Midwife Licensure Exam Independent Delivery & Emergency Obstetric Care — Normal Spontaneous Delivery — Independent Conduct & Hands-On TechniqueExam Answer Templates

Marks

1

Topic

Mechanisms of Labor — Flexion

Difficulty

easy

Template Id

T1

Examiner Tip

Examiners want both the NAME of the diameter and the mechanism or measurement. One word alone ('flexion') without 'suboccipitobregmatic' may earn zero on a strict marking key.

Model Answer

The smallest diameter of the fetal head is the suboccipitobregmatic diameter, measuring approximately 9.5 cm. It is achieved when the fetal head is fully flexed (chin on chest).

Question Type

very_short_answer

Answer Structure

• Line 1: Name the diameter (suboccipitobregmatic) and state its measurement (~9.5 cm) [1 mark]

Scoring Breakdown

Common Mark Deductions

• Writing 'occipitofrontal' or 'biparietal' diameter instead of suboccipitobregmatic
• Stating the diameter without linking it to flexion
• Writing an incorrect measurement (e.g., 11 cm or 13 cm)

Key Phrases To Include

• suboccipitobregmatic
• 9.5 cm
• flexion
• chin on chest

Marks

2

Topic

Mechanisms of Labor — Cardinal Movements

Difficulty

easy

Template Id

T2

Examiner Tip

Use the mnemonic ED FIERE during the exam. Examiners check ORDER, not just presence. Even if all 7 are listed but in the wrong sequence, marks will be deducted.

Model Answer

The seven cardinal movements of labor in order are: 1. Engagement 2. Descent 3. Flexion 4. Internal rotation 5. Extension 6. Restitution (External rotation) 7. Expulsion Mnemonic: ED FIERE (Engagement, Descent, Flexion, Internal rotation, Extension, Restitution, Expulsion).

Question Type

short_answer

Answer Structure

• List all 7 movements numbered in correct sequence [2 marks: 1 mark for first 3-4 movements in order, 1 mark for completing the remaining movements correctly]

Scoring Breakdown

Common Mark Deductions

• Reversing 'Extension' and 'Restitution' — a very common error
• Writing 'External rotation' without noting it is also called 'Restitution'
• Omitting 'Descent' because it is easy to forget as it runs throughout labor
• Listing only 5 or 6 movements instead of all 7

Key Phrases To Include

• Engagement
• Descent
• Flexion
• Internal rotation
• Extension
• Restitution
• Expulsion

Marks

2

Topic

Mechanisms of Labor — Extension and Restitution

Difficulty

medium

Template Id

T3

Examiner Tip

A clear, one-sentence definition for each term followed by the clinical significance (what it does) is the most efficient structure for 2-mark differentiation questions.

Model Answer

Extension: The flexed fetal head extends (straightens) under the pubic arch. This is the movement by which the head is actually born — the occiput, bregma, forehead, face, and chin are delivered in sequence. Restitution (External Rotation): After the head is born, it rotates to realign with the fetal shoulders, which are still in the oblique diameter of the pelvis. This rotation returns the head to its natural relationship with the shoulders before the shoulders are delivered.

Question Type

short_answer

Answer Structure

• Sentence 1-2: Define Extension — head extends under pubic arch; HOW the head is born [1 mark]
• Sentence 3-4: Define Restitution — head realigns with shoulders AFTER birth; prepares for shoulder delivery [1 mark]

Scoring Breakdown

Common Mark Deductions

• Confusing extension with expulsion
• Not mentioning that restitution involves the shoulders
• Saying 'the head rotates during extension' — rotation is internal rotation, not extension

Key Phrases To Include

• extends under the pubic arch
• head is born
• realigns with shoulders
• external rotation
• occiput

Marks

3

Topic

Active Management of the Third Stage of Labor

Difficulty

medium

Template Id

T4

Examiner Tip

Examiners award 1 mark per component. If the ORDER is correct and all three are present with key details, you earn all 3 marks. Write as a numbered list so the examiner can check off each point immediately.

Model Answer

The three components of AMTSL in order are: 1. Uterotonic drug — Administer Oxytocin 10 IU intramuscularly (IM) within ONE minute of the baby's birth, after ruling out a second twin. 2. Controlled Cord Traction (CCT) — Using the Brandt-Andrews maneuver: apply counter-traction above the symphysis pubis with one hand while applying steady, gentle downward traction on the cord with the other hand during a uterine contraction. 3. Uterine massage — Immediately after the placenta is delivered, massage the uterine fundus through the abdomen until the uterus is firm and well-contracted.

Question Type

short_answer

Answer Structure

• Point 1: Uterotonic — name the drug, dose, route, and timing [1 mark]
• Point 2: Controlled Cord Traction — include counter-traction and direction of traction [1 mark]
• Point 3: Uterine massage — timing (after placental delivery) and goal (firm, contracted uterus) [1 mark]

Scoring Breakdown

Common Mark Deductions

• Writing the components out of order (e.g., massage before CCT)
• Omitting the dose (10 IU) or route (IM) of oxytocin
• Not mentioning counter-traction — this is the safety element that prevents uterine inversion
• Forgetting to specify WHEN uterine massage is done (after placental delivery, not during CCT)

Key Phrases To Include

• Oxytocin 10 IU IM
• within one minute
• Controlled Cord Traction
• counter-traction
• Brandt-Andrews
• uterine massage
• firm and well-contracted

Marks

3

Topic

AMTSL — Uterotonic Administration Safety

Difficulty

medium

Template Id

T5

Examiner Tip

Case studies reward clinical thinking. The clue in this scenario is the 'large, firm abdomen' — always read the scenario for red flags and respond to them before performing the routine step.

Model Answer

Before administering oxytocin, I should PALPATE the mother's abdomen to rule out a second (undiagnosed) twin. Reason: If a second baby is present and oxytocin is given prematurely, the uterotonic will cause the uterus to contract powerfully around the unborn baby, trapping it inside and causing fetal distress or death. Once a second baby is confirmed absent, give Oxytocin 10 IU IM within one minute of the first baby's birth as the first component of AMTSL.

Question Type

case_study

Answer Structure

• Action: Palpate the abdomen to rule out a second twin [1 mark]
• Reason/rationale: Oxytocin given with a second baby present traps and endangers the unborn baby [1 mark]
• Follow-through: After confirming singleton, give Oxytocin 10 IU IM within 1 minute [1 mark]

Scoring Breakdown

Common Mark Deductions

• Proceeding to give oxytocin without addressing the scenario clue (large, firm abdomen)
• Not explaining the rationale — the 'why' is worth a separate mark
• Writing 'ergometrine' as the drug of choice — oxytocin is always first-line

Key Phrases To Include

• rule out a second twin
• palpate the abdomen
• Oxytocin 10 IU IM
• within one minute
• uterotonic contraction
• trap the unborn baby

Marks

2

Topic

AMTSL — Uterotonic Drugs and Contraindications

Difficulty

medium

Template Id

T6

Examiner Tip

Pharmacology questions in the MLE often pair a contraindication with 'what should you use instead.' Always answer both parts to earn full marks.

Model Answer

Ergometrine (methylergometrine) is contraindicated in pre-eclampsia because it causes severe vasoconstriction and can raise blood pressure to dangerously high levels, which may precipitate a stroke or eclamptic convulsion in a woman who already has elevated blood pressure. The drug of choice instead is Oxytocin 10 IU IM, which is equally effective in preventing postpartum hemorrhage and does not significantly raise blood pressure.

Question Type

short_answer

Answer Structure

• Sentence 1-2: State the reason (vasoconstriction → raises BP → risk of stroke/convulsion) [1 mark]
• Sentence 3: Name the alternative drug — Oxytocin 10 IU IM [1 mark]

Scoring Breakdown

Common Mark Deductions

• Saying ergometrine is 'not available' rather than 'contraindicated' in hypertension
• Failing to name the alternative drug
• Naming misoprostol as first-line (oxytocin is always preferred when available)

Key Phrases To Include

• vasoconstriction
• raises blood pressure
• pre-eclampsia
• contraindicated
• Oxytocin 10 IU IM
• drug of choice

Marks

5

Topic

Controlled Delivery of the Head — Second Stage Technique

Difficulty

hard

Template Id

T7

Examiner Tip

For a 5-mark long-answer question, examiners expect FIVE distinct, scoreable points. Write in clear numbered or lettered points. Mixing EINC terminology (spontaneous bearing-down, no routine suctioning, non-supine position) signals to the examiner that you know current Philippine national practice.

Model Answer

Controlled delivery of the fetal head is the most important skill in preventing perineal trauma during a normal spontaneous delivery. The following steps outline the correct technique: 1. Positioning and preparation: Ensure the mother is in a comfortable position (upright, semi-sitting, lateral, or supported semi-recumbent). Wash hands, don sterile gloves, and prepare a clean pad or cloth for perineal support. This aligns with EINC practice, which discourages routine flat lithotomy. 2. Encourage spontaneous bearing-down: During the second stage, guide the mother to push naturally with contractions using spontaneous, short bearing-down efforts rather than prolonged, forceful Valsalva pushing. This is the EINC-recommended approach. 3. Control the occiput as the head crowns: As the fetal head crowns at the vulva, place one hand (over a cloth) on the occiput and apply gentle, firm pressure to keep the head FLEXED and to slow down its advance — preventing the head from 'popping' out suddenly. 4. Perineal support (modified Ritgen maneuver): With the other hand, apply a clean pad or cloth to the perineum and provide support as the head extends. This guard on the perineum reduces the risk of third- and fourth-degree tears. 5. Panting between contractions: As the head is crowning, instruct the mother to PANT (short, rapid breaths) rather than push between contractions. This slow, controlled delivery allows the perineum to stretch gradually. 6. Allow the head to extend: Guide the head as it extends naturally under the pubic arch. Deliver the occiput first, followed by the bregma, forehead, face, and finally the chin — in that sequence. 7. Post-delivery check: Once the head is delivered, wipe the face. Do NOT routinely suction the mouth and nose if the baby has clear amniotic fluid and is breathing — this is an EINC-eliminated practice. Note: Episiotomy is NOT performed routinely. It is done ONLY on clear clinical indication (e.g., imminent severe tear, fetal distress requiring rapid delivery).

Question Type

long_answer

Answer Structure

• Point 1: Positioning and preparation (sterile gloves, EINC position) [1 mark]
• Point 2: Encourage spontaneous bearing-down — not Valsalva (EINC) [1 mark]
• Point 3: Hand on occiput to keep head flexed and slow delivery [1 mark]
• Point 4: Perineal support with other hand (Ritgen maneuver) + panting between contractions [1 mark]
• Point 5: Episiotomy is NOT routine + no routine suctioning (EINC points) [1 mark]

Scoring Breakdown

Common Mark Deductions

• Omitting the instruction to pant between contractions
• Writing 'perform episiotomy routinely' — this is an EINC-eliminated practice and will cost a mark
• Not specifying hand positions (one on occiput, one supporting perineum)
• Failing to mention the EINC component (no routine suctioning) in a 5-mark answer that expects comprehensive coverage
• Writing a vague answer like 'apply pressure on the head' without specifying direction (flexion), hand, or purpose

Key Phrases To Include

• spontaneous bearing-down
• Valsalva
• crowning
• occiput
• flexed
• perineal support
• Ritgen maneuver
• pant
• episiotomy not routine
• no routine suctioning
• EINC
• sterile gloves

Marks

3

Topic

Checking and Managing the Nuchal Cord

Difficulty

medium

Template Id

T8

Examiner Tip

The somersault maneuver is a high-yield EINC concept that appears in MLE questions. Mentioning it by name immediately signals to the examiner that you are current on national practice and earns the mark.

Model Answer

A nuchal cord is the umbilical cord looped around the fetal neck at the time of delivery. Management: 1. Loose nuchal cord: After the fetal head is delivered, gently feel around the neck. If the cord is loose, slip it over the baby's head and continue delivery normally. 2. Tight nuchal cord: If the cord is tight and cannot be loosened, the preferred EINC technique is the somersault maneuver — keep the baby's head close to the mother's thigh and deliver the body through the loop of cord without cutting it. This preserves the cord and the placental transfusion. 3. The cord is clamped and cut before shoulder delivery ONLY if the tight cord truly cannot be reduced by any means. Routine suctioning after delivery of the head is NOT performed if the amniotic fluid is clear and the baby is breathing.

Question Type

short_answer

Answer Structure

• Definition of nuchal cord [0.5 mark, often bundled with management]
• Management of LOOSE cord: slip over the head [1 mark]
• Management of TIGHT cord: somersault maneuver preferred; clamp-cut only as last resort [1 mark]
• EINC point: avoid early cord clamping/cutting [0.5 mark]

Scoring Breakdown

Common Mark Deductions

• Recommending routine clamp-and-cut for all nuchal cords — this is outdated practice
• Not differentiating between loose and tight cord management
• Omitting the somersault maneuver — this is the key EINC concept examiners look for

Key Phrases To Include

• nuchal cord
• loose cord
• slip over the head
• tight cord
• somersault maneuver
• clamp and cut only as last resort
• placental transfusion
• EINC

Marks

2

Topic

Delivery of the Shoulders and Body

Difficulty

easy

Template Id

T9

Examiner Tip

A simple rule to remember: DOWN for the first (anterior) shoulder, UP for the second (posterior) shoulder. Think of following the natural curve of the birth canal.

Model Answer

After the head is delivered and restitution (external rotation) has occurred: 1. With the next contraction, apply GENTLE DOWNWARD TRACTION on the head to deliver the ANTERIOR shoulder from under the symphysis pubis. 2. Then apply GENTLE UPWARD TRACTION on the head to deliver the POSTERIOR shoulder over the perineum, supporting the perineum throughout. 3. The body then follows and is delivered in a slow, controlled manner. Important: Do NOT apply fundal pressure at any time during shoulder delivery.

Question Type

short_answer

Answer Structure

• Step 1: Downward traction → anterior shoulder [1 mark]
• Step 2: Upward traction → posterior shoulder [1 mark — including 'no fundal pressure' earns the second mark]

Scoring Breakdown

Common Mark Deductions

• Reversing the direction of traction (upward for anterior, downward for posterior)
• Not specifying which shoulder comes first (anterior before posterior)
• Recommending fundal pressure — this is dangerous and incorrect

Key Phrases To Include

• downward traction
• anterior shoulder
• symphysis pubis
• upward traction
• posterior shoulder
• perineum
• no fundal pressure

Marks

1

Topic

Postpartum Monitoring and PPH Definition

Difficulty

easy

Template Id

T10

Examiner Tip

Remember: 500 mL for vaginal, 1000 mL for cesarean. These are numerical facts examiners test directly. Write the number clearly.

Model Answer

PPH after a vaginal delivery is defined as a blood loss of 500 mL or more. The mother should be monitored (vital signs, fundal tone, and lochia) every 15 minutes for the first 2 hours postpartum.

Question Type

very_short_answer

Answer Structure

• Part A: ≥500 mL blood loss = PPH after vaginal delivery [0.5 mark]
• Part B: Monitor every 15 minutes for the first 2 hours [0.5 mark — often counted as one combined 1-mark answer]

Scoring Breakdown

Common Mark Deductions

• Writing 1000 mL as the threshold (that is for cesarean section, not vaginal delivery)
• Writing 'every 30 minutes' instead of every 15 minutes
• Omitting what to monitor (fundal tone and lochia are expected in context)

Key Phrases To Include

• 500 mL
• vaginal delivery
• every 15 minutes
• first 2 hours
• fundal tone
• lochia

Marks

3

Topic

Placental Inspection and Assessment

Difficulty

medium

Template Id

T11

Examiner Tip

The succenturiate lobe question is a classic MLE topic. The key sign is a blood vessel that runs off the disc and ends abruptly in the membranes. Practice saying: '2 arteries, 1 vein' until it becomes automatic.

Model Answer

Placental inspection is done systematically after delivery: 1. Maternal (cotyledon) side: Place the placenta flat with the maternal surface upward. Examine all cotyledons — they should fit together like pieces of a puzzle with no missing or rough areas. A missing cotyledon suggests a retained placental fragment. 2. Fetal (shiny/amnion) side: Turn the placenta over and examine the shiny fetal surface. Trace the fetal blood vessels outward from the cord insertion. If a blood vessel runs to the edge of the placental disc and then continues into the membranes, this strongly suggests a SUCCENTURIATE (accessory) LOBE that was left behind in the uterus. 3. Membranes: Check that the amnion and chorion are intact and complete with no obvious missing sections. 4. Umbilical cord: Count the cord vessels — a normal cord contains TWO arteries and ONE vein (total of 3 vessels). A single umbilical artery may be associated with fetal anomalies. If the placenta is suspected to be incomplete, this is a REFERRAL situation — do NOT attempt manual removal at the BHS/lying-in level.

Question Type

short_answer

Answer Structure

• Step 1: Inspect maternal side — all cotyledons present, no missing pieces [1 mark]
• Step 2: Inspect fetal side — vessels tracing to membrane edge = succenturiate lobe [1 mark]
• Step 3: Check membranes and cord (2 arteries, 1 vein) + referral if incomplete [1 mark]

Scoring Breakdown

Common Mark Deductions

• Describing only the maternal surface without mentioning the fetal surface
• Not knowing the specific sign of a succenturiate lobe (vessel running off the disc into membranes)
• Stating the cord has '2 veins and 1 artery' — this is reversed; it is 2 arteries and 1 vein
• Not mentioning referral for incomplete placenta

Key Phrases To Include

• cotyledons
• maternal side
• fetal side
• blood vessel running to membrane edge
• succenturiate lobe
• 2 arteries and 1 vein
• complete membranes
• refer if incomplete

Marks

1

Topic

Perineal Laceration Repair and Referral

Difficulty

easy

Template Id

T12

Examiner Tip

This question tests the scope of practice under RA 7392. Always frame your answer as 'midwife can do... but refers...' to demonstrate you understand the boundaries of independent midwifery practice.

Model Answer

A midwife can independently repair first-degree and second-degree perineal lacerations. Third-degree and fourth-degree lacerations (involving the anal sphincter and/or rectal mucosa) require REFERRAL to a physician/surgeon at a higher-level facility.

Question Type

very_short_answer

Answer Structure

• Line 1: 1st and 2nd degree — midwife can repair independently [0.5 mark]
• Line 2: 3rd and 4th degree — refer [0.5 mark]

Scoring Breakdown

Common Mark Deductions

• Stating the midwife can repair all degrees of tears
• Not specifying why 3rd/4th degree are referred (anal sphincter/rectal mucosa involvement)
• Omitting the referral statement — this is the safety-critical part of the answer

Key Phrases To Include

• first-degree
• second-degree
• independently repair
• third-degree
• fourth-degree
• anal sphincter
• referral

Marks

1

Topic

EINC — Newborn Care After Delivery

Difficulty

easy

Template Id

T13

Examiner Tip

MLE MCQ questions on EINC often test whether you know what NOT to do. The key phrase is 'clear amniotic fluid + breathing baby = no suctioning needed.' This is the EINC principle.

Model Answer

Answer: C — Routine suctioning of the mouth and nose is NOT performed in EINC practice for a newborn with clear amniotic fluid who is crying or breathing. This is an EINC-eliminated unnecessary procedure. Suctioning is only considered when the newborn is not breathing or has meconium-stained amniotic fluid.

Question Type

very_short_answer

Answer Structure

• State the correct answer (C) with a one-sentence rationale [1 mark]

Scoring Breakdown

Common Mark Deductions

• Choosing option A or D, which represent old/outdated practice
• Choosing option B (partially true but incomplete — routine suctioning is broadly eliminated, not just based on meconium)

Key Phrases To Include

• EINC
• not performed routinely
• clear amniotic fluid
• breathing/crying baby
• eliminated practice

Marks

5

Topic

Postpartum Hemorrhage — Detection, Initial Stabilization, and Referral

Difficulty

hard

Template Id

T14

Examiner Tip

Case study questions in the MLE always test whether you know the limits of midwifery practice. You will lose the referral mark if you do not explicitly state the need to refer. For high-risk scenarios, always end with: 'Refer to [facility] immediately while continuing to monitor.' This shows you understand RA 7392.

Model Answer

Danger signs identified: 1. Uterine atony — the uterus is soft and boggy (not firmly contracted), the most common cause of postpartum hemorrhage. 2. Heavy continuous vaginal bleeding — this represents significant ongoing blood loss. 3. Signs of hypovolemic shock — BP 90/60 mmHg (hypotension) and pulse 110 bpm (tachycardia). Priority actions of the midwife (Detect and Refer protocol): 1. Shout for help / activate the emergency referral system immediately. 2. Perform uterine massage NOW: massage the fundus firmly through the abdomen to stimulate contraction. 3. Ensure oxytocin (if not yet given or if repeat dose is available) — 10 IU IM or 20 IU IV drip per BEmONC protocol. 4. Position the mother flat, elevate the legs to improve venous return (shock position). 5. Establish IV access (large-bore IV line) and begin IV fluid resuscitation with Plain Normal Saline or Ringer's Lactate as per BEmONC standing order while awaiting transport. 6. Keep the mother warm, monitor vital signs every 5 minutes, and document everything. 7. Prepare and REFER to the nearest RHU/hospital with a physician immediately — this is a life-threatening emergency beyond the independent midwife's scope at the BHS level. The midwife's role here is to initiate stabilizing measures and REFER — not to independently manage hemorrhagic shock.

Question Type

case_study

Answer Structure

• Identify all 3 danger signs with explanation [1.5 marks — 0.5 per danger sign]
• Immediate action: shout for help + uterine massage + oxytocin [1 mark]
• Shock management: positioning + IV fluid per BEmONC [1 mark]
• REFERRAL statement — mandatory for full marks [1 mark]
• Monitoring and documentation [0.5 mark]

Scoring Breakdown

Common Mark Deductions

• Omitting the REFERRAL statement — this is the most common and costliest error in case study questions
• Not identifying all three danger signs (uterine atony + bleeding + shock)
• Writing only uterine massage without mentioning oxytocin or IV fluids
• Failing to address the shock (low BP, fast pulse) in the answer
• Writing 'manage' the hemorrhage independently at the BHS — the midwife's role is to DETECT, STABILIZE, and REFER

Key Phrases To Include

• uterine atony
• soft and boggy
• postpartum hemorrhage
• hypovolemic shock
• uterine massage
• Oxytocin 10 IU IM
• IV fluid resuscitation
• shock position
• BEmONC
• REFER immediately
• vital signs every 5 minutes

Marks

5

Topic

Postpartum Danger Signs and Referral

Difficulty

medium

Template Id

T15

Examiner Tip

For 'enumerate' questions worth 5 marks, write exactly 5 numbered points — no more, no less. Each point needs a NAME (what the sign is) and ideally a brief descriptor (what makes it significant or referable). Bullet-point format is faster and easier for examiners to mark.

Model Answer

The following are five postpartum danger signs requiring IMMEDIATE referral from the BHS lying-in facility: 1. Heavy or continuous vaginal bleeding with or without a soft, boggy uterus (uterine atony) — blood loss ≥500 mL or bleeding that does not stop with uterine massage and oxytocin. This indicates postpartum hemorrhage (PPH). 2. Retained placenta — if the placenta has not delivered within 30 minutes after the birth of the baby despite controlled cord traction and a well-contracted uterus. Manual removal of retained placenta is beyond the BHS midwife's independent scope. 3. Signs of hypovolemic shock — rapid, weak pulse (tachycardia >100 bpm), falling blood pressure (systolic <90 mmHg), pallor, cold clammy skin, and dizziness. These indicate major blood loss and require IV resuscitation and emergency referral. 4. Third-degree or fourth-degree perineal laceration — a tear extending into or through the anal sphincter (3rd degree) or rectal mucosa (4th degree). Repair requires a surgeon or obstetrician in a higher-level facility. 5. Prolonged second stage or any sign of obstructed labor — if there is no progress in descent despite adequate contractions, the presenting part is not advancing, or there are maternal signs of exhaustion and fetal distress. This indicates the birth cannot be completed safely at the BHS level.

Question Type

long_answer

Answer Structure

• Danger sign 1: PPH / heavy bleeding with boggy uterus [1 mark]
• Danger sign 2: Retained placenta beyond 30 minutes [1 mark]
• Danger sign 3: Hypovolemic shock signs (tachycardia, hypotension, pallor) [1 mark]
• Danger sign 4: Third/Fourth degree perineal tear [1 mark]
• Danger sign 5: Prolonged second stage / obstructed labor [1 mark]

Scoring Breakdown

Common Mark Deductions

• Listing vague signs like 'pain' or 'discomfort' without specifics
• Repeating the same danger sign twice in different words (e.g., bleeding and PPH as two separate points)
• Not linking the danger sign to a referral action
• Listing fetal danger signs rather than maternal postpartum danger signs

Key Phrases To Include

• postpartum hemorrhage
• ≥500 mL
• boggy uterus
• retained placenta
• 30 minutes
• hypovolemic shock
• tachycardia
• hypotension
• third-degree
• fourth-degree
• anal sphincter
• obstructed labor
• refer immediately