape
4. Variable, but usually posterior, inclination of the sacrum
5. Large sacrosciatic notch
6. Narrow, outwardly shaped subpubic arch

The fetal head can engage only in the anteroposterior diameter and usually does so in the
occipitoposterior position, because there is more space in the posterior pelvis.

Platypelloid
The platypelloid pelvis is best described as being a flattened gynecoid pelvis. It is found in
only 3% of women, and it has the following characteristics:

1. A short anteroposterior and wide transverse diameter creating an oval-shaped inlet

2. Straight or divergent side walls
3. Posterior inclination of a flat sacrum
4. A wide bispinous diameter
5. A wide subpubic arch

The overall shape is that of a gentle curve throughout. The fetal head has to engage in the
transverse diameter

La pelvis osea se divide en una verdadera o menor y en una falsa o mayor que se
encuentran divididas por la línea ileopectínea o líneas trerminales y del promotorio sacrol.
El estrecho superior de la pelvis queda definido por el plano de las líneas terminales.

The greater pelvis (false pelvis, pelvis major) is the part of the pelvis (Fig. 3.2A):

 Superior to the pelvic inlet.

 Bounded by the iliac alae posterolaterally and the anterosuperior aspect of the S1
vertebra posteriorly.
 Occupied by abdominal viscera (e.g., the ileum and sigmoid colon).

The lesser pelvis (true pelvis, pelvis minor) is the part of the pelvis:

 Between the pelvic inlet and the pelvic outlet.

 Bounded by the pelvic surfaces of the hip bones, sacrum, and coccyx.
 That includes the true pelvic cavity and the deep parts of the perineum (perineal
compartment), specifically the ischioanal fossae.
 Of major obstetrical and gynecological significance.

Engagement occurs when the widest diameter of the fetal presenting part has passed
through the pelvic inlet. In cephalic presentations, the widest diameter is biparietal; in
breech presentations, it is intertrochanteric.
The station of the presenting part in the pelvic canal is defined as its level above or
below the plane of the ischial spines. The level of the ischial spines is assigned as "zero"
station, and each centimeter above or below this level is given a minus or plus designation,
respectively.
In the majority of women, the bony presenting part is at the level of the ischial spines
when the head has become engaged. The fetal head usually engages with its sagittal
suture in the transverse diameter of the pelvis. The head position is considered to be
synclitic when the biparietal diameter is parallel to the pelvic plane and the sagittal suture
is midway between the anterior and posterior planes of the pelvis. When this relationship is
not present, the head is considered to be asynclitic (Figure 9-6).
There is a distinct advantage to having the head engage in asynclitism in certain situations.
In a synclitic presentation, the biparietal diameter entering the pelvis measures 9.5 cm; but
when the parietal bones enter the pelvis in an asynclitic manner, the presenting diameter
measures 8.75 cm. Therefore, asynclitism permits a larger head to enter the pelvis than
would be possible in a synclitic presentation.

The first stage is from the onset of true labor to complete dilation of the cervix. The second stage
is from complete dilation of the cervix to the birth of the baby. The third stage is from the birth of
the baby to delivery of the placenta. The fourth stage is from delivery of the placenta to
stabilization of the patient's condition, usually at about 6 hours postpartum.

DESCENT.

Descent is brought about by the force of the uterine contractions, maternal bearing-down
(Valsalva) efforts, and, if the patient is upright, gravity.

FLEXION.

Partial flexion exists before labor as a result of the natural muscle tone of the fetus. During
descent, resistance from the cervix, walls of the pelvis, and pelvic floor cause further flexion of the
cervical spine, with the baby's chin approaching its chest. In the occipitoanterior position, the
effect of flexion is to change the presenting diameter from the occipitofrontal to the smaller
suboccipitobregmatic (see Figure 9-2). In the occipitoposterior position, complete flexion may not
occur, resulting in a larger presenting diameter, which may contribute to a longer labor.

INTERNAL ROTATION.

In the occipitoanterior positions, the fetal head, which enters the pelvis in a transverse or oblique
diameter, rotates so that the occiput turns anteriorly toward the symphysis pubis. Internal
rotation probably occurs as the fetal head meets the muscular sling of the pelvic floor. It is often
not accomplished until the presenting part has reached the level of the ischial spines (zero station)
and therefore is engaged. In the occipitoposterior positions, the fetal head may rotate posteriorly
so the occiput turns toward the hollow of the sacrum. Alternatively, the fetal head may rotate
more than 90 degrees, positioning the occiput under the pubic symphysis and thus converting to
an occipitoanterior position.

EXTENSION.

The flexed head in an occipitoanterior position continues to descend within the pelvis.
Because the vaginal outlet is directed upward and forward, extension must occur before the
head can pass through it. As the head continues its descent, there is bulging of the perineum
followed by crowning. Crowning occurs when the largest diameter of the fetal head is
encircled by the vulvar ring. At this time, the vertex has reached station +5. When
necessary, an incision in the perineum (episiotomy) may aid in reducing perineal
resistance, although current management is to allow the fetus to deliver without an
episiotomy. The head is born by rapid extension as the occiput, sinciput, nose, mouth, and
chin pass over the perineum.

In the occipitoposterior position, the head is born by a combination of flexion and

extension. At the time of crowning, the posterior bony pelvis and the muscular sling
encourage further flexion. The forehead, sinciput, and occiput are born as the fetal chin
approaches the chest. Subsequently, the occiput falls back as the head extends, and the
nose, mouth, and chin are born.

EXTERNAL ROTATION.
In both the occipitoanterior and occipitoposterior positions, the delivered head now returns
to its original position at the time of engagement to align itself with the fetal back and
shoulders. Further head rotation may occur as the shoulders undergo an internal rotation to
align themselves anteroposteriorly within the pelvis.

EXPULSION.

Following external rotation of the head, the anterior shoulder delivers under the symphysis pubis,
followed by the posterior shoulder over the perineal body and the body of the child.

Clinical management of the second stage.

As in the first stage, certain steps should be taken in the clinical management of the second stage
of labor.

MATERNAL POSITION.

With the exception of avoiding the supine position, the mother may assume any comfortable
position for effective bearing down.

BEARING DOWN.

With each contraction, the mother should be encouraged to hold her breath and bear down with
expulsive efforts. This is particularly important for patients with regional anesthesia because their
reflex sensations may be impaired.

FETAL MONITORING.

During the second stage, the fetal heart rate should be monitored continuously or evaluated every
5 minutes in patients with obstetric risk factors. Fetal heart rate decelerations (head compression
or cord compression) with recovery following the uterine contraction may occur normally during
this stage.

VAGINAL EXAMINATION.

Progress should be recorded approximately every 30 minutes during the second stage. Particular
attention should be paid to the descent and flexion of the presenting part, the extent of internal
rotation, and the development of molding or caput. During the second stage of labor, the
retracted cervix is no longer palpable.

DELIVERY OF THE FETUS.

When delivery is imminent, the patient is usually placed in the lithotomy position, and the skin
over the lower abdomen, vulva, anus, and upper thighs is cleansed with an antiseptic solution.
Uncomplicated deliveries, particularly in multiparous women, may be carried out in the supine
position with the thighs flexed. The left lateral position may be used to deliver patients with hip or
knee joint deformities that prevent adequate flexion, or for patients with a superficial or deep
venous thrombosis in one of the lower extremities.

As the perineum becomes flattened by the crowning head, an episiotomy may be performed to
prevent perineal lacerations. Recent studies indicate that the performance of episiotomies may
result in a higher proportion of lacerations that involve the anal sphincter (third degree) or anal
mucosa (fourth degree). Although these more extensive lacerations may be surgically repaire d,
there is an increasing awareness of the occasional complication of anal incontinence of gas or
feces following vaginal delivery.

To facilitate delivery of the fetal head, a Ritgen maneuver is performed (Figure 9-11). The right
hand, draped with a towel, exerts upward pressure through the distended perineal body, first to
the supraorbital ridges and then to the chin. This upward pressure, which increases extension of
the head and prevents it from slipping back between contractions, is counteracted by downward
pressure on the occiput with the left hand. The downward pressure prevents rapid extension of
the head and allows a controlled delivery.

Once the head is delivered, the airway is cleared of blood and amniotic fluid using a bulb suction
device. The oral cavity is cleared initially and then the nares are cleared. Suction of the nares is not
performed if fetal distress or meconium-stained liquor is present because it may result in gasping
and aspiration of pharyngeal contents. A second towel is used to wipe secretions from the face
and head.

After the airway has been cleared, an index finger is used to check whether the umbilical cord
encircles the neck. If so, the cord can usually be slipped over the infant's head. If the cord is too
tight, it can be cut between two clamps.

Following delivery of the head, the shoulders descend and rotate into the anteroposterior
diameter of the pelvis and are delivered (Figure 9-12). Delivery of the anterior shoulder is aided
by gentle downward traction on the externally rotated head. The brachial plexus may be injured
if excessive force is used. The posterior shoulder is delivered by elevating the head. Finally, the
body is slowly extracted by traction on the shoulders.

After delivery, blood will be infused from the placenta into the newborn if the baby is held below
the mother's introitus. Usually, the cord is clamped and cut within 15 to 20 seconds. Delayed cord
clamping can result in neonatal hyperbilirubinemia as additional blood is transferred to the
newborn infant. The newborn is then placed under an infant warmer.

Third Stage of Labor

Immediately after the baby's delivery, the cervix and vagina should be thoroughly inspected
for lacerations and surgical repair performed if necessary. The cervix, vagina, and perineum
may be more readily examined before the separation of the placenta, as no uterine bleeding
should be present to obscure visualization at this time.
Delivery of the placenta.
Separation of the placenta generally occurs within 2 to 10 minutes of the end of the second
stage of labor. Squeezing of the fundus to hasten placental separation is not recommended
because it may increase the likelihood of passage of fetal cells into the maternal circulation.
Signs of placental separation are as follows: (1) a fresh show of blood from the vagina, (2)
the umbilical cord lengthens outside the vagina, (3) the fundus of the uterus rises up, and
(4) the uterus becomes firm and globular. Only when these signs have appeared should the
assistant attempt traction on the cord. With gentle traction and counterpressure between the
symphysis and fundus to prevent descent of the uterus into the pelvis, the placenta is
delivered.
Following delivery of the placenta, attention should be paid to any uterine bleeding that
may originate from the placental implantation site. Uterine contractions, which reduce this
bleeding, may be hastened by uterine massage and the use of oxytocin. It is routine to add
20 U of oxytocin to the intravenous infusion after the baby has been delivered. The placenta
should be examined to ensure its complete removal and to detect placental abnormalities. If
the patient is at risk of postpartum hemorrhage (e.g., because of anemia, prolonged
oxytocic augmentation of labor, multiple gestation, or hydramnios), manual removal of the
placenta, manual exploration of the uterus, or both may be necessary.

Perineal lacerations.
Perineal lacerations, with or without episiotomy, may be classified as follows:

 First degree: A laceration involving the vaginal epithelium or perineal skin

 Second degree: A laceration extending into the subepithelial tissues of the vagina
or perineum with or without involvement of the muscles of the perineal body
 Third degree: A laceration involving the anal sphincter
 Fourth degree: A laceration involving the rectal mucosa

If an episiotomy has been performed (Figure 9-13), it should be repaired as illustrated in Figure 9-
14. Absorbable sutures (00) should be used, and a rectal examination should ensure that the
sutures have not inadvertently transected the rectal mucosa. A third-degree tear (Figure 9-15)
should be repaired as shown in Figure 9-16.

Fourth Stage of Labor

The hour immediately following delivery requires close observation of the patient. Blood pressure,
pulse rate, and uterine blood loss must be monitored closely. It is during this time that postpartum
hemorrhage commonly occurs, usually because of uterine relaxation, retained placental
fragments, or unrepaired lacerations. Occult bleeding (e.g., vaginal hematoma formation) may
manifest as pelvic pain. An increase in pulse rate, often out of proportion to any decrease in blood
pressure, may indicate hypovolemia

TEST DE BISHOP PARA LA INDUCCIÓN Y AUMENTO DEL PARTO

0 1 2 3
CERVIX
POSICION POSTERIOR MEDIO ANTERIOR
CONSISTENCIA FIRME MEDIO BLANDO
BORRAMIENTO, 3CM O 30% 2CM O 40 A 1 CM O 60 A BORRADO O
LONGITUD 50% 70% MAYOR AL
80%
DILATACIÓN 0 1-2CM 3 A 4 CM >5CM
CABEZA FETAL
ESTACIÓN -3 -2 -1 +1

Several mechanical and pharmacologic approaches promote cervical ripening prior to

the actual induction of uterine contractions. Local application of prostaglandins may
be used. Currently approved pharmacologic treatments include intravaginal application of
prostaglandin E2 using a vaginal insert called cervidil (on a string), which can be removed
quickly if the medication causes hyperstimulation. Recently cytotec, a synthetic
prostaglandin E1 analogue, has been approved for cervical ripening. One 25 μg tablet
placed intravaginally has been shown to effectively initiate cervical ripening. Alt hough
prostaglandin administration has been demonstrated to shorten the duration of labor
induction, the impact on cesarean section rates due to failed induction has been minimal.
Other methods of cervical ripening may include intraute rine place ment of catheters
or the use of osmotic dilators (see Figure 27-5). Manual separation of the chorioamnion
from the lower uterine segment does not necessarily speed the onset of labor. Although
controversial, artificial rupture of the membranes may be utilized to increase uterine
activity, and perhaps to speed cervical change, when performed in conjunction with
administration of oxytocin.

>A 7 INDUCCIÓN DIRECTA CON INFUCIÓN DE OXITOCINA

< A 7 MADURACIÓN CERVICAL CON MANIOBRAS MECANICAS COMO LA MANIOBRA DE HAMILTON
QUE CONSISTE EN EL DESPAGAMIENTO DE LAS MEMBRANAS Y PGE2

Table 9-3. Indications and contraindications for induction and augmentation of labor
Induction Augme ntation
INDICATIONS
MATERNAL
Preeclampsia Abnormal labor (in the presence of inadequate uterine
Diabetes mellitus activity)
Heart disease
Prolonged latent phase
Prolonged active phase
 FETOPLACENTAL
Prolonged pregnancy
Intrauterine growth restriction (IUG-R)
Abnormal fetal testing
Rh incompatibility
Fetal abnormality
Premature rupture of membranes (PROM)
Chorioamnionitis
CONTRAINDICATIONS
MATERNAL
ABSOLUTE Same contraindications as for maternal and fetoplacental
Contracted pelvis
RELATIVE
Prior uterine surgery
Classic cesarean section
Complete transection of uterus (myomectomy, reconstruction)
Overdistended uterus
FETOPLACENTAL
Preterm fetus without lung maturity
Acute fetal distress
Abnormal presentation

PRIMERA FASE
-Tricotomía (rasurar vello púbico), previo aseo con agua y jabón
-Antisepsia de la región vulvoperineal
-Evacuación de la ámpula rectal
-Aplicación analgésica obstétrica
-Amniotomía oportuna
- Ayuno desde que inicia el parto y aplicación de venoclisis
-Vigilancia estrecha de todos los signos vitales tanto maternas como fetales
-Posición Semi-fowler o decúbito lateral para evitar el sx supino
-Valoración del tono, la frecuencia y la intensidad de las contracciones
-Exploración vaginal para observar la dilatación del cérvix y progreso de la presentación
-Traslado a la sala de parto

Segunda fase
-Posición ginecológica
-Asepsia y antisepsia ingunio crural, glútea y de la cara interna de los muslos
-Cateterismo vesical
-Equipo para parto
-Oxigenoterapia
-Episitomia media o paramedia con xilocaína
-Control del desprendimiento de la cabeza fetal, permitiendo su deflexión progresiva y paulatina
evitando su descompresión abrupta
-Aspiración de la boca y nariz. Efectuar giro de restitución, favorecer el desprendimiento del
hombro anterior y del posterior con un mov. de ascenso de la cabeza fetal, frenar la expulsión del
tronco y los hombros en caso de cordón umbilical enredado.
-Colocar al bebé en posición horizontal o levemente inclinado con la cabeza hacia abajo y en plano
inferior al del abdomen materno, se pinza y secciona el cordón.
-Se entrega el RN al pediatra para su valoración

TERCERA FASE
-REVISAR LA PLACENTA YTODO LO QUE TENGA
-SE HACE REVISIÓN OBLIGADA DEL CERVIX, LA VAGINA Y EL PERINE
-SE REPARAN DAÑOS COMO LA EPISIOTOMIA Y LAS LESIONES DEL PERINE
-CHECAR SIGNOS VITALES