Textbook of Obstetrics

FUNDAMENTALS OF REPRODUCTION 17
t Gametogenesis 17 t Ovulation 19 t Fertilization 21 t Morula 22 t Implantation 22
Trophoblast 24 The decidua 24 t Chorion and Chorionic villi 25
t Development of inner cell mass 26

THE PLACENTA AND FETAL MEMBRANES 28
t Development 28 t Structures 30 t Placenta circulation 31 t Placental ageing 34
t Placental function 35 Amniotic cavity, Amnion and Amniotic fluid 37
The umbilical cord 39

THE FETUS 41
t Fetal physiology 42 The fetal circulation 43 t Changes of fetal circulation at birth 44

PHYSIOLOGICAL CHANGES DURING PREGNANCY 46
t Genital organs 46 t Breasts 49 t Cutaneous changes 50 t Weight gain 50
t Body water metabolism 51 t Hematological changes 51 t Cardiovascular changes 52
t Metabolic changes 54 t Systemic changes 55

ENDOCRINOLOGY IN RELATION TO REPRODUCTION 57
t Placental endocrinology 57 t Protein hormones 58 t Steroidal hormones 60
t Changes of endocrine glands 61 t Maintenance of lactation 63

DIAGNOSIS OF PREGNANCY 64
t First trimester 64 t Second trimester 68 t Last trimester 70 t Differential diagnosis of pregnancy 72 t Chronological appearance of specific symptoms and signs of pregnancy 72
Signs of previous child birth 73 t Estimation of gestational age and prediction of expected date of delivery 73 t Estimation of fetal weight 74

THE FETUS-IN-UTERO
75
t Methods of obstetrical examination 77

FETAL SKULL AND MATERNAL PELVIS
83
t Fetal skull 83 t Maternal pelvis 87 t Physiological enlargement of pelvis 93

ANTENATAL CARE, PRE-CONCEPTIONAL COUNSELING AND CARE
t Procedure at the first visit 94 t Examination 96 t Procedure at the subsequent visits 98
Antenatal advice 99 t Minor ailments in pregnancy 101 t Values of antenatal care 102
t Pre-conceptional counseling and care 102 t Summary 103

ANTENATAL ASSESSMENT OF FETAL WELL BEING
t Clinical evaluation of fetal well being 104 t Special investigations 105
t Early pregnancy assessment 105 Assessment in late pregnancy 108
t Other investigations in late pregnancy 110 t Summary 111 t Key points 112

NORMAL LABOR
t Causes of onset of labor 113 t Contractile system of the myometrium 115
True labor pains 116 t Stages of labor 116 t Physiology 117
t Events in labor: First stage 118; Second stage 121; Third stage 122;
t Mechanism of normal labor 123 Anatomy of normal labor 127
t Clinical course: First stage 128; Second stage 130; Third stage 131
t Place of delivery 132
Management of normal labor 132: First stage 134; Second stage 135;
Immediate care of the newborn 137; Third stage 139
t Scheme of management 141 t Key points 142

NORMAL PUERPERIUM
t Involution of the uterus 144 t Involution of other pelvic structures 145 t Lochia 146
t General physiological changes 146 t Menstruation and ovulation 147
t Lactation 148 t Management of normal puerperium 150 t Management of ailments 151
t Postnatal care 153

VOMITING IN PREGNANCY
t Vomiting in pregnancy 154 t Hyperemesis gravidarum 154 t Summary 157

HEMORRHAGE IN EARLY PREGNANCY
t Spontaneous abortion (miscarriage) 158: Threatened 160; Inevitable 161; Complete 162
Incomplete 163; Missed 163; Septic 164; Recurrent 167
t Induction of abortion 172 t Medical Termination Of Pregnancy (MTP) 172:
First trimester 174; Midtrimester 175 t Complications of MTP 176
t Ectopic pregnancy 177: Tubal 178; Interstitial 183; Unruptured tubal 185;
Abdominal 188; Ovarian 189; Cornual 189; Cervical 189
t Gestational Trophoblastic Diseases (GTD) 190: Hydatidiform mole 190;
Partial mole 198; Placental Site Trophoblastic Tumor (PSTT) 198;
Persistent gestational trophoblastic neoplasia 199

MULTIPLE PREGNANCY, HYDRAMNIOS AND ABNORMALITIES OF PLACENTA AND CORD
Twins 200 Triplets, Quadruplets 210 t Polyhydramnios 211 t Oligohydramnios 215
Abnormalities of placenta and cord 216

HYPERTENSIVE DISORDERS IN PREGNANCY
t Pre-eclampsia 219: Etiopathogenesis 220; Pathophysiology 221; Clinical types 224
Clinical features 224; Complications 226; Prediction and prevention 227; Management 227
Acute fulminant pre-eclampsia 230 t Eclampsia 230: Management 233
t Gestational 236 t Chronic 238 t Essential 238 t Chronic renal diseases 239
t Key points 240

ANTEPARTUM HEMORRHAGE
t Placenta previa 241: Clinical features 243; Placentography 244; Differential diagnosis 245
Complications 246; Management 248; General remarks on cesarean section 250;
Guide to lower segment approach 251 Abruptio placentae 252: Clinical features 255;
Complications 256; Management 256 t Indeterminate bleeding 259 t Summary 259

MEDICAL AND SURGICAL ILLNESS COMPLICATING PREGNANCY
t Hematological disorders in pregnancy 260: Anemia 260; Iron deficiency 262;
Complications 264; Treatment 264; Megaloblastic 268; Dimorphic 270; Aplastic 270;
Hemoglobinopathies 272; Sickle cell hemoglobinopathies 272;
Thalassemia syndromes 273; Platelet disorders 274
t Heart disease in pregnancy 275; Management 277;
Specific heart disease and the management 279; Rheumatic 279; Congenital 279;
Acyanotic 279; Cyanotic 280; Other congenital heart lesions 280; Cardiomyopathies 280
t Diabetes Mellitus 281; Gestational Diabetes Mellitus (GDM) 281; Overt diabetes 282
Thyroid dysfunction 287 t Jaundice 288 t Cholestasis 289 t Viral hepatitis 289
t Epilepsy 291 Asthma 291 t Systemic Lupus Erythematosus (SLE) 292
Tuberculosis 293 t Syphilis 294 t Parasitic and Protozoal infections 296
t Malaria 296 Toxoplasmosis 297 t Listeriosis 297
t Intestinal worms 297 t Pyelonephritis 298 Asymptomatic Bacteriuria (ASB) 298
t Proteinuria 299 t Hematuria 299 t Retention of urine 299
t Viral infections 299: Rubella 299; Measles 300; Influenza 300
Chicken pox (varicella) 300; Cytomegalovirus 300; Parvo viruses 300;
Mumps 300 Herpes simplex virus 301; HIV (AIDS) 301
t General surgery 303: Acute appendicitis 304; Trauma 304; Acute pancreatitis 304;
Symptomatic cholelithiasis 304; Peptic ulcer 304 t Laparoscopy in pregnancy 304 t Acute pain abdomen 305

GYNECOLOGICAL DISORDERS IN PREGNANCY
Abnormal vaginal discharge 306 t Congenital malformations 306 t Carcinoma cervix 307
Abnormal cervical cytology 307 t Fibroid 309 t Ovarian tumor 310
t Retroverted gravid uterus 311 t Genital prolapse 312

PRETERM LABOR, PRETERM RUPTURE OF THE MEMBRANES, POSTMATURITY, INTRAUTERINE DEATH OF THE FETUS
t Preterm labor 314 t Prelabor Rupture Of The Membranes (PROM) 317
t Post-term pregnancy 318 t Intrauterine Fetal Death (IUD) 322

SPECIAL CASES
t Pregnancy with prior cesarean delivery 327: Scar integrity 328; Scar dehiscence 328;
Management 329; Vaginal Birth After Previous Cesarean (VBAC) 329
t Pregnancy in a Rh-negative woman 331: Alloimmunization 332; Fetal affection by the Rh antibody 333; Prevention of Rh-immunization 334; Antenatal investigation protocol of Rh-negative woman 335; Plan of delivery 337; Scheme of management of Rh-negative women 338; Intrauterine fetal transfusion 339; Exchange transfusion in the newborn 339; Prognosis 341 t Elderly primigravida 341 t Grand multipara 342
t Bad obstetric history 342 t Obesity 343 t Key points 344

CONTRACTED PELVIS
t Variation of female pelvis 345 Anatomical features of parent pelvic types 346
t Mechanism of labor 348 t Diagnosis 349 t X-ray pelvimetry 351
t Disproportion 352: Diagnosis 352; Management 354
Trial labor 355 t Midpelvic and outlet disproportion 356

ABNORMAL UTERINE ACTION
Types 357 t Uterine inertia 358 t Incoordinate uterine action 359
t Spastic lower segment 360 t Constriction ring 360 t Cervical dystocia 360
t Generalized tonic contraction 361 t Precipitate labor 361
Tonic uterine contraction and retraction 362 t Management of dysfunctional labor 364
t Key points 364

MALPOSITION, MALPRESENTATION AND CORD PROLAPSE
t Occipito-posterior position 365 t Deep transverse arrest 372 t Breech presentation 374
Antenatal Management 379 t Management of vaginal breech delivery 381
t Management of complicated breech delivery 385 t Face presentation 388
t Brow presentation 392 Transverse lie 393 t Unstable lie 397
t Compound presentation 397 t Cord prolapse 398

PROLONGED LABOR, OBSTRUCTED LABOR, DYSTOCIA CAUSED BY FETAL ANOMALIES
t Prolonged labor 401 t Obstructed labor 404
t Dystocia caused by fetal anomalies 405
t Shoulder dystocia 406: Hydrocephalus 406; Neural Tube Defects (NTD) 408;
Enlargement of fetal abdomen 409; Monsters 409; Conjoined twins 409
t Key points 409

COMPLICATIONS OF THE THIRD STAGE OF LABOR
t Postpartum hemorrhage 410: Management of third stage bleeding 412;
Manual removal of placenta 413; Management of true postpartum hemorrhage 414;
Secondary postpartum hemorrhage 417
t Retained placenta 418 t Placenta accreta 419 t Inversion of the uterus 420

INJURIES TO THE BIRTH CANAL
t Vulva 422 t Perineum 422 t Vagina 423 t Cervix 423 t Pelvic hematoma 424
t Rupture of the uterus 426 t Visceral injuries 431 t Key points 431

ABNORMALITIES OF THE PUERPERIUM
t Puerperal pyrexia 432 t Puerperal sepsis 432 t Subinvolution 436
t Urinary complications 437 t Breast complications 437 t Puerperal venous thrombosis 439
t Pulmonary embolism 441 t Obstetric palsies 442 t Puerperal emergencies 442
t Psychiatric disorders during puerperium 442

THE TERM NEWBORN INFANT
t Physical features 444 Assessment of gestational age 446
t Immediate care 447 t Daily observation and care 447 t Infant feeding 448
Breast feeding 449; Artificial feeding 453 t Childhood immunization program 455

LOW BIRTH WEIGHT BABY
t Preterm baby 456 t Intrauterine Growth Restriction (IUGR) 461 t Key points 467

DISEASES OF THE FETUS AND THE NEWBORN
Asphyxia neonatorum 468 t Fetal respiration 468 t Perinatal asphyxia 469
t Resuscitation 472 t Respiratory distress 473
t Idiopathic respiratory distress syndrome 474 t Meconium Aspiration Syndrome (MAS) 476
t Jaundice 476 t Hemolytic disease 480 t Hemorrhagic disease 480 Anemia 481
t Seizures 481 t Birth injuries 483 t Perinatal infections 487 t Conjunctivitis 489
t Congenital malformations and prenatal diagnosis 491
t Prenatal dignosis and fetal therapy 492 t Downs syndrome 494
t Surgical emergencies 495 t Non-immune fetal hydrops 497

PHARMACOTHERAPEUTICS IN OBSTETRICS
t Oxytocics 498: Oxytocin 498; Ergot derivatives 501; Prostaglandins 503
Antihypertensive therapy 505 t Diuretics 507 Tocolytic agents 507
Anticonvulsants 509 Anticoagulants 510 t Maternal drug intake and breast feeding 510;
t Fetal hazards on maternal medication 511; t FDA risk categories 512;
t Maternal medication and fetal or neonatal affection 513
Analgesia and anesthesia in obstetrics(B Hore) 514: Anatomy and physiology of pain 514; Analgesia for labor and delivery 515; Sedatives and analgesics 516;
Inhalation methods 516; Regional anesthesia 517; Infiltration analgesia 519;
Psychoprophylaxis 519; General anesthesia for cesarean section 520 t Key points 521

INDUCTION OF LABOR
t Indications and contraindications 522 t Parameters to assess prior to induction 523
t Methods of cervical ripening 523
t Methods of induction of labor 524: Medical 524; Surgical 525; Combined 527
Active management of labor 528 t Partograph 531 t Key points 531

POPULATION DYNAMICS AND CONTROL OF CONCEPTION
t Population dynamics 532 t Control of conception 532 t Contraception 533
t Methods 534: Barrier methods 534; Natural contraception 536;
Intrauterine Contraceptive Devices (IUDs) 537; Steroidal contraceptions 543;
Combined oral contraceptives 543; Injectable steroids 550;
Emergency contraception 551; Sterilization 552; Vasectomy 552;
Female sterilization 554 t Contraceptive prescription 558
t Ongoing trials and selective availability 559: Centchroman 559; Combined injectable contraceptives 560; Biodegradable implants 560; Newer IUDs 560; t Key points 561

OPERATIVE OBSTETRICS
t Dilatation and evacuation 563 t Management protocol of uterine perforation 565
t Suction evacuation 566 t Menstrual regulation 566 t Manual vacuum aspiration 567
t Hysterotomy 567 t Episiotomy 568 t Operative vaginal delivery 572 t Forceps 572
t Ventouse 580 t Version 583 t External cephalic version 583 t Internal version 585
t Bipolar version 585 t Destructive operations 586 t Craniotomy 586 t Decapitation 587
t Evisceration 588 t Cleidotomy 588 t Postoperative care 588 t Cesarean section 588
Lower segment 591; Classical 595; Complications 596;
Measures to reduce cesarean births 598 t Symphysiotomy 598

SAFE MOTHERHOOD, EPIDEMIOLOGY OF OBSTETRICS
t Safe motherhood 599 t Obstetric care and the society 600
t Reproductive and Child Health (RCH) care 600 t Epidemiology of obstetrics 601
t Maternal mortality 602 t Maternal morbidity 605 t Perinatal mortality 605
t Still births 607 t Neonatal deaths 608 t Key points 608

SPECIAL TOPICS IN OBSTETRICS
t Intrapartum fetal monitoring 609: Electronic Fetal Monitoring (EFM) 610
Nonreassuring fetal status 613
t Shock in obstetrics (BN Chakraborty) 614: Classification 618; Hemorrhagic shock 618;
Endotoxic shock 620 Acute renal failure 621;
t Blood coagulation disorders in obstetrics 626 t High risk pregnancy (KM Gun) 630
t Immunology in obstetrics 634 t Critical care in obstetrics 636; ICU 638

CURRENT TOPICS IN OBSTETRICS
Audit in obstetrics 640 t Medicolegal aspects of obstetric practice 641
t Day care obstetrics 641 Antibiotic prophylaxis in cesarean section 642
The pre-conception and prenatal diagnostic techniques and PNDT Act 642
t Umbilical cord blood banking 642 t Stem cells and therapies in obstetrics 643

IMAGING IN OBSTETRICS (USG, CT, MRI, RADIOLOGY), AMNIOCENTESIS AND GUIDES TO CLINICAL TESTS
t Ultrasound in obstetrics 644: 3-D scanning 644; Indications 645; First trimester 646;
Midtrimester 646; Doppler 649; Third trimester 649;
Ultrasound markers of chromosomal abnormalities 650
t Magnetic resonance imaging 650 t Radiology in obstetrics 650 Amniocentesis 651
t Guides to clinical tests 652: Urine 652; Tests for blood coagulation disorders 653;
Collection of blood sample 654; Cervical and vaginal cytology 655

PRACTICAL OBSTETRICS
t Clinical thermometer 656 t Obstetric instruments 656 t Specimens 667
t Imaging studies (USG plates) 668 t Processing of instruments 669
t Drugs 670 t Doppler fetal monitor 670

INDEX 671-692