DC Odtn s

Textbook of

OBSTETRICS

including

Perinatology and Contraception

OTHER BOOKS BY THE SAME AUTHOR

■ Textbook of Gynecology

■ A Guide to Clinical Obstetrics and Gynecology

■ Bedside Clinics & Viva-voce in Obstetrics and Gynecology

■ Master Pass in Obstetrics and Gynaecology

■ Emergencies in Manipulative and Operative Obstetrics

DC Datta. s

Textbook of

OBSTETRICS

including

Perinatology and Contraception

Eighth Edition

DC DUTTA

MBBS, DGO, MO (CaL)

Professor and Head, Department of Obstetrics and Gynecology Nilratan Sircar Medical College and Hospital, Kolkata, India

Edited by

HIRALALKONAR

(HONS; GOLD MEDALIST)

MBBS (CaL), MD (PGI), DNB (INDIA)

MNAMS, FACS (USA), FRCOG (LONDON)

Chairman, Indian College of Obstetricians and Gynecologists Professor, Department of Obstetrics and Gynecology Calcutta National Medical College and CR Hospital, Kolkata, India One-time Professor and Head, Dept., Obst. & Gyne.

Midnapore Medical College and Hospital, West Bengal University of Health Sciences, Kolkata, India

Rotation Registrar in Obstetrics, Gynecology and Oncology

Northern and Yorkshire Region, Newcastle-upon-Tyne, UK

Examiner of MBBS, DGO, MD and PhD of different Indian universities

and National Board of Examination, New Delhi, India

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© Copyright reserved by Mrs Madhusri Konar

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Information contained in this book is up-to-date, believed to be reliable when checked with the sources and is in accordance with the accepted standard at the time of publication. However, with ongoing research and passage of time, new knowledge may modify some of it. The reader should, therefore, approach the book with a realistic attitude (particularly the drugs and doses) and should carry the professional responsibility. The readers are asked to verify the information contained herein from other sources. Neither the publisher nor the author(s)/editor(s) assume(s) any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.

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Textbook of Obstetrics

Enlarged & Revised Reprint of Seventh Edition : November 201 3 Eighth Edition: 201 5

ISBN 978-93-5152-723-7 Printed at

Dedicated to

The students of obstetrics past and present

Preface to the Eighth Edition

DC Dutta's Textbook of Obstetrics is in service to the medical fraternity for the last 31 years. It primarily aims at the medical students, trainee residents, practicing doctors and the midwives. It has evolved to provide comprehensive and updated information in a concise and easy-to-read format. The eighth edition has come out with an international standard to meet the overwhelming demand in many parts of the world. All the chapters have been extensively revised and strategically reorganized. Medical advances up to the time of publication have been incorporated. Contemporaneous guidelines from different professional and academic organizations like RCOG, ACOG, WHO, FIGO, NICHD, CDC, NICE, ICOG and DIPSI are provided. Management options based on experience, derived from large obstetric services are also mentioned. This is particularly so in a situation where no evidence exists or it is difficult to follow due to limitation of resources. Objective of this edition is to provide current cutting edge information, to enable the candidates to qualify the examination in India and its equivalents internationally.

Dutta's eighth edition in its fully coloured format is profusely illustrated with a total number of 320 line drawings, sketches and photographs. In recognition of the advanced technology, the book provides sonograms, including Doppler studies, M R Images, microphotographs, data graphs and laparoscopic images. All these are in most vivid colors. Practical obstetrics (Chapter 42) with a total number of 52 high-quality photographs of instruments, specimens, sonograms, M R Images and drugs is of immense value, specifically for the practical part of the examination. The total information in Chapter 42 amounts to a mini textbook-cum-colour atlas in obstetrics.

For easy text reference and reading, contents and index have also been expanded. A list of abbreviations and a few updated reviews with websites are provided. The uniqueness of this text lies in its presentations, which are simple, lucid and unambiguous. Presentation of summary tables, algorithms and key-points for each chapter are a special attraction. These are for quick revision and recapitulation before the examination.

This book is available in various e-Book formats. Dutta's has a long-standing association with its sister books: Textbook of Gynecology (6th Edition-2013), Bedside Clinics and Viva-voce (1st Edition-2015), Master Pass in Obstetrics and Gynaecology (2nd Edition-2015)

I had the opportunity to visit many of the medical institutions in this country and abroad. The feedback that I received from the teachers and students was invaluable. Many of these suggestions have been addressed to in this edition.

I do hope this comprehensive textbook will continue to be of immense educational resource to the readers as ever.

I am grateful to all who have taught me, most of all the patients and my beloved students.

Vlll Textbook of Obstetrics

According to the author’s desire, the book is dedicated to the students of obstetrics — past and present, who strive continuously to improve maternal and newborn’s health, wherever they work.

P-13, New CIT Road Kolkata - 700 014

Hiralal Konar

Preface to the First Edition

Over the years, there was an absolute dearth of a single comprehensive textbook of obstetrics, worth to be prescribed to the students. Moreover, of the textbooks currently available, most have been written with an orientation for the developed countries.

Being constantly insisted and hard-pressed by my beloved students, I ultimately decided to write a compact, comprehensive and practically oriented textbook of obstetrics. It is an attempt to encourage the students to learn obstetrics in a comparatively easy way. The aim was to emphasize the simplicities rather than complexities of knowledge. The book is written in a clear and concise language and in author's own style, which holds the reader's interest. Controversies are avoided and the management of the obstetrical problems is being highlighted with the facilities available to most of the third world countries. Extensive illustrations and flow charts (schemes) have been used as and when needed to add lucidity and clarity to the subject and to emphasize the practical nature of the book.

Although the book has been written primarily for the undergraduates, it should also prove to be useful to nurses (midwives), those aspiring for diploma and postgraduate degrees in obstetrics and also to the practicing obstetricians. I, however, do not consider this book to be an ideal one but a humble attempt has been made to remove the bottlenecks, as far as possible, of the books available to the students at present.

Acknowledgments: Very little of what is worthwhile in this book could not have been brought to publication without the generous cooperation, advice and assistance of many of my colleagues, seniors and juniors.

Dr BN Chakravarty, MBBS, DGO, MO (CaL), FRCOG (Eng.), Professor, Dept, of Obst. and Gyne., Nilratan Sircar Medical College, Calcutta; Dr KM Gun, MBBS, DGO, MO (CaL), FRCOG (Eng.), FRCS (Edin.), FACS, Professor, Dept, of Obst. and Gyne., Medical College, Calcutta; Dr Santosh Kr Paul, MBBS, DGO, MO (CaL), Reader, Dept, of Obst. and Gyne., Nilratan Sircar Medical College, Calcutta; Dr B Hore, MBBS, DA, MS (CaL), Professor and Head of the Dept, of Anesthesiology, North Bengal Medical College, Siliguri; Dr BC Lahari, MBBS, DGO, MO (CaL), FRCS (Edin.), FRCOG (Eng.), FACS (USA), FAMS (Ind.), Professor, Dept, of Obst. and Gyne., Medical College, Calcutta; Dr P Raha, MBBS, DTM & H, PhD, FCAL, Professor, Dept, of Pathology and Bacteriology, RG Kar Medical College, Calcutta; Dr J Mitra, MBBS, DGO, MO (CaL), FLCS, FIMS, FRCOG, Professor, Dept, of Obst. and Gyne., Institute of Postgraduate Medical Education and Research, Calcutta; Dr Aroti Roy, MBBS, FRCOG (Eng.), Professor Dept, of Obst. and Gyne., RG Kar Medical College, Calcutta, and Dr H Dattagupta, MBBS, DGO, FRCOG (Eng.), Asstt. Professor, Dept, of Obst. and Gyne., Medical College, Calcutta; Dr NN Roychowdhury, MBBS, DGO, MO (CaL), PhD, FRCS, FRCOG, FACS, FAMS, Professor, Dept, of Obst. and Gyne., Medical College, Calcutta; Dr N Chowdhury, MBBS, DGO, MO (CaL), Professor, Dept, of Obst. and Gyne., Institute of Postgraduate Medical Education and Research, Calcutta.

X Textbook of Obstetrics

Dr NG Das, BSc, MBBS, MS (CaL), Professor and Head of the Dept, of Anatomy, Nilratan Sircar Medical College, Calcutta; Dr PK Talulcdar, MBBS (CaL), DCH (Lond.), MRCP (Lond.), MRCP (Eng.), Lecturer, Pediatrics, NRS Medical College, Calcutta; Dr Subir Kumar Dutta, MBBS, DCP, MD (Path. & Bact.), Lecturer, Dept, of Pathology and Bacteriology, University College of Medicine, Calcutta; Dr Samar Rudra, MBBS, DGO, MRCOG (Eng.), Ramakrishna Mission Seva Pratishthan, Calcutta.

I have much pleasure in expressing my cordial appreciation to the house-surgeons, internees and students of Nilratan Sircar Medical College, Calcutta for all the help they have rendered in the preparation of the final drafts of the manuscripts, checking the proofs and in compiling the Index. Without their constant encouragement and active assistance, this book could never have been published. I express my sincere thanks to my publisher 'Central Educational Enterprises' for their sincere efforts in publishing the book within the stipulated period in spite of the adverse circumstances.

In preparing a textbook like this, I have utilized the knowledge of a number of stalwarts in my profession and consulted many books and publications. I wish to express my appreciation and gratitude to all of them, including the related authors and publishers.

As a teacher, I have learnt a lot from the students and more so while writing this book and, as such, I could not think of dedicating the book to anyone else but the students of obstetrics for which I express my gratitude.

Mahalaya 8th September, 1983 P-13, New CIT Road Kolkata - 700 014

DC Dutta

Acknowledgments

The job of editing such a comprehensive text is stupendous. I have consulted many of my esteemed colleagues in the profession in this country and abroad, multitude of eminent authors, many current evidence-based studies, guidelines and recommendations. I do gratefully acknowledge my legacy to all the teachers, related authors and the publishers.

I express my sincere thanks to all the teachers and students of different medical institutes, midwifery institutes, nursing colleges in India and abroad for their valued suggestions, new ideas and contribution of photographs. The editor always welcomes the views of the students and the teachers through online access of the Student-Teacher Platform in our websites hiralalkonar. com and dcdutta.com, and e-mail ID h.kondr@gmail.com.

The eighth edition gratefully acknowledges the insightful wisdom of the following teachers, who are associated since the first edition of the book.

Dr KM Gun MD, FRCOG, FRCS, FACS, Professor (Rtd), Dr BN Chakravorty MD, FRCOG, DSc, Director, Institute of Reproductive Medicine, Kolkata, Dr B Hore MD, Professor (Rtd), Consultant Anesthetist, Dr Subir Kumar Dutta MD, Professor (Rtd), Consultant Pathologist for their contribution, continued guidance and valuable suggestions. The manuscript of the chapter on perinatology (Chapter 33) has been thoroughly read and authoritatively revised by Dr Shyamal Banerjee, MD, Professor, Department of Pediatrics, NRS Medical College Hospital, Kolkata, for which he deserves special appreciations. The author expresses his sincere thanks to Professor S Banerjee, DME, Dept, of H&FW, Govt, of West Bengal, Professor (Mrs) M Roy, Principal, Professor PB Chakraborty, MSVP and Professor (Mrs) A Biswas, Head of the Dept., Obs. & Gynae. for their support and encouragement. Mrs Madhusri Konar, MA, BEd deserves full credit for her sincere and patient secretarial job as ever. General Electrical Pvt Ltd is appreciated for the good quality of ultrasonograms. During the production of this textbook, I had the continued assistance and support of a good number of skilled personnel from the publishing house. The author gratefully acknowledges Shri Jitendar P Vij, Group Chairman and Mr Ankit Vij, Group President, Jaypee Brothers Medical Publishers (P) Ltd for their generous support. The author expresses his sincere thanks to Dr Salcshi Arora, Dr Mrinalini Balcshi, Ms Nitasha Arora, along with the entire team of Jaypee Brothers Medical Publishers (P) Ltd, New Delhi for their professional guidance, suggestions and support in bringing out this thoroughly revised eighth edition.

I would like to extend my sincere thanks to all the respected teachers and beloved students, who contacted me with their suggestions for the improvement of this book. Their input has been invaluable and is much appreciated. I wish I could acknowledge each one of them in writing.

P-13, New CIT Road Kolkata - 700 014

Hiralal Konar

Contents

Preface . vii-x

Acknowledgments . xi

H Anatomy of Female Reproductive Organs 1

■ External Genitalia 1 ■ Internal Genital Organs 4 ■ Muscles and Fascia in relation to the Pelvic Organs 11 ■ Pelvic Floor 11 ■ Perineum 12 ■ Pelvic Fascia 14 ■ Pelvic Cellular Tissue 14 ■ Female Urethra 15 ■ The Urinary Bladder 15 ■ Pelvic Ureter 16 ■ The Breast 16

| Fundamentals of Reproduction 1 9

■ Gametogenesis 19 • Oogenesis 19 • Spermatogenesis 20

■ Ovulation 22

■ Fertilization 23 • Morula 24 • Blastocyst 25

■ Implantation 25 ■ Trophoblast26 ■ The Decidua 27 ■ Chorion and Chorionic Villi 28 ■ Development of Inner Cell Mass 29 ■ Events following Fertilization 30

Q The Placenta and Fetal Membranes 32

■ The Placenta 32 • Development 32 • The Placenta at Term 33 • Structures 34

■ Placental Circulation 36 ■ Placental Aging 39 ■ Placental Function 39

■ The Fetal Membranes 41 • Amniotic Cavity, Amnion and Amniotic Fluid 42

■ The Umbilical Cord 44

Q The Fetus 46

■ Fetal Physiology 47 ■ The Fetal Circulation 49 ■ Changes of the Fetal Circulation at Birth 50

| Physiological Changes During Pregnancy 52

■ Genital Organs 52 ■ Breasts 56 ■ Cutaneous Changes 56 ■ Weight Gain 57 ■ Body Water Metabolism 58

■ Hematological Changes 58 ■ Cardiovascular System 60 ■ Metabolic Changes 61 ■ Systemic Changes 62

| Endocrinology in Relation to Reproduction 65

■ Maturation of Graafian Follicles and Ovulation 65 ■ Maintenance of Corpus Luteum after Fertilization 65

■ Placental Endocrinology 66 • Protein Hormones 66 • Steroidal Hormones 68 • Diagnostic Value of Placental Hormones 69

■ Changes of Endocrine Glands during Pregnancy 70 ■ Maintenance of Lactation 72

XIV Textbook of Obstetrics

| Diagnosis of Pregnancy 73

■ First Trimester (First 12 Weeks) 73 ■ Second Trimester (13-28 Weeks) 78 ■ LastTrimester (29-40 Weeks) 80

■ Differential Diagnosis of Pregnancy 81 ■ Summary of Diagnosis of Pregnancy 82 ■ Chronological Appearance ofSpecific Symptoms and Signs of Pregnancy 82 ■ Signs of Previous Child Birth 83 ■ Estimation of Gestational Age and Prediction of Expected Date of Delivery 83 ■ Estimation of Fetal Weight 84

Q The Fetus-in-Utero 85

■ Methods of Obstetrical Examination 87

| Fetal Skull and Maternal Pelvis 94

■ Fetal Skull 94

■ Maternal Pelvis 98 • Physiological Enlargement of Pelvis 105

) Antenatal Care, Preconceptional Counseling and Care 1 06

■ Procedure at the First Visit 106 ■ Procedure at the Subsequent Visits 1 1 1 ■ Antenatal Advice 1 12 ■ Minor Ailments in Pregnancy 1 14 ■ Values of Antenatal Care 1 16 ■ Preconceptional Counseling and Care 1 16

Q Antenatal Assessment of Fetal Well-Being 119

■ Clinical Evaluation of Fetal Well-Being 119 ■ Special Investigations 120 ■ Early Pregnancy 121

■ Antepartum Fetal Surveillance (Late Pregnancy) 121 ■ Other Investigations in Late Pregnancy 124

Q Prenatal Genetic Counseling, Screening and Diagnosis 1 27

■ Prenatal Genetic Screening 127 ■ Prenatal Diagnosis 129 ■ Noninvasive Method of Prenatal Testing 131

ftl Normal Labor 134

■ Causes of Onset of Labor 134 ■ Contractile System of the Myometrium 136 ■ Physiology of Normal Labor 138 ■ Events in First Stage of Labor 140 ■ Events in Second Stage of Labor 143 ■ Events in Third Stage of Labor 143 ■ Mechanism of Normal Labor 145 ■ Anatomy of Labor 149

■ Clinical Course of First Stage of Labor 151 • Second Stage of Labor 153 • Third Stage of Labor 154 • Place of Delivery 154

■ Management of Normal Labor 155 • First Stage 157 • Second Stage 158 • Immediate Care of the Newborn 1 61 • Third Stage 1 62 • Active Management of Third Stage of Labor 1 64

| Normal Puerperium 168

■ Involution of the Uterus 168

■ Involution of Other Pelvic Structures 170 • Lochia 170

■ General Physiological Changes 171

■ Lactation 172 • Physiology of Lactation 173

■ Management of Normal Puerperium 174 ■ Management of Ailments 1 76 ■ Postnatal Care 178

] Vomiting in Pregnancy 180

■ Vomiting in Pregnancy 180 ■ Hyperemesis Gravidarum 181

| Hemorrhage in Early Pregnancy 1 85

■ Spontaneous Abortion (Miscarriage) 185 • Threatened Miscarriage 187 • Inevitable 189 •Complete189 • Incomplete 190 • Missed 190 • Septic Abortion 191 • Recurrent 195

■ Cervical Incompetence 197 ■ Induction of Abortion 202 ■ Medical Termination of Pregnancy (MTP) 202

■ Methods of Termination of Pregnancy 203 • First Trimester 203 • Mid Trimester 204 • Medical Methods 204 • Surgical Methods 205 • Complications of MTP 206

Contents XV

■ Ectopic Pregnancy 207 • Tubal 208 • Unruptured Tubal Ectopic Pregnancy 21 1 • Chronic or Old Ectopic 21 2 • Interstitial Pregnancy 214

■ Abdominal Pregnancy 218 ■ Ovarian Pregnancy 220 ■ Cornual Pregnancy 220 ■ Cervical Pregnancy 220 ■ Gestational Trophoblastic Diseases (GTD) 221 ■ Hydatidiform Mole 222 ■ Partial or Incomplete Mole 230 ■ Placental Site Trophoblastic Tumor (PSTT) 231 ■ Persistent Gestational Trophoblastic Disease 231

Q Multiple Pregnancy, Amniotic Fluid Disorders, Abnormalities of Placenta and Cord 233

■ Twins 233 ■ Triplets, Quadruplets 244

■ Amniotic Fluid Disorders 246 • Polyhydramnios 246 • Oligohydramnios 250

■ Abnormalities of Placenta and Cord 251

Q Hypertensive Disorders in Pregnancy 255

■ Preeclampsia 256 • Etiopathogenesis 257 • Pathophysiology 258 • Clinical Types 260 • Clinical Features 261 • Complications 263 • Prophylactic Measures 264 • Management 264 • Acute Fulminant Preeclampsia 267

■ Eclampsia 268 • Clinical Features of Eclampsia 270 • Management 271

■ Gestational Hypertension 276 ■ Chronic Hypertension 277 ■ Essential Hypertension 277 ■ Chronic Renal Diseases in Pregnancy 278

Q Antepartum Hemorrhage 282

■ Placenta Previa 282 • Clinical Features 284 • Placentography 286 • Differential Diagnosis 287 • Complications 288 • Management 289 • Practical Guideline for Cesarean Delivery 291 • Practical Guide to Lower Segment Approach for Placenta Previa 293 • Practical Guidelines to Lower Segment Approach for Placenta Previa Accreta 293

■ Abruptio Placentae 294 • Clinical Features 297 • Complications 297 • Treatment 299

■ Indeterminate Bleeding 301

] Medical and Surgical Illness Complicating Pregnancy 303

■ Hematological Disorders in Pregnancy 303 • Anemia in Pregnancy 303 • Hemoglobinopathies 316

• Sickle Cell Hemoglobinopathies 316 • Thalassemia Syndromes 317 • Platelet Disorders 318

■ Heart Disease in Pregnancy 319

■ Diabetes Mellitus and Pregnancy 325 • Gestational Diabetes Mellitus (GDM) 326 • Overt Diabetes 327

■ Thyroid Dysfunction and Pregnancy 334

■ Jaundice in Pregnancy 335 • Cholestasis 336

■ Viral Hepatitis 336 ■ Epilepsy in Pregnancy 338 ■ Asthma in Pregnancy 339 ■ Systemic Lupus Erythematosus (SLE) 340 ■ Tuberculosis in Pregnancy 341 ■ Syphilis in Pregnancy 342

■ Parasitic and Protozoal Infestations in Pregnancy 344 • Malaria 344 • Toxoplasmosis 345

• Listeriosis 346 • Intestinal Worms 346

■ Pyelonephritis in Pregnancy 346 ■ Asymptomatic Bacteriuria (ASB) 347

■ Viral Infections in Pregnancy 348 • Rubella 348 • Measles 349 • Influenza 349 • Chickenpox (Varicella) 349 • Cytomegalovirus (CMV) 349 • Parvoviruses 349 • Mumps (RNA) 350 • Herpes Simplex (DNA) Virus (HSV) 350 • Dengue 350

■ Human Immunodeficiency Virus Infection (HIV) and Acquired Immunodeficiency Syndrome (AIDS) 350 ■ Surgical Illness during Pregnancy 353 ■ Acute Pain in Abdomen during Pregnancy 355

Q Gynecological Disorders in Pregnancy 356

■ Abdominal Vaginal Discharge 356 ■ Congenital Malformation 356 ■ Carcinoma Cervix with Pregnancy 357 ■ Leiomyomas with Pregnancy 359 ■ Ovarian Tumor in Pregnancy 360 ■ Retroverted Gravid Uterus 361 ■ Morbid Anatomic Changes if Left Uncared for 362 ■ Genital Prolapse in Pregnancy 363

XVI Textbook of Obstetrics

Preterm Labor, Preterm Rupture of the Membranes, Postmaturity,

Intrauterine Fetal Death

■ Preterm Labor 365 ■ Prelabor Rupture of the Membrane (PROM) 369 ■ Management 369 ■ Prolonged and Post-term Pregnancy 371 ■ Intrauterine Fetal Death (IUFD) 375

365

m

Complicated Pregnancy

381

■ Pregnancy with Prior Cesarean Delivery 381 • Integrity of the Scar 381 • Evidences of Scar Rupture (or Scar Dehiscence) during Labor 383 • Management of a Pregnancy with Prior Cesarean Delivery 383 • Vaginal Birth After Previous Cesarean (VBAC) 384

■ Pregnancy in a Rh-negative Woman 386 • Red Cell Alloimmunization 387 • Fetal Affection by the Rh-antibody 388 • Manifestations of the Hemolytic Disease of the Fetus and Newborn (HDFN)388 • Prevention of Rh-immunization 389 • Antenatal Investigation Protocol of Rh-negative Mothers 391 • Plan of Delivery 393

■ Exchange Transfusion in the Newborn 396 • Prognosis 397

■ Elderly Primigravida 398 ■ Grand Multipara 398 ■ Bad Obstetric History (BOH) 399 ■ Obesity in Pregnancy 400

^ Contracted Pelvis 402

■ Valiation of Female Pelvis 402 ■ Asymmetrical or Obliquely Contracted Pelvis 405 ■ Mechanism of Labor in Contracted Pelvis with Vertex Presentation 405 ■ Diagnosis of Contracted Pelvis 406

■ Disproportion 409 • Diagnosis of Cephalopelvic Disproportion (CPD) 410 • Effects of Contracted Pelvis on Pregnancy and Labor 412 • Management 412

■ Trial Labor 412 ■ Midpelvic and Outlet Disproportion 414

] Abnormal Uterine Action 415

■ Types 41 5 ■ Uterine Inertia 416 ■ Incoordinate Uterine Action 417 ■ Spastic Lower Segment 418

■ Constriction Ring 419 ■ Cervical Dystocia 419 ■ Generalized Tonic Contraction 419 ■ Precipitate Labor 420 ■ Tonic Uterine Contraction and Retraction 420 ■ Summary 423

] COMPLICATED LABOR-Malposition, Malpresentation and Cord Prolapse 424

■ Occiput-Posterior Position (OP) 424 ■ Arrested Occipitoposterior Position 430 ■ Deep Transverse Arrest (DTA) 431 ■ Manual Rotation for Occipitoposterior Position 431 ■ Breech Presentation 434

■ Antenatal Management 439 ■ Management ofVaginal Breech Delivery 441 ■ Assisted Breech Delivery 442

■ Management of Complicated Breech 446 ■ Face Presentation 449 ■ Brow Presentation 453

■ Transverse Lie 454 ■ Unstable Lie 459 ■ Compound Presentation 459 ■ Cord Prolapse 460

| Prolonged Labor, Obstructed Labor, Dystocia Caused by Fetal Anomalies 463

■ Prolonged Labor 463 ■ Obstructed Labor 467 ■ Dystocia Caused by Fetal Anomalies 468

■ Shoulder Dystocia 469 • Hydrocephalus 470 • Neural Tube Defects 471 • Enlargement of Fetal Abdomen 472 • Monsters 472 • Conjoined Twins 473

] Complications of the Third Stage of Labor 474

■ Postpartum Hemorrhage (PPH) 474

■ Primary Postpartum Hemorrhage 475 • Management of Third Stage Bleeding 477 • Steps of Manual Removal of Placenta 478 • Secondary Postpartum Hemorrhage 483

■ Retained Placenta 484 ■ Placenta Accreta 486 ■ Inversion of the Uterus 487

| Injuries to the Birth Canal 489

■ Vulva 489 ■ Perineum 489 ■ Vagina 491 ■ Cervix 491 ■ Pelvic Hematoma 492 ■ Rupture of the Uterus 493 ■ Visceral Injuries 499

Contents XVII

Abnormalities of the Puerperium

500

■ Puerperal Pyrexia 500 ■ Puerperal Sepsis 500 ■ Subinvolution 505 ■ Urinary Complications 505

■ Breast Complications 506 ■ Puerperal VenousThrombosis and Pulmonary Embolism 508 ■ Pulmonary Embolism (PE) 510 ■ Obstetric Palsies 51 1 ■ Puerperal Emergencies 51 1 ■ Psychiatric Disorders during Puerperium 51 2 ■ Psychological Response to Perinatal Deaths and Management 51 3

m

The Term Newborn Infant

■ Physical Features of the Newborn 514 ■ Immediate Care of the Newborn 517

■ Infant Feeding 519 • Breastfeeding 519 • Artificial Feeding 524

■ Childhood Immunization Program 526

514

Low Birth Weight Baby

■ Preterm Baby 528 ■ Fetal Growth Restriction (FGR) 533

527

m Disease of the Fetus and the Newborn

541

■ Perinatal Asphyxia 541 ■ Fetal Respiration 541

■ Respiratory Distress in the Newborn 547 • Idiopathic Respiratory Distress Syndrome 547 • Meconium Aspiration Syndrome (MAS) 550

■ Jaundice of the Newborn 551 • Hyperbilirubinemia of the Newborn 552 • Kernicterus 553

■ Hemolytic Disease of the Newborn 554 • ABO Group Incompatibility 555

■ Bleeding Disorders in the Newborn 555 ■ Anemia in the Newborn 556 ■ Seizures in Newborn 557

■ Birth Injuries of the Newborn 558 • Intracranial Hemorrhage (ICH) 559

■ Other Injuries 561 ■ Perinatal Infections 563 ■ Ophthalmia Neonatorum (Conjunctivitis) 564 ■ Skin Infections 565 ■ Necrotizing Enterocolitis 566 ■ Mucocutaneous Candidiasis 567 ■ Congenital Malformations and Prenatal Diagnosis 567 ■ Down's Syndrome (Trisomy 21) 568 ■ Congenital Malformations in Newborn and the Surgical Emergencies 569 ■ Nonimmune Fetal Hydrops (NIFH) 571

^ Pharmacotherapeutics in Obstetrics 573

■ Oxytocics in Obstetrics 573 • Oxytocin 573 • Ergot Derivatives 577 • Prostaglandins (PGS) 578

■ Antihypertensive Therapy 581 ■ Diuretics 582 ■ Tocolytic Agents 583 ■ Anticonvulsants 584

■ Anticoagulants 585 ■ Maternal Drug Intake and Breastfeeding 586 ■ Fetal Hazards on Maternal Medication during Pregnancy 587

■ Analgesia and Anesthesia in Obstetrics 590 • Anatomical and Physiological Considerations 590

• Analgesia during Labor and Delivery 591 • Sedatives and Analgesics 592 • Inhalation Methods 592

• Regional (Neuraxial) Anesthesia 593 • Infiltration Analgesia 595 • General Anesthesia for Cesarean Section 596

^ Induction of Labor 598

■ Indications and Contraindications 598 ■ Parameters to Assess Prior to Induction 599 ■ Methods of Cervical Ripening 599

■ Methods of Induction of Labor 600 • Medical 600 • Surgical 601 • Combined 604

■ Active Management of Labor 605 ■ Partograph 607

| Population Dynamics and Control of Conception 609

■ Population Dynamics 609 ■ Control of Conception 610

■ Contraception 610 • Method 611 • Barrier Methods 61 1 • Natural Contraception 614 • Intrauterine Contraceptive Devices (lUCDs) 615 • Steroidal Contraceptions 621 • Combined Oral Contraceptives (Pills) 622 • Injectable Progestins 628 • Implant 628 • Emergency Contraception (EC) 629

• Sterilization 631 • Vasectomy 631 • Female Sterilization 632 • Laparoscopic Sterilization 635

• Contraceptive 637 • Contraceptive Counseling and Prescription 637

■ OngoingTrials and Selective Availability 638 • Centchroman Prescription 638 • Combined Injectable Contraceptives 639 • Biodegradable Implants 639 • Newer lUDs 639

XV111 Textbook of Obstetrics

Q Operative Obstetrics 642

■ Dilatation and Evacuation 642 ■ Management Protocol of Uterine Perforation 645 ■ Suction Evacuation 645

■ Menstrual Regulation 646 ■ Manual Vacuum Aspiration 646 ■ Hysterotomy 647 ■ Episiotomy 647

■ Operative Vaginal Delivery 651 ■ Forceps 651 «Ventouse660

■ Version 663 • External Cephalic Version 663 • Internal Version 665 • Bipolar Version 666

■ Destructive Operations 666 • Craniotomy 666 • Decapitation 668 • Evisceration 668 • Cleidotomy668 • Postoperative Care Following Destructive Operations 669

■ Cesarean Section (CS) 669 • Lower Segment 671 • Classical 676 • Complication of Cesarean Section 677

■ Measures to Reduce Cesarean Births 679 ■ Symphysiotomy 679

m Safe Motherhood, Epidemiology of Obstetrics 680

■ Safe Motherhood 680 ■ Obstetric Care and the Society 681 ■ Reproductive and Child Health (RCH)

Care 681 ■ Epidemiology of Obstetrics 683 ■ Maternal Mortality 683 ■ Maternal Near Miss 687

■ Maternal Morbidity 687 ■ Perinatal Mortality 687 ■ Stillbirths 690 ■ Neonatal Deaths 690

■ Women's Health (MDGs) Beyond 2015; 690

] Special Topics in Obstetrics 692

■ Intrapartum Fetal Monitoring 692 • Electronic Fetal Monitoring 693 • Nonreassuring Fetal Status (NRFS) 697

■ Shock in Obstetrics 699 • Classification 702 • Hemorrhagic Shock 704 • Endotoxic Shock 705

■ Acute Kidney Injury (AKI) 706 ■ Blood Coagulation Disorders in Obstetrics 71 1 ■ High-riskPregnancy716

■ Immunology in Obstetrics 719 ■ Critical Care in Obstetrics 722 ■ ICU 723

] Current Topics in Obstetrics 726

■ Antibiotic Prophylaxis in Cesarean Section 726 ■ Day Care Obstetrics 726 ■ Legal and Ethical Issues in Obstetric Practice 727 ■ Audit In Obstetrics 728 ■ The Preconception and Prenatal DiagnosticTechniques and PNDT Act 729 ■ Umbilical Cord Blood Banking 729 ■ Stem Cells and Therapies in Obstetrics 730

Q Imaging in Obstetrics (USG, MRI, CT, Radiology), Amniocentesis and 732

Guides to Clinical Tests

■ Ultrasound In Obstetrics 732 • Three-dimensional Ultrasonography (3D Scanning) 733 • First Trimester 734 • Midtrimester 735 • Doppler 737 • Third Trimester 739

■ Magnetic Resonance Imaging (MRI) in Obstetrics 739 ■ Computed Tomography (CT) 740 ■ Radiology in Obstetrics 740 ■ Amniocentesis 741

■ Guides to Clinical Tests 742 • Urine 742 • Tests for Blood Coagulation Disorders 743 • Collection of Blood Sample 744 • Cervical and Vaginal Cytology 746

Q Practical Obstetrics 747

■ Clinical Thermometer 747 ■ Obstetric Instruments 747 ■ Specimens 758 ■ Imaging Studies (USG Plates) 759 ■ Processing of Instruments 763 ■ Oxytocics: Oxytocin, Methergin, Misoprostol (PGE^; Carboprost (PGF2a), Prostin (PGE2) 764 ■ Doppler (Ultrasound) Fetal Monitor 764

Index

765

Abbreviations

AC	Abdominal Circumference	CDC	: Center for Disease Control
aCL	anti-Cardiolipin Antibodies	CH	: Crown Heel
ACOG	American College of Obstetricians	CIN	: Cervical Intraepithelial Neoplasia
	and Gynecologists	CIRCI	: Critical Illness-related Corticosteroid
AFI	Amniotic Fluid Index		Insufficiency
AFP	Alpha Fetoprotein	CMQCC	: California Maternal Quality Care
AFV	Amniotic Fluid Volume		Collaboration
AGS	: Antigas Gangrene Serum	CO	Cardiac Output
ALT	: Alanine Amniotransferase	COCs	Combined Oral Contraceptives
AMTSL	: Active Management of Third Stage of	COX	Cyclo-oxygenase
	Labor	CPAP	Continuous Positive Airway Pressure
AN	: Atrial Natriuretic Factor	CPD	Cephalopelvic Disproportion
APH	: Antepartum Hemorrhage	CPK	Creatinine Phosphokinase
aPLs	: anti-Phospholipid Antibodies	CPT	Complete Perineal Tear
APTT	: Activated Partial Thromboplastin	CRH	Corticotrophin-releasing Hormone
	Time	CRL	Crown Rump Length
ARDS	Acute Respiratory Distress Syndrome	CRP	C-Reactive Protein
ARM	Artificial Rupture of Membranes	CRS	Congenital Rubella Syndrome
ART	Assisted Reproductive Technology	CS	Cesarean Section
ASD	Atrial Septal Defect	CSE	Combined Spinal Epidural
AST	Aspartate Amniotransferase	CST	Contraction Stress Test
ATP	Adenosine Triphosphate	CT	Computed Tomography
ATS	Anti-Tetanus Serum	CTG	Cardiotocography
AUA	Abnormal Uterine Action	CTPA	Computed Tomographic Pulmonary
P2GP-1	(32 Glycoprotein-1		Angiography
BMI	Body Mass Index	CVP	: Central Venous Pressure
BPD	Biparietal Diameter	CVS	: Chorionic Villus Sampling
BPD	Broncho-pulmonary Dysplasia	CVS	: Congenital Vericella Syndrome
BPP	Biophysical Profile	CXR	: Chest X-ray
CBG	Corticosteroid-binding Globulin	D/D	: Diamniotic-Dichorionic
CCF	Congestive Cardiac Failure	D/M	: Diamniotic-Monochorionic

XX Textbook of Obstetrics

D&E	Dilatation and Evacuation
DBP	Diastolic Blood Pressure
DFMC	Daily Fetal Movement Counting
DIC	Disseminated Intravascular Coagulopathy
DIPSI	Diabetes in Pregnancy Study Group India
DMPA	Depot Medroxy Progesterone Acetate
DTA	Deep Transverse Arrest
DV	Ductus Venosus
DVT	Deep Vein Thrombosis
EFM	Electronic Fetal Monitoring
EACA	Epsilon Amino Caproic Acid
EAS	External Anal Sphincter
ECG	Electro Cardiography
ECV	External Cephalic Version
EDD	Expected Date of Delivery
EFM	Electronic Fetal Monitoring
EGN	Etonogestrel
EmOC	Emergency Obstetric Care
EmONC	Emergency Obstetric and Newborn Care
EPF	: Early Pregnancy Factor
ERPC	: Evacuation of Retained Products of Conception
ES	Embryonic Stem
FBS	Fetal Blood Sampling
FDP	Fibrin Degradation Products
FFA	Free Fatty Acid
ffDNA	free fetal DNA
FFP	Fresh Frozen Plasma
FGR	Fetal Growth Restriction
FHR	Fetal Heart Rate
FHS	Fetal Heart Sound
FIGO	International Federation of Gynecology and Obstetrics
FISH	Fluorescence in situ Hybridization
FL	Femur Length
FMH	Fetomaternal Hemorrhage
FRU	First Referral Unit
FSH	Follicle-stimulating Hormone
GA	Gestational Age
GBS	Group B Streptococcus
GDM	Gestational Diabetes Mellitus

GLUT	Glucose Transporter
GLUT-1	Glucose Transporter-1
GnRH	Gonadotropin-releasing Hormone
GTN	Gestational Trophoblastic Neoplasia
GTN	Glyceryl Trinitrate
GTT	Glucose Tolerance Test
HAART	Highly Active Anti-retroviral Therapy
Hb	Hemoglobin
HC	Head Circumference
hCG	Human Chorionic Gonadotropin
HCS	Hemopoietic Stem Cells
hCT	Human Chorionic Thyrotropin
HDFN	Hemolytic Disease of the Fetus and Newborn
HDL	: High Density Lipoprotein
HELLP	: Hemolysis, Elevated Liver Enzymes, Low Platelet
HIE	Hypoxic Ischemic Encephalopathy
HIV	Human Immunodeficiency Virus
HLA	Human Leucocyte Antigen
HMD	Hyaline Membrane Disease
HPL	Human Placental Lactogen
HR	Heart Rate
IAS	Internal Anal Sphincter
ICA	Incordinate Uterine Action
ICH	Intracranial Hemorrhage
ICOG	Indian College of Obstetricians & Gynaecologists
IFM	Intrapartum Fetal Monitoring
IGF-1	Insulin Growth Factor-1
igG	Immunoglobulin G
IOL	Induction of Labour
IPT	Intraperitoneal Transfusion
ITU	Intensive Care Unit
IUD	Intrauterine Device
IUCD	Intrauterine Contraceptive Device
IUFD	Intrauterine Fetal Death
IUGR	Intrauterine Growth Restriction
IUT	Intrauterine Transfusion
IVC	Inferior Vena Cava
IVH	Intraventricular Hemorrhage
IVIg	Intravenous Immunoglobulin
IVT	Intravascular Transfusion
JSY	Janani Suraksha Yojana

Abbreviations XXI

KB	Kleihauer-Betke
L : S Ratio	Lecithin-Sphingomyelin Ratio
L/S	Lecithin/Sphingomyelin
LA	Lupus Anticoagulant
LAM	Lactational Amenorrhoea
LBW	Low Birth Weight
LDH	Lactic Dehydrogenase
LDL	Low Density Lipoprotein
LGA	Large for Gestational Age
LH	Luteinizing Hormone
LMA	Left Mentoanterior
LMP	Last Menstrual Period
LMWH	Low Molecular Weight Heparin
LNG-IUS	Levonorgestrel-lntrauterine System
LOA	Left Occiput Anterior
LOP	Left Occiput Posterior
LOT	Left Occiput Transverse
LPD	Luteal Phase Defect
LSA	Left Sacrum Anterior
LSCS	Lower Segment Cesarean Section
LVP	Largest Vertical Pocket
M/M	Monoamniotic-Monochorionic
MAP	Mean Arterial Pressure
MCA	Middle Cerebral Artery
MCU	Microcirculatory Unit
MDGs	Millennium Development Goals
MFMU	Maternal Fetal Medicine Unit
MLCK	Myocin Light Chain Kinase
MMR	Maternal Mortality Ratio
MOMs	Multiples of the Medians
MRA	Magnetic Resonance Angiography
MRI	Magnetic Resonance Imaging
MSAFP	Maternal Serum Alphafeto Protein
MVA	Manual Vacuum Aspiration
NEC	Necrotising Enterocolitis
NICE	National Institute of Clinical Excellence
NICHD	: National Institute of Child Health and Development
NICU	: Neonatal Intensive Care Unit
NK	: Natural Killer Cells
NO	: Nitric Oxide
NPN	: Non-Protein Nitrogen
NRFS	: Non-reassuring Fetal Status

NST	Non-stress Test
NSV	No-Scalpel Vasectomy
NT	Nuchal Translucency
NTD	Neural Tube Defect
OA	Occiput Anterior
OGN	Oestrogen
OP	Occiput Posterior
OT	Operation Theatre
PAPP-A	Pregnancy-associated Plasma Protein-A
PBI	Protein-bound Iodine
PCA	Patient-controlled Analgesia
PCOS	Polycystic Ovarian Syndrome
PCR	Polymerase Chain Reaction
PCWP	Pulmonary Capillary Wedge Pressure
PDA	Patent Ductus Arteriosus
PDS	Poly Dioxanone