INTRODUCTION

My self-Sujit Kumar Nath M. Sc Nursing 1st Year student Tripura Institute of

Paramedical Science. I was posted in IGM Hospital, Labor room. Here I got a patient
who is suffering from lower abdominal pain, Leaking per vagina. I have taken this case
for my care plan.

HISTORY COLLECTION
DATA COLLECTION—
Name of the mother : - Joba Sutradhar

Age of the mother : -22yrs

Obstetrical score : -G1P0A0L0

Antenatal diagnosis : -Primigravida

Last menstrual period : -16/9/23

Expected date of delivery : -23/06/24

Date of admission : - 19/06/24

Gestational age (as on date of admission): -39 weeks 3 da y s

Name of the husband : - Pradip Sutradhar

Age of the husband : - 27 years

Language spoken : -Bengali

Religion : - Hindu

Address : - Pratapgarh,Agartala

SOCIO ECONOMIC HISTORY—

Head of the family: Her husband

Income: Rs. 30,000/month.

House type: Pucca

Water supply: Tap water

 Electricity: Available

Ventilation: Available, cross ventilation is present

Sanitation: Sanitary latrine is present.

Drainage system: Open drainage system is present

FAMILY HISTORY—

Type of Family - Nuclear family.

No of family member- 4

History of consanguineous marriage-Absent

History of hereditary illness- Absent

FAMILY COMPOSITION—

S AG RELATIONSHIP EDUCATIO OCCUPATIO HEALTH

L NAME E WITH PATIENT N N STATUS
N AN
O D
SEX
1 Pranesh 52 Father-i n-l a w IX passed Business Healthy
Sutradhar years

2 Basanti Roy 44 Mother-in-law VIII passed House wife Healthy

years

3 Pradip 27 Husband X passed Business Healthy

Sutradhar years

4 Jaya 22 Patient himself XII passed House wife Unhealthy

Sutradha years
r
FAMILY TREE—

Lt.Paresh Lt. Maya rani Paul

Pranesh Sutradhar, 52 yrs. Basanti Roy, 44 yrs.

Pradip Sutradhar, 27 yrs. Jaya Sutradhar, 22 yrs.

(Husband) (Patient)

New born boy baby

KEY POINT: -

= Male (Grandfather in law)

= Female (Grandmother in law)

= Male

= Female

= Female (Patient)
 PERSONAL HISTORY-
Nutrition-She is non vegetarian; she takes 3 times meals. she also takes extra diet in breakfast and
evening tea and snacks.

Education- Her educational qualification is XII passed

Rest and sleep-7-8 hours per
Daily Activity-She do some home activity
Habits and hobbies-she like watch to TV in free time
Hygiene-She maintain her personal hygiene
Menstrual history-
Age of Menarche-13 yrs.
Duration-4 to 5 days
Flow-Normal
LMP-16\09\23

Marital history-

Married-2 Years ago

Relationship with husband-Good

Consanguineous Marriage-Absent
Contraception history- she not uses any contraceptive device
Drug history- she not takes any drug or medicine in before pregnancy
Sexual history- Her sexual life is normal
Elimination history- She passed urine 4-5 times per day
She passed stool 1-2 times per day

PAST MEDICAL HISTORY-

There is no significant of any past medical history except of common cold and cough.

SURGICAL HISTORY—

There is no significant of any past surgical history

PRESENT MEDICAL HISTORY

Patient was admitted in IGM Hospital with complain of pain in lower abdomen (labor pain),
Leaking per vagina.

PAST OBSTETRICAL HISTORY:

Mother is primi gravida

GENERAL PHYSICAL EXAMINATION: -

General appearance-

Body Built - Thin

Activity – Dul

Posture-Normal

Pallor- Present

Consciousness - Patient is Conscious

Skin:

Colour-Patient skin colour is pallor.

Moisture-Skin moisture is dry

Texture-Skin texture is dry.

Edema- Edema is absent.

Head:

Hair-Hair colour is black, equally distributed

Scalp-Scalp is clear, dandruff absent.

Face: Anxiousness is present

Eyes

Eye brows-symmetrical

Eye lids- Eye lids is normal,

Eye lashes - Eye lashes is equally distributed

Eye balls- Eye balls is movable

Sclera-Sclera is normal whitish colour

Conjunctiva -conjunctiva is slight white

Pupils - Pupils is react with light

Vision-Normal

Nose

Nasal Septum- Not deviated

Nostril- Nostril is normal.

EARS

External Ear - External car is normal absent of any discharge.

Gross hearing- Gross hearing normal

Pinna - Pinna is symmetrical.

Discharge - Discharge absent.

MOUTH

Lips- Lips are dry.

Gums-Gums are normal and gingivitis absent

Teeth-Teeth are whitish and equally distributed

Tongue - Tongue are normal but slight white in colour

Throat - Throat are normal

Neck:

Range of motion-Range of motion normal

Thyroid gland-Thyroid glands are not enlarged

Lymph nodes - Lymph nodes are not enlarged

Chest:

Inspection

Shape-chest shape is normal. Symmetry of expansion

Breast - Primary and secondary areola present Montgomery tubercles are also present

, nipples are erected.

Palpation-Absence of any abnormal mass

Auscultation-S1andS2 sound are present

Abdomen:

Inspection: -

Size-Normal

Shape-cylindrical shape

Linea nigra-present

Striae gravidrum – Present

Umbilicus - Protruded.

Scar marks-Absent.
Palpation:

Abdominal girth-80 com

Fundal height-32 cm

Fundal palpation-Broad irregular mass I felt, suggest as buttock of fetus.

Lateral Palpation:

Left Side-Smooth and continuous resistant is felt suggest as back of fetus.

Right Side-Knob like Structure are present Suggest as limbs.

Pelvic Grip- The fetal head is not engaged

Pawlick grip: In the Pawlick grip smooth hand felt, suggest of fetal head is present in the

lower part of uterus.

Auscultation:

Fetal Heart Sound-130 b/min

Finding of the abdominal Examination

Lie-Longitudinal

Presentation-Cephalic presentation.

Attitude-flexion

Position - LOA

Denomination-occiput
 Extremity

Upper capillary refill - Normal.

Numbness- Absent.

Range of motion-Performed, but dull.

Nails: Nails are clean and short

Lower:

Range of motion-very dull

Edema-Absent.

varicosity-Absent.

Homan's sign-pain absent.

Back:
Curves- Absent, Lordosis on kyphosis are absent

Genito urinary system:

Discharge- Present

Bleeding -Absent

Vulva- Normal
.
INVESTIGATION: -

DATE INVESTIGATION MOTHERS NORMAL REMARKS

VALUE VALUE
19/06/24 Hemoglobin 11.9 gm 12-13 gm Low

19/06/24 Blood group O (+VE)

19/06/24 RBS 87mg/dl 80-110mg/dl Normal

15/01/24 VDRL/HBsAg NR

15/01/24 HIV NR

19/06/24 Urea 17.23mg/dl 14-40mg/dl Normal

19/06/24 Creatinine 0.74mg/dl 0.6-1.1mg/dl Normal

19/06/24 Urine for Sugar Absent

19/06/24 Albumin Absent

LABOUR PROGRESS CHART:

SUMMARY OF LABOUR:

Contractions commenced on -20/06/24 at 6 Am

Membranes ruptured at-20/06/24 at 8 am

Condition of liquor is normal

Expulsive contractions commenced at -20/06/24 at 10 am

Date and time of delivery on 20/06/24 at 12.30 pm

Delivery of the placenta at -20/06/24 at 12.40 pm

Weight of the placenta: -500 gm

Length of the cord: -48 cm

Episiotomy type: -j type

Bleeding PV: Present (Normal bleeding)

Condition of the uterus: -Involution started of the uterus

Drugs given: Ing oxytocin 10-unit IM

LENGTH OF LABOUR:

I STAGE= Six hours

II STAGE= One hour

III STAGE = 15 minute

Total = Seven hour fifteen minutes.

 CONDITION AFTER DELIVERY :

Mother:

Pulse-76 b/min

BP-130/80 mmHg

Uterus-The condition of the uterus is normal

Vaginal Bleeding-Normal

BABY:-

Sex-Male

Weight-2.8 kg

Length-44 cm

Head circumference-32 cm

Chest circumference-31 cm

Mother and baby transferred to post-natal word

 THE THIRD STAGE OF LABOUR

The third stage of labour begins with the birth of the baby and ends with the delivery of the
placenta and fetal membranes. Normally, it should last less than 30 minutes.

Natural processes during the third stage

In a complication-free labour, the third stage is when natural physiological processes

spontaneously deliver the placenta and fetal membranes. For this to happen
unproblematically, the cervix must remain open and there needs to be good uterine
contraction. In the majority of cases, the processes occur in the following order:

1. Separation of the placenta: The placenta separates from the wall of uterus. As it detaches,
blood from the tiny vessels in the placental bed begins to clot between the placenta and the
muscular wall of the uterus (the myometrium).

2. Descent of the placenta: After separation, the placenta moves down the birth canal and
through the dilated cervix

3. Expulsion of the placenta: The placenta is completely expelled from the birth canal

This expulsion marks the end of the third stage of labour. Thereafter, the muscles of the
uterus continue to contract powerfully and thus compress the torn blood vessels. This,
(together with blood clotting) quickly reduces and stops the postpartum bleeding.
(a) Placenta not separated at the beginning of third stage. (b) Placenta begins separating and a
blood clot forms behind it. (c) Placenta descending through the cervix. (d) Placenta
completely expelled marks the end of third stage; the uterus contracts powerfully.

Common complications of third stage of labour

Retained placenta

The placenta remains inside the uterus for longer than 30 minutes after delivery of the baby,
usually due to one or more of the following:

 Uterine contractions may be inadequate to expel the placenta

 The cervix might have retracted too fast and partially closed, trapping the placenta in the
uterus

 The bladder may be full and obstructing placental delivery.

Excessive bleeding (PPH)

PPH is the loss of more than 500 ml of blood following delivery of the baby. Most bleeding
comes from where the placenta was attached to the uterus, and is bright or dark blood and
usually thick. PPH occurs when the uterus fails to contract well, usually due to:
 Partially separated placenta (it remains partly attached to the uterine wall

 Completely separated placenta, but retained inside the uterus

 Atonic uterus; the muscular wall of the uterus could not contract powerfully enough to
arrest the natural bleeding which occurs when the placenta separates.

Uterine inversion

The uterus is pulled ‘inside out’ as the baby or the placenta is delivered, and partly emerges
through the vagina.

Active management of third stage of labour (AMTSL)

A birth attendant applying active management of third stage of labour (AMTSL) is the
key to reducing the risk of the complications

The term ‘active management’ indicates that waiting for spontaneous placental delivery.
Rather, intervene in a carefully programmed sequential manner, as follows:

 As soon as the baby is delivered, put it on the mother’s abdomen in skin-to-skin contact with
her. Cover them with a blanket.

 Clamp the baby’s umbilical cord at two sites and cut it in between

The six steps of AMTSL in sequence

1. Check the uterus for the presence of a second baby.

2. In less than one minute, administer a uterotonic drug (a hormone-like chemical that makes
the uterus contract more powerfully).

3. Apply controlled cord traction.

4. After delivery of the placenta, immediately start massaging the uterus.

5. Examine the placenta to make sure it is complete and none of it has been retained in the
uterus.

6. Examine the woman’s vagina, perineum and external genitalia for lacerations and active
bleeding.

Check the uterus – is there a second baby?

Immediately after the birth of the baby, check for the presence of a second baby by palpating
the uterus through the mother’s abdomen. When feel certain that the uterus does not contain
a second baby, and can feel that it has reduced in size to no larger than at 24 weeks of
gestation, go to step 2. The reason for checking so carefully is because the drug will
administer to the mother in step 2 will make the uterus contract so powerfully that it will
damage a baby that remains inside it. If find that there is a twin, give the uterotonic
drug after the birth of the second baby.

Administer a uterotonic drug to help the uterus contract

The commonly used uterotonic drugs in obstetric practice are:

 misoprostol (tablets)

 oxytocin (injectable)

 ergometrine (injectable).

Dosages of uterotonic drugs

In less than one minute after the delivery of the baby, and after clamping and cutting the
umbilical cord, give the mother one of the following:

 misoprostol 600 micrograms (µg), i.e. three 200 µg tablets by mouth with a drink of water.

OR

 oxytocin 10 international units (IU) injected deep into the woman’s thigh muscles
(intramuscular injection, IM).
 OR

 ergometrine 0.4–0.5 milligrams (mg) injected deep into the woman’s thigh muscles
(intramuscular injection, IM).

When the uterus is well contracted it will feel very hard. This should occur between 2–7
minutes after the administration of the drug, depending on which one is given.

Advantages and disadvantages of the uterotonic drugs

 Shivering: this may start 1 hour after taking misoprostol and will subside after 2–6 hours.
Ask the family to offer the mother warm tea or ‘admit’, as well as blankets.

 Fever: this is rarer, but may start after the shivering. It is not necessarily a sign of infection
and it will disappear within 2–8 hours after taking the drug.

 Diarrhoea: may also occur and normally lasts less than a day.

 Nausea and vomiting: can also occur, but will subside 2–6 hours afterwards.

Step 3 Apply controlled cord traction with counter-pressure

When the uterus is well contracted it will feel very hard. This should occur 2–3 minutes after
the administration of one of the uterotonic drugs. Then controlled cord traction with
counter pressure is used to help to expel the placenta

To avoid inversion of the uterus (turning inside out and coming out of the vagina), controlled
cord traction should NEVER be applied without counter-pressure to the abdomen.
 Controlled cord traction. The right hand is pulling the clamped umbilical cord (making
traction) while the left hand is exerting counter-pressure on the lower abdomen, just above
the pubic bone.

How to do controlled cord traction with counter-pressure

1. Clamp the umbilical cord close to the perineum (once pulsation of the blood vessels stops in
the cord of a healthy newborn) and hold the cord in one hand.

2. Place the other hand just above the woman’s pubic bone and stabilize the uterus by
applying counter-pressure to the abdomen during controlled cord traction.

3. Keep slight tension on the cord and await a strong uterine contraction (usually every 2–3
minutes).

4. With the strong uterine contraction, encourage the mother to push and very gently pull
downward on the cord to deliver the placenta. Continue to apply counter-pressure to the
uterus.

5. Between contractions, gently hold the cord and wait until the uterus is well contracted again.

6. With the next contraction, repeat controlled cord traction with counter-pressure.

7. If the placenta does not descend during 30–40 seconds of controlled cord traction do
not continue to pull on the cord.

8. The following actions complete the rest of the delivery of the placenta.
9. As the placenta is delivered, it should be caught in both hands at the vulva to prevent the
membranes tearing and some being left behind. Hold the placenta in two hands and gently
turn it until the membranes are twisted Slowly pull to complete the delivery of the placenta.
10. Delivery of the placenta.

4 Massage the uterus

Right after the placenta is delivered, rubbing the uterus is a good way to contract it and stop
the bleeding. Many women need their uterus rubbed to help it to contract

Rub the uterus immediately after the birth, then every 15 minutes for 2 hours, then every 30
minutes. Show the woman how to rub her own uterus, or a relative may help.

Step 5 Examine the placenta and fetal membranes

look carefully at the placenta to be sure that none of it is missing.

If a portion of the maternal surface (bottom of the placenta,) is missing, or there are torn
membranes with blood vessels, suspect that retained placenta fragments remain in the uterus
and refer the mother quickly.
 Checking the underside (maternal surface) of the placenta to see if it is intact.

The top of the placenta

Checking the placenta for completeness

1. Hold the placenta in the palms of hands, with the maternal side facing upward. Make sure
that all the lobules are present and fit together.

2. Then hold the cord with one hand, allowing the placenta and membranes to hang down.

3. Place the other hand inside the membranes, spreading the fingers out, to make sure that the
membranes are complete
 Hold the membranes open like this to check they are complete.

4. Ensure that the position of cord attachment to the placenta is normal, and inspect the cut end
of the cord for the presence of two arteries and one vein.

The cut end of the cord has two arteries and one vein.

1. Safely dispose of the placenta by either burying it where it will not be dug up by animals, or
incinerate it if you have the facilities to do so in your community.

2. If the membranes tear, gently examine the upper vagina and cervix of the woman. You must
wear sterile/disinfected gloves and use a sponge forceps to remove any pieces of membrane
that are present.

It is dangerous for the mother if any parts of the placenta or membranes are left behind in the
uterus.
 Placental examination (using a dummy placenta) demonstrating correct inspection of the
maternal surface (underside). The lobes should complete: no tear or sign of breakage when
the placenta is stretched flat over the health worker’s hand.

Step 6 Examining for cuts, tears and bleeding

A deep tear in the vagina can lead to postpartum haemorrhage.

1. Gently separate the labia and inspect the lower vagina and perineum for lacerations that may
need to be repaired to prevent further blood loss.

2. Gently cleanse the vulva and perineum with boiled (then cooled) warm water or a weak
antiseptic solution.

3. Apply a clean pad or cloth with firm pressure to the area that is bleeding for about 10
minutes. If bleeding continues after this time, refer the woman immediately, keeping the
pressure applied to the wound.

4. Monitor the woman every 15 minutes - this means measuring her vital signs, massaging her
uterus to ensure that it is contracted and checking for excessive vaginal bleeding.
 Intervention in complications after applying AMTSL

Excessive bleeding (postpartum haemorrhage or PPH)

Excessive bleeding and the actions to take if the woman has postpartum haemorrhage (PPH).

 Rubbing the uterus and (if you have been trained to do it) using the two-handed pressure
method

 Giving a second dose of oxytocin 10 IU by intramuscular injection, or a second dose

of misoprostol 400 µg rectally (by pushing the tablets gently into the rectum through the
woman's anus), or by putting the tablets under her tongue where they can slowly dissolve.

 Initiating breastfeeding immediately after delivery: the contractions that expel the milk will
also make the uterus contract.

Retained placenta

Retained placenta is when the placenta remains in the uterus beyond 30 minutes after the
birth of the baby. If this happens:

 Do not attempt further controlled cord traction to separate the placenta.

 Follow the instructions for pre-referral treatment as given above for PPH and get the woman
to a health facility for emergency care as quickly as possible.
 NURSING MANAGEMENT ASSESSMENT

1.Assess the patient pain level

2.Assess the fluid level of the patient

3.Assess the activity level of the patient

4.Assess the nutrition of the patient

5.Assess the knowledge level of the patient

NURSING DIAGNOSIS

1. Acute pain related to progress of labour as evidence by facial expression

2. Activity intolerance related to labour pain or episiotomy wound pain as evidence by

general observation.

3. In affective fluid volume related to less intake of fluid and loss of blood as evidence by

feeling of thirst.

4. Impaired nutrition level less than body requirement related to in adequate intake of

essential nutrition as evidence by weakness.

5. Knowledge deficit related to the cause sign and symptoms and treatment process as evidence

by asking frequent question.

THEORY APPLICATION

Mrs. Joba Sutradhar was admitted in the IGM hospital. She is primi mother. suffering lower
abdominal and episiotomy wound pain,weakness.So she cannot do care himself due to her
condition. She needs support from others to perform daily living activities. So, I applied
Dorothea Orem’s self-care Deficit Theory for my patient while caring him to improve her
health status by setting the goals with both the nurse and the patient’s mutual understanding.

According to Dorothea Orem the conceptual frame work is

SELF CARE

R R

SELF
R THERAPEUTIC
CAPABILITIES
SELF CARE
(SELF CARE
DEMAND
AGENENCY)

R R

NURSING
CAPABILITIES
(NURSING AGENCY)
IN MY PATIENTS CONDITION THE FRAMEWORK ARE AS FOLLOWING

SELF CARE

R R

SELF
CAPABILITI THERAP
ES EUTIC
(SELF CARE SELF
CARE
AGENENCY
) DEMAND
NURSING
Limited CAPABILITIES
activity  Activity
 In
(NURSING
Risk of AGENCY)
infection


activity
 Nursing care plan

Assess Nursing Goal Planning Rational Implement Evalua

ment diagnosis tion tion

SUBJECTI Acute pain To -To assess the -To know Assessed the Patients pain
VE related to reduce type ,duration the pain level. level is
DATA episiotomy as the pain , severity of baseline -Provided slightly
Patient says evidence by level pain. data. comfortable reduced in
that I am patient -Provide -To position. some extent
heaving pain verbalization comfortable minimize -provided
in lower position. the pain diversional
abdomen -Provide level. therapy and
OBJECTIV diversional -To divert psychological
E DATA therapy and the main support.
Patient looks psychological from pain. -Administered
dull support. -To reduce medication
-Administer the pain
medication as level.
per as doctors
order.
ASSESS NURSING GOAL PLAN RATI IMPLE EVAL
MENT DIGNOSIS NING ONAL MENT UATION
ATION

SUBJECTIVE Activity To -Assess the It will -Assessed the Patient

DATA intolerance increase activity level help to activity level maintained
Patient related to the of the patient. collect of the patient. normal
complain that pain, as activity -Arrange all base line -Arranged all activity
she is evidence by level the article data for the article near level.
feel Pain and facial near the case the patient
not interest to expression,an patient side. study. side.
do any work xirty -Give -It will -Patient feel
OBJECTIVE psychological help to relax
DATA support. promote
Patient is activity
look weak and level of
anxious. the
patient.

-It will
also help
to
promote
activity
level of
the
patient.
ASSESS NURSING GOAL PLANNING RATIONAL IMPLEME EVALUA
MENT DIAGN NTATION TION
OSIS
SUBJECTIVE Deficit To -Assess the -To assess -Assessed the Patient’s fluid
DATA fluid maintain fluid level of the fluid fluid level of level will be
Patient volume Fluid patient level patient maintained
complain that related to volume -Advice to -To -Advised to
I am thirsty excessive patient to maintain patient to take
OBJECTIVE blood loss take large normal fluid large amount
DATA after amount of volume of fluid
Patient is delivery fluid level -advised the
dehydrated -Advice the -To patient to take
patient to maintain fruit juice
take fruit normal fluid
-advised the
juice volume
patient to take
level
-Advice the fruits juice
-To
patient to -Maintained
maintain
take fruits intake and out
normal fluid
juice put chart
level
-Maintain
intake and
out put chart
 HEALTH EDUCATION:-

Nutrition and dietary pattern:-

 Provide nutritious balance diet to the patient.

 Advice the family members give proper position to the patient before giving
food.
 Provide liquid and light diet to the patient.
 To take plenty of water and fluid.
Rest and Sleep:-
 To take adequate rest and sleep.
 Sleep about 8-10 hours per day.
Care of Breast:-
 To clean the nipple and breast

Personal hygiene:

 Advised the patient and family members to wash hands

before and after giving breast milk.
 Advised the patient to brush the teeth twice a day bath daily.
 Advised the patient to wash clothes regularly
 To clean the perineal area.

Exercise:

 Encouraged the patient to do some active and passive exercise.

 Advice the patient to do deep breathing exercise.

Medication:

 Advised the patient to take medicine at proper time without forgetting.

  Encouraged the patient to complete the full dose as ordered by the
physician/surgeon.
Immunization:
 Advised mother about the importance of immunization.
 To take baby’s immunization as per immunization schedule.
Follow up care:

 Advised the patient to come for regular check-up.

 Advised the family members to provide psychological support to the patient.
CONCLUSION

The third stage of labor has traditionally been defined as the time between the birth of the
baby and the delivery of the placenta and membranes. It is the third stage that is the most
perilous for the woman because of the risk of postpartum hemorrhage (PPH). Active
management of third stage of labour (AMTSL) is the best intervention to reduce the risk of
PPH by more than 60%. Therefore, AMTSL has to be applied routinely (to all delivering
mothers). Common complications that can occur during third stage of labour include
retained placenta, postpartum haemorrhage and uterine inversion. Administer misoprostol
or oxytocin within one minute of the delivery of the baby. A well-contracted uterus is felt
as firm to hard, well delineated and with no active vaginal bleeding, unless the source of
bleeding is due to tear or lacerations of the lower genital area.
BIBLIOGRAPHY

1. Bhaskar Nima. “Midwifery and Gynecological Nursing”: A NURSING

PROCESS APPROACH. Volume 1. 1st edition, New Delhi: The Trained Nurses'
Association of India; 2013. P. 1145-1149.
2. Chintamani. Mani M, Lewis SL, Heitkemper MM, Dirksen SR, O'Brien PG,
Bucher L editors. “Textbook of Obstetrics and Gynecology”. New Delhi: Elsevier
India Pvt Ltd; 2011. P. 613-618

3. Sharma JB, “Textbook of Obstetrics, Avichal publishing Company”, 2nd edition,

page no. 504- 514

4. Murray Sharon Et Al. “Foundations of Maternal-Newborn and Women’s Health

Nursing”.7th Edition. Elsevier Publication. 2019.Page No.454-461.
5. Konar Hiralal. D.C Dutta's “Textbook of Obstetrics”. 10th ed. New Delhi:
Wolters Kluwer (India) Pvt Ltd; 2013. P. 697-703.
6. E. Malcolm Symonds & Ian. M. Symonds, “Essential obstetrics and gynecology”
page no: 107-110.